Transcript Provider Delivered Care Management Billing Guidelines Webinar

1
Michigan Primary Care
Transformation Project (MiPCT)
Payment Update and Process Webinar
April 12, 2012
2
Agenda
• Context and Overview
• Payer Updates
▫
▫
▫
▫
BCBSM
BCN
Medicaid
Medicare
There will be an opportunity to ask questions at the end
of each payer’s update presentation.
3
BCBSM Update
4
Recent BCBSM Developments
• All underwritten groups are still participating
• Self-Funded groups that have joined:
▫ URMBT, Zeledyne, Severstal, Magna, Visteon, Gordon
Foods
• Additional MiPCT payments forthcoming end of
April
▫ $3.06 PMPM for two months, based on latest
attribution
BCBSM PDCM Payment Policy Design
• Fee-for-service methodology – 7 payable codes for services
performed by qualified non-physician practitioners
▫ Face-to-face (individual and group)
▫ Telephone-based
• Payable to approved/“privileged” providers only
▫ Non-approved providers billing for these services are
subject to recovery
• BCBSM will pay the lesser of provider charges or BCBSM’s
maximum fee
▫ Subject to PCMH enhanced compensation provisions
▫ Determined by rendering provider identified on the claim
 PCMH-designation status uplifts of 10% or 20%
 CNPs or PAs paid at 85%
• No cost share imposed on members EXCEPT members with
Qualified High Deductible Health Plans with a Health
Savings Account
5
High Deductible Health Plans
• Only members who have a High Deductible Health
Plan with a Health Savings Account will be financially
liable for PDCM services
• To identify the amount of cost share, providers can
use Web-DENIS or CAREN IVR to verify if deductible
has been met
• Amount of payment will vary based on where member is at in
fulfilling their deductible requirement
• Patient cost share can be identified by looking in the patient
liability column, similar to what you would see for any other
patient
6
7
PDCM Codes and Fees
CODE
SERVICE
FEE*
G9001
Initial assessment
$112.67
G9002
Individual face-to-face visit (per encounter)
$56.34
98961
Group visit (2-4 patients) 30 minutes
$14.08
98962
Group visit (5-8 patients) 30 minutes
$10.47
98966
Telephone discussion 5-10 minutes
$14.45
98967
Telephone discussion 11-20 minutes
$27.81
98968
Telephone discussion 21+ minutes
$41.17
*Net of Incentive amount
8
General Conditions of Payment
• For billed services to be payable, the following
conditions apply:
▫ The patient must be eligible for PDCM coverage.
▫ The services must be delivered and billed under the auspices of a
practice or practice-affiliated PO approved by BCBSM for PDCM
reimbursement.
 Based on patient need
 Ordered by a physician, PA or CNP within the approved practice
 Performed by the appropriate qualified, non-physician health care
professional employed or contracted with the approved practice or PO
 Billed in accordance with BCBSM billing guidelines
• Non-approved providers billing for PDCM services will
be subject to audit and recoveries.
9
Care Management Training Guidelines
▫ Services provided by Moderate care managers are
billable once care managers complete approved selfmanagement training.
▫ Services provided by Complex care managers are
billable once care managers have completed approved
Complex Care Management training.
▫ PDCM-codes should not be billed by untrained care
managers
10
Patient Eligibility
• The patient must have active BCBSM coverage that includes the
BlueHealthConnection® Program. This includes:
▫ BCBSM underwritten business
▫ ASC (self-funded) groups that elect to participate
▫ Medicare Advantage patients
• Checking eligibility:
▫ Eligible members with PDCM coverage will be flagged on the monthly patient list
▫ Providers should also check normal eligibility channels (e.g., WebDENIS, CAREN
IVR) to confirm BCBSM overall coverage eligibility
• The patient must be an active patient under the care of a physician, PA or
CNP in a PDCM-approved practice and referred by that clinician for PDCM
services
▫ No diagnosis restrictions are applied
▫ Referral should be based on patient need
• The patient must be an active participant in the care plan
Services billed for non-eligible members will be rejected with provider liability.
11
Provider Requirements: Care Management Team
• Individuals performing PDCM services must be qualified non-physician
practitioners employed by practices or practice-affiliated POs approved for
PDCM payments
• The team must consist of:
▫ A lead care manager who:
 Is an RN, licensed MSW, CNP or PA
 Has completed an MiPCT-accepted training program
▫ Other qualified allied health professionals:
 Any of the above, plus…
 Licensed practical nurse, certified diabetes educator, registered dietician, masters of
science trained nutritionist, clinical pharmacist, respiratory therapist, certified asthma
educator, certified health educator specialist (bachelor’s degree or higher), licensed
professional counselor, licensed mental health counselor
• Each qualified care team member must:
▫ Function within their defined scope of practice
▫ Work closely and collaboratively with the patient’s clinical care team
▫ Work in concert with BCBSM care management nurses as appropriate
Note: Only lead care managers may perform the initial assessment services (G9001)
Provider Requirements: Billing and Rendering
Provider
•
PDCM services are only payable to practices or POs approved for PDCM reimbursement.
▫For 2012, MiPCT-participating providers only
•
Two potential models
▫Practice-based care management team
▫Physician-organization-based care management team
Practice-based
Physician
Organizationbased
•
•
Rendering
Provider
Billing
Provider
Physician, CNP
or PA within the
PDCM-approved
practice
Physician
practice
PO-based billing
entity
The rendering provider identified on the claim determines the fee.
Rendering and billing providers must be appropriately enrolled with BCBSM.
▫For PO-based arrangement, the PO must obtain an NPI and enroll with BCBSM
▫Affiliated clinicians identified as the Rendering Provider on PDCM claims must be registered in connection
with the PO entity
BCBSM’s Provider Consulting area is prepared to assist with the enrollment process.
Please contact Laurie Latvis at [email protected]
12
13
Billing and Documentation: General Guidelines
• The following general billing guidelines apply to PDCM services:
▫ Approved practices/POs only
▫ Professional claim
 7 procedure codes
 PDCM may be billed with other medical services on the same claim
 PDCM may be billed on the same day as other physician services
▫ No diagnostic restrictions
 All relevant diagnoses should be identified on the claim
▫ No quantity limits (except G9001)
▫ No location restrictions
▫ Documentation demonstrating services were necessary and delivered as
reported
▫ Documentation identifying lead CM isn’t required, but documentation
must be maintained in medical records identifying the provider for each
patient interaction
14
Code-Specific Requirements: G9001
Initiation of Care Management (Comprehensive Assessment)
G9001
Coordinated Care Fee, Initial Rate (per case)
• Payable only when performed by an RN, MSW, CNP or PA with approved level of
care management training (i.e., lead care manager)
• One assessment per patient per year
• Contacts must add up to at least 30 minutes of discussion
• Assessment should include:
▫ Identification of all active diagnoses
▫ Assessment of treatment regimens, medications, risk factors, unmet needs, etc.
▫ Care plan creation (issues, outcome goals, and planned interventions)
• Billed claims must include:
▫ Date of service (date patient is “enrolled” in care management)
▫ All active diagnoses identified in the assessment process
• Record documentation must additionally include:
▫ Dates, duration, name/credentials of care manager performing the service
▫ Formal indication of patient engagement/enrollment
▫ Physician coordination and agreement
NOTE: More detailed requirements/expectations applicable to Medicare
Advantage patients are under development.
15
Code-Specific Requirements: G9002
Individual, Face-to-Face Care Management Visit
G9002 Coordinated Care Fee, Maintenance rate (per encounter)
• Payable when performed by any qualified care management team member
• No quantity limits
• Encounters must:
▫ Be conducted in person
▫ Be a substantive, focused discussion pertinent to patient’s care plan
• Claims reporting requirements:
▫ Each encounter should be billed on its own claim line
▫ All diagnoses relevant to the encounter should be reported
• Record documentation must additionally include:
▫ Date, duration, name/credentials of team member performing the service
▫ Nature of discussion and pertinent details relevant to care plan (progress,
changes, etc.)
16
Code-Specific Requirements: 98961, 98962
Group Education & Training Visit
98961
98962
Education and training for patient self-management for 2-4 patients, 30 minutes
Education and training for patient self-management for 5-8 patients, 30 minutes
• Payable when performed by any qualified care management team member
• No quantity limits (for example, if call lasted more than 30 minutes you would bill
additional codes for each 30 minute increment)
• Each session must:
▫
▫
▫
Be conducted in person
Have at least two, but no more than eight patients present
Include some level of individualized interaction
• Claims reporting requirements:
▫
▫
▫
▫
Services should be separately billed for each individual patient
Code selection depends upon total number of patient participants in the session
Quantity depends upon length of session (reported in thirty minute increments)
All diagnoses relevant to the encounter should be reported
• Additional documentation requirements:
▫
▫
▫
Dates, duration, name/credentials of care manager performing the service
Nature of content/objectives, number of patients present
Any updated status on patient’s condition, needs, progress
17
Code-Specific Requirements: 98966, 98967, 98968
Telephone-based Services
98966
98967
98968
Telephone assessment and management, 5-10 minutes
Telephone assessment and management, 11-20 minutes
Telephone assessment and management, 21+ minutes
• Payable when performed by any qualified care management team member
• No more than one per date of service (if multiple calls are made on the same day, the
times spent on each call should be combined and reported as a single call)
• Each encounter must:
▫
▫
▫
Be conducted by phone
Be at least 5 minutes in duration
Include a substantive, focused discussion pertinent to patient’s care plan
• Claims reporting requirements
▫
▫
Code selection depends upon duration of phone call
All diagnoses relevant to the encounter should be reported
• Additional documentation requirements:
▫
▫
Dates, duration, name/credentials of care manager performing the call
Nature of the discussion and pertinent details regarding updates on patient’s condition, needs,
progress
18
BCN Update
Recent Developments
• All underwritten groups are still participating
• Presented to some self-fund groups
– Informally notified that at least two groups will
participate
• Propose paying the $1.50 pmpm for
Performance Transformation to the noncapitated groups quarterly
– Calculate the membership monthly
19
Care Coordination Payment
• Effective April 1, 2012 and forward, providers
need to submit claims for care coordination
services rendered
• For January 1 to March 31, 2012, BCN will pay a
lump sum equal to three times the average
monthly care coordination payment
– Average monthly care coordination will be calculated
using claims validated and billed for July and August
2012 dates of service
– Payment will be made no later than October 31, 2012
PDCM Payment Policy Design
• Fee-for-service methodology – 7 payable codes for services
performed by qualified non-physician practitioners
– Face-to-face (individual and group)
– Telephone-based
• Payable to approved/“privileged” providers only
– Non-approved providers billing for these services are
subject to recovery
• BCN will pay the lesser of provider charges or BCN’s
maximum fee
– CNPs or PAs paid at 85%
• No cost share imposed on members
21
PDCM Codes and Fees
CODE
SERVICE
G9001
Initial assessment
G9002
Individual face-to-face visit (per encounter)
98961
Group visit (2-4 patients) 30 minutes
98962
Group visit (5-8 patients) 30 minutes
98966
Telephone discussion 5-10 minutes
98967
Telephone discussion 11-20 minutes
98968
Telephone discussion 21+ minutes
• Use applicable regional fee schedule
– Call your BCN provider representative with questions
22
General Conditions of Payment
• For billed services to be payable, the following conditions
apply:
– The patient must be eligible for PDCM coverage.
– The services must be delivered and billed under the auspices of a
practice or practice-affiliated PO approved by BCN for PDCM
reimbursement.
• Based on patient need
• Ordered by a physician, PA or CNP within the approved practice
• Performed by the appropriate qualified, non-physician health care
professional employed or contracted with the approved practice or
PO
• Billed in accordance with BCN billing guidelines
• Non-approved providers billing for PDCM services will
be subject to audit and recoveries.
23
Care Management Training Guidelines
(same as BCBSM)
– Services provided by Moderate care managers are
billable once care managers complete approved selfmanagement training.
– Services provided by Complex care managers are
billable once care managers have completed approved
Complex Care Management training.
– PDCM-codes should not be billed by untrained care
managers
24
Patient Eligibility
• Provider panels are available through Health e-Blue web
– Instructions will be forthcoming detailing how to identify the
self-funded membership not participating in MiPCT
– Providers should also check normal eligibility channels (e.g.,
WebDENIS, CAREN IVR) to confirm BCN overall coverage
eligibility
• The patient must be an active patient under the care of a
physician, PA or CNP in a PDCM-approved practice No
diagnosis restrictions are applied
– Order for PDCM should be based on patient need
• The patient must be an active participant in the care plan
Services billed for non-eligible members will be rejected with provider liability.
25
Provider Requirements: Care Management
Team (same as BCBSM)
•
•
Individuals performing PDCM services must be qualified non-physician
practitioners employed by practices or practice-affiliated POs approved for
PDCM payments
The team must consist of:
– A lead care manager who:
• Is an RN, licensed MSW, CNP or PA
• Has completed an MiPCT-accepted training program
– Other qualified allied health professionals:
• Any of the above, plus…
• Licensed practical nurse, certified diabetes educator, registered dietician, masters of
science trained nutritionist, clinical pharmacist, respiratory therapist, certified asthma
educator, certified health educator specialist (bachelor’s degree or higher), licensed
professional counselor, licensed mental health counselor
•
Each qualified care team member must:
– Function within their defined scope of practice
– Work closely and collaboratively with the patient’s clinical care team
– Work in concert with BCN care management nurses as appropriate
Note: Only lead care managers may perform the initial assessment services (G9001)
26
Provider Requirements: Billing and
Rendering Provider
•
PDCM services are only payable to practices or POs approved for PDCM reimbursement.
–For 2012, MiPCT-participating providers only
•
Two potential models
–Practice-based care management team
–Physician-organization-based care management team
Practice-based
Physician
Organizationbased
•
•
Rendering
Provider
Billing
Provider
Physician, CNP
or PA within the
PDCM-approved
practice
Physician
practice
PO-based billing
entity
The rendering provider identified on the claim determines the fee.
Rendering and billing providers must be appropriately contracted with BCN as a PCP
–For PO-based arrangement, the PO must obtain an NPI and enroll with BCBSM. BCN will then load the
PO
–Affiliated clinicians identified as the Rendering Provider on PDCM claims must be registered in
connection with the PO entity
27
Billing and Documentation: General
Guidelines
•
The following general billing guidelines apply to PDCM services:
– Approved practices/POs only
– Professional claim
• 7 procedure codes
• PDCM may be billed with other medical services on the same claim
• PDCM may be billed on the same day as other physician services
• PDCM codes and T codes may not be billed for the same member
– No diagnostic restrictions
• All relevant diagnoses should be identified on the claim
– No location restrictions
– Documentation demonstrating services were necessary and delivered as
reported
– Documentation identifying lead CM isn’t required, but documentation
must be maintained in medical records identifying the provider for each
patient interaction
28
Code-Specific Requirements: G9001
Initiation of Care Management (Same as BCBSM)
G9001
•
•
•
•
•
•
Coordinated Care Fee, Initial Rate (per case)
Payable only when performed by an RN, MSW, CNP or PA with approved level of care
management training (i.e., lead care manager)
One assessment per patient per year
Contacts must add up to at least 30 minutes of discussion
Assessment should include:
– Identification of all active and chronic diagnoses
– Assessment of treatment regimens, medications, risk factors, unmet needs, etc.
– Care plan creation (issues, outcome goals, and planned interventions)
Billed claims must include:
– Date of service (date patient is “enrolled” in care management)
– All active diagnoses identified in the assessment process
Record documentation must additionally include:
– Dates, duration, name/credentials of care manager performing the service
– Formal indication of patient engagement/enrollment
– Physician coordination and agreement
29
Code-Specific Requirements: G9002
Individual, Face-to-Face Care Management Visit (Same as
BCBSM)
G9002
•
•
•
•
•
Coordinated Care Fee, Maintenance rate (per encounter)
Payable when performed by any qualified care management team member
No quantity limits
Encounters must:
– Be conducted in person
– Be a substantive, focused discussion pertinent to patient’s care plan
Claims reporting requirements:
– Each encounter should be billed on its own claim line
– All diagnoses relevant to the encounter should be reported
Record documentation must additionally include:
– Date, duration, name/credentials of team member performing the service
– Nature of discussion and pertinent details relevant to care plan (progress,
changes, etc.)
30
Code-Specific Requirements: 98961, 98962
Group Education & Training Visit
98961
Education and training for patient self-management for 2-4 patients, 30
minutes
98962
Education and training for patient self-management for 5-8 patients, 30
minutes
•
•
•
Payable when performed by any qualified care management team member
Current limit is 4 hours per day
Each session must:
– Be conducted in person
– Have at least two, but no more than eight patients present
– Include some level of individualized interaction
•
Claims reporting requirements:
–
–
–
–
•
Services should be separately billed for each individual patient
Code selection depends upon total number of patient participants in the session
Quantity depends upon length of session (reported in thirty minute increments)
All diagnoses relevant to the encounter should be reported
Additional documentation requirements:
– Dates, duration, name/credentials of care manager performing the service
– Nature of content/objectives, number of patients present
– Any updated status on patient’s condition, needs, progress
31
Code-Specific Requirements: 98966, 98967, 98968
Telephone-based Services
98966
98967
98968
•
•
•
Telephone assessment and management, 5-10 minutes
Telephone assessment and management, 11-20 minutes
Telephone assessment and management, 21+ minutes
Payable when performed by any qualified care management team member
No more than one per date of service (if multiple calls are made on the same day, the
times spent on each call should be combined and reported as a single call)
Each encounter must:
– Be conducted by phone
– Be at least 5 minutes in duration
– Include a substantive, focused discussion pertinent to patient’s care plan
•
Claims reporting requirements
– Code selection depends upon duration of phone call
– All diagnoses relevant to the encounter should be reported
•
Additional documentation requirements:
– Dates, duration, name/credentials of care manager performing the call
– Nature of the discussion and pertinent details regarding updates on patient’s condition,
needs, progress
32
QUESTIONS?
Contact: James H. Haskins IV
[email protected]
248-799-6314
Or
Regional Provider Affairs Director
33
34
Medicaid Update
Medicaid Attribution
• Medicaid managed care population only
• Attributed member:
▫ Medicaid beneficiary enrolled in a Medicaid
Health Plan AND
▫ assigned Primary Care Provider is affiliated with
participating practice/PO
Enrollee Lists
• Attribution process occurs on the first business day
of the month
• Medicaid enrollee lists submitted to Michigan Data
Collaborative (MDC)
• MDC will post enrollee lists on MDC secure site for
retrieval by PO
– Automated message from MIShare at UMHS
– [email protected]
– [email protected]
• PO responsible for transmitting enrollee lists to
practices
Payment Calculation
• Medicaid payments calculated as Per Member
Per Month (PMPM) based on monthly
attribution counts:
▫ $3.00 PMPM Care Coordination paid to PO
▫ $1.50 PMPM Practice Transformation paid to
Practice
▫ $3.00 variable payment based on performance
paid to PO
Provider Enrollment
Required for Payment
• PO’s will be enrolled as an MCO in CHAMPS
system by DCH.
• Practices must enroll as either an individual sole
proprietor or as a group in Medicaid CHAMPS
system.
• PO Enrollment questions:
[email protected]
• Provider Enrollment questions: 800-292-2550
Payment Timing
• Quarterly EFT payments appear as gross adjustment
• Reconcile payment amount with your enrollee list
• Payments released mid month after end of the
quarter
– April (QTR 1)
– July (QTR 2)
– October (QTR 3)
• Regularly check the Payment Update Tab on
MIPCTdemo.org for new/updated information
• Payment questions: [email protected]
40
Medicare Update
UMHS CMS Payment Processing and
Distribution to POs
• CMS does not have a mechanism to pay POs directly
•
To accommodate this, CMS sends individual line item remittances to UMHS (as they
did for practice transformation to the practices).
•
Though not ideal, CMS will not change their practice – thus UMHS must receive,
reconcile and then distribute payments
•
Work is underway and a front-end application has been built to:
- Reconcile claims with member lists
- Calculate PO payments
- Produce PO payment summary
• This will result in a payment delay for the first set of care coordination
payments. Goal is to distribute to POs by early June. Earlier if at all possible.
• Afterward UMHS will work to get on a regular cycle of payment distribution.