Provider Delivered Care Management: Frequently Asked Questions

Transcription

1 Provider Delivered Care Management: Frequently Asked Questions Table of Contents Table of Contents The Basics... 2 Patient Lists... 3 Training... 3 Billing and Coding... 4 Oncology... 9 Medicare Advantage Pediatric Practices Program Evaluation BlueHealthConnection Linkage to Interpretive Guidelines/PCMH Additional Information... 15

2 The Basics What is Provider Delivered Care Management? Provider Delivered Care Management enables patients to receive care management through the BlueHealthConnection benefit from a trained clinician care manager in the physician office. How did Provider Delivered Care Management start? Provider Delivered Care Management was piloted with over 250 providers across Michigan. The pilot started on April 1, 2010 and ended March 31, After the pilot ended, Provider Delivered Care Management became a program that is part of the Physician Group Incentive Program at Blue Cross Blue Shield of Michigan. Does Provider Delivered Care Management Work? Studies have found that care management delivered in-person, under the guidance of the patient s primary care physician, is highly effective. 1, 2 What is MiPCT? The Michigan Primary Care Transformation Project (MiPCT) is a three-year Center for Medicare and Medicaid Services (CMS) multipayer demonstration project to test the Patient-Centered Medical Home model. Who participates in MiPCT? Primary care providers who have been BCBSM Patient Centered Medical Home Designated for four years in a row (2010, 2011, 2012 and 2013), and who retain their PCMH designation for the duration of the demonstration project. The MiPCT-participating providers are the only providers eligible to bill for Provider Delivered Care Management Services.. How many providers participate in MiPCT? Approximately 400 practices representing nearly 1,700 providers across the state are participating in MiPCT. When did MiPCT begin? The MiPCT program began on January 1, 2012 Is there overlap between Provider Delivered Care Management and MiPCT? The terms Provider Delivered Care Management and MiPCT are synonymous for the purposes of the MiPCT pilot; when receiving information that says PDCM or Provider Delivered Care Management, know that it relates to the MiPCT program. 1 Brown, R. The promise of care coordination: Models that decrease hospitalization and improve outcomes for Medicare beneficiaries with chronic illness. (2009) 2 Sochalski J, Jaarsma T., Krumholz, HM, Laramee A, McMurray JJV, Naylor MD, Rich MW, Riegel B, Stewart S. What works in chronic care management: The case of heart failure. Health Affairs, 28(1),

3 Patient Lists What is the Patient List? The Monthly Patient List is what providers should use to verify patient eligibility for Provider Delivered Care Management. If a patient is included on the monthly list, practice unit staff can assume they are eligible to receive care management services. Patients with high-deductible health plan with an Health Savings Account will be flagged on the list and will need to meet their deductible amount before services will be covered. How do I obtain the patient list? Each month the Michigan Data Collaborative will provide Physician Organizations with a list of patients who are eligible for care management and are attributed to a MiPCT Physician based on BCBSM data. What should be done with the list once the PO receives it? Previously, physician organizations obtained the list from their Blue Cross Blue Shield of Michigan EDDI folders. In 2013, physician organizations are sent a single, all-payer patient list once per month from the Michigan Data Collaborative. For more information about the distribution process, please michigandatacollaborative@umich.edu. Once the list is received, it should be distributed to participating practices within 10 business days. What should the practices do with the patient list? Once POs have distributed the list of eligible patients to participating practices, the practices will review the list. The list will be used in conjunction with the provider s clinical information and knowledge of the patient to decide which patients should be offered care management. We encourage the practice to use either Web-DENIS or CAREN to check that the patient has active BCBSM coverage before delivering care; new for 2013, Web-DENIS or CAREN can also be used to check if a patient is eligible for Provider Delivered Care Management. Once a patient has been identified as eligible for care management, they can be contacted by phone or mail to set up appointments for in-person meetings at the office and real time follow up the same day for patients who are scheduled for an office visit.. What kind of information is on the list? The list includes information about patients health status and recent health care use, such as emergency department visits. Flags are also included, to indicate engagement with a BCBSM Case Manager, utilization of specialty pharmacy, and other information that may be helpful in determining whether outreach to a specific patient is appropriate. Training

4 What are the qualifications of the providers delivering care management? The providers delivering care management services are specially trained care managers and other clinical team members working under the direction of a physician. Where does the care manager work? The care manager works in the physician practice, or with the practice via their affiliated Physician Organization, to provide inperson and/or telephonic care management. Who trains the care managers at the providers office? The training for both Hybrid and Complex Care Managers is conducted by Master Trainers who are affiliated with the Michigan Care Management Resource Center at the University of Michigan. What types of training are available? Care Managers receive either Complex Care Management or Moderate-Risk Care Management Training, depending on which type of patients they are working with. All care managers are also required to complete a MiPCT-approved self-management training course. A list of approved courses is available at mipctdemo.wordpress.com. Educational opportunities, tools and resources are available please visit mipctdemo.wordpress.com and micmrc.org for more information. Billing and Coding What are the interventions for Provider Delivered Care Management? The interventions for Provider Delivered Care Management will be a combination of individual and group face-to-face visits, with some telephone follow-up. How do physician organizations ensure they can bill for Provider Delivered Care Management? Physician Organizations will need to obtain an NPI and register with Blue Cross Blue Shield of Michigan in order to bill for Provider Delivered Care Management. In addition, all physicians participating in Provider Delivered Care Management must also be registered with BCBSM. Who should I contact to get more information on enrollment? Please contact your BCBSM Provider Consultant at Blue Cross Blue Shield for more information on the enrollment and registration process.

5 Which kinds of practitioners can bill for Provider Delivered Care Management? Non-physician providers qualified to perform patient assessments and bill the initial patient evaluation code (G9001) are registered nurses, clinical licensed master s social workers, certified nurse practitioners and physician assistants. Non-physician providers who are qualified to bill all other care management codes are registered nurses, clinical licensed master s social workers, certified nurse practitioners, physician assistants, licensed practical nurses, certified diabetes educators, registered dieticians, master s of science-trained nutritionists, clinical pharmacists, respiratory therapists, certified asthma educators, certified health educator specialists (with a bachelor s degree or above in health education), licensed professional counselors and licensed mental health counselors. There are two categories of codes that can be billed for PDCM services: Codes to be billed for care management services delivered by the care management team Codes to be billed by and paid to physicians for care management activities that they perform The following chart summarizes the billable PDCM codes by who can bill for each service. Provider Type Service Care Manager Other Care Team Members Physician or Mid-level provider* Initial Assessment G G9008 Face-to-face Encounter G9002 ** Phone 98966, 98967, Group 98961, ** Team Conference -- G9007 Complex Care Coordination 99487, * This includes physicians and mid-level providers, such as CNPs and PAs, who are acting as the primary care provider. Mid-level providers will be reimbursed at 85% of the fee. **These encounters should be billed as E & M visits. Who is eligible to receive Provider Delivered Care Management services? Reimbursement for care management services will be available for patients who meet the following eligibility criteria: Active BCBSM coverage that includes the BlueHealthConnection program Employer that has opted into the Provider Delivered Care Management Program One or more conditions that indicate that care management services have the potential to improve patient well-being A referral for care management services from a physician, certified nurse practitioner or physician assistant in a participating Provider Delivered Care Management practice at which the patient has an established care relationship. Agree to actively participate in a Provider Delivered Care Management plan

6 What kinds of services are included in Provider Delivered Care Management? Provider Delivered Care Management will provide services to patients based on their conditions and level of need: for moderately complex patients, services will include goal-setting, self-management support, and care transitions. Services for medically complex patients will also include care coordination and comprehensive care planning. What is the reimbursement for Provider Delivered Care Management codes? You can view the fees paid to physicians (net of the physician organization component) for each of the care management codes in our fee schedules on web-denis. The dollar amounts listed reflect the amount indicated in the payment voucher BCBSM remits for each service. To view our fee schedules: Log in to web-denis. Click on BCBSM Provider Publications and Resources. Click on Entire Fee Schedules and Fee Changes. PDCM services are included among the codes subject to Fee Uplifts under BCBSM s Physician Patient Centered Medical Home (Exception: G9008 is not subject to the fee uplift). The actual maximum allowed amount payable to the provider shall be determined based upon the credentials and designation status of the individual provider that is identified as the Rendering Provider on the claim. Are there any specific criteria associated with the codes? G9001 (initial patient evaluation for moderate or complex patients). May be billed only once per year; may also encompass multiple visits, at least one of which must be face-to-face. G9002 (face to face follow-up visit for moderate or complex patients). May be billed more than once per year, on a separate claim line for each encounter. It is not a requirement that G9001 be billed first. There may be instances where a telephone call is made prior to completing the initial assessment (i.e. Care Transitions to Home). G9007 (coordinated care for scheduled team conference). Can be used to bill for scheduled face-to-face meetings between the primary care physician and the care manager to formally discuss a patient s care plan. Other team members, such as a pharmacist, dietician, mental health provider, etc., may also be present. G9008 (physician-coordinated care oversight services). Billable by the physician at the initiation of care management as an enrollment fee. 1. Differs from G9001 because G9001 is the comprehensive assessment conducted by the care manager with the patient prior to enrollment in care management (and annually thereafter). CPT codes 98961, 98962, 98966, 98967, (group education and telephone assessment for moderate or complex patients; may be billed more than once per year, on a separate claim line for each encounter). 1. Billing should take place for the total time per day per patient, and not each individual call. CPT codes and (complex chronic care coordination services). These codes may only be billed once per month 1. Billing should be for the total time per month per patient spent on care coordination with other providers or agencies

7 2. The duration of communication time must be at least 31 minutes in a calendar month to be billable is for the first minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month represents each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month. (This is an add-on code that should be reported only in conjunction with 99487) For more detailed information about billing guidelines for the PDCM codes, please refer to the PDCM Payment Policies document. Can providers continue to bill t-codes if they also bill g-codes? G-codes are intended to take the place of T-codes for patients who are attributed to MiPCT-participating providers. Providers should not bill Provider Delivered Care Management codes and T-codes for the same patient. Are there different codes for moderate versus complex patients? No. There are no differences in how a provider should bill for services for a moderate or complex patient. What criteria must the provided services meet in order to be payable? For Provider Delivered Care Management services to be payable by BCBSM, the services must be: Based on patient need and tied to patient care goals Ordered by a physician, physician assistant or certified nurse practitioner in a practice that has been approved to offer Provider Delivered Care Management (The practice must have an established relationship with the patient and be accountable for the clinical management of the patient.) Billed by the approved practice or physician organization responsible for the care management team, in accordance with BCBSM billing guidelines Performed by a qualified non-physician care management team member employed by or under contract with an approved Provider Delivered Care Management practice or its affiliated PO. Physicians will work with the qualified non-physician providers to ensure that patient care is integrated and well-coordinated. How is patient eligibility determined? Currently, BCBSM underwritten business is automatically included in Provider Delivered Care Management; Administrative Services Contract (ASC) groups pay their own claims, so they are not automatically included in the program, but have a choice about whether or not to participate. BCBSM Account Managers are reaching out to ASC groups to educate them about Provider Delivered Care Management. Who pays for Provider Delivered Care Management services?

8 Provider Delivered Care Management is included in the current administrative fee for underwritten employer groups that have BlueHealthConnection. For ASC (self-funded) groups, costs will be incurred based on claims submitted for eligible patients who receive services related to the Provider Delivered Care Management codes listed in this document. Please note that there will not be any out-of-pocket cost to patients for the care management services provided in the office; patients should therefore not be billed for services related to Provider Delivered Care Management. However, BCBSM is legally obligated to apply a cost share for patients who have a Qualified High Deductible Health Plan with a Health Savings Account and have not yet met their deductible amount. How is participation in Provider Delivered Care Management being recorded? The services must be ordered by a physician, physician assistant (PA) or Certified Nurse Practitioner (CNP) and there must be documentation in the patient record indicating that the patient has agreed to participate (in the Electronic Medical Record, patient record, visit note, et cetera). The same mechanism that practices use for documenting the patient-provider partnership may also be used for indicating participation in Provider Delivered Care Management. Can the reimbursement amount vary based on who bills the service? The reimbursement amount will vary based on whether the rendering field on the claim indicates the provider is a physician or a qualified non-physician provider, as well as whether the provider is a MiPCT PCMH designee. BCBSM will reject Provider Delivered Care Management claims, as provider liable, for patients who do not have coverage for these services. Is there a cost to patients for the services? There is no copayment or deductible cost to patients for the Provider Delivered Care Management services, so patients should not be billed for these services. However, if a patient has a high-deductible health plan with a Health Savings Account, you may bill the patient for the care management services as you would bill any other patient with a high-deductible health plan. How will I know if a patient is in a high-deductible health plan? To alert you to the presence of patients with a copay, patients with a high-deductible health plan will be flagged for high_deduct_plan on the monthly MiPCT patient list. However, we strongly recommend verifying with patients about whether or not they have this kind of plan, due to the manual nature of our data processes. If the patient has questions about their coverage, please advise them to call the number on the back of their BCBSM ID card. What should I do if I d like more information about billing and coding for Provider Delivered Care Management? Please access the billing guidelines, available at

9 Oncology When will the program be expanded to other provider specialties? The program is tentatively scheduled to launch to PGIP oncology PUs on November 1, Who will be eligible? Oncology practices that are currently participating in the Physician Group Incentive Program (PGIP) and are members of POs that participate in the Providered Delivered Care Management (PDCM) program. What are the eligibility requirements? PGIP oncology PUs that are interested in participating in PDCM must have access to an oncology nurse that has completed nurse care management training through the Care Management Resource Center (CMRC) and completed a CMRC-approved selfmanagement program. Additionally, each oncology PU must have 50% of the identified core PCMH-N capabilities fully in place including capability 5.1, 24/7 phone access to a clinical decision-maker. The following table lists all core PCMH-N capabilities. 2.0 Patient registry Capability 2.1 Capability 2.5 Capability Performance reporting Capability 3.4 Data validated 4.0 Individual care management Capability 4.1 PCMH training Capability 4.2 Capability 4.3 Capability 4.5 Capability 4.6 Capability 4.7 Capability 4.8 Capability 4.10 Capability 4.16 Capability Extended access Patient registry for all chemotherapy patients Attributed practitioner Patient demographics and clinical parameters Integrated team of multi-disciplinary providers Evidence-based care guidelines in use at point of care Action plan and self-management goal-setting Appointment tracking and reminders one chronic condition Follow-up for needed services one chronic condition Planned visits one chronic condition Medication review and management Advance care planning Palliative care

10 Capability 5.1 Capability 5.4 Capability hour access to a clinical decision-maker by phone with feedback loop within 24 hours All patients fully informed about after-hours care availability Practice unit has telephonic or other access to interpreters for all languages common to practice's established patients 13.0 Coordination of care Capability 13.1 Notified of each patient admission and discharge Capability 13.2 Process for coordinating information exchange with other providers Capability 13.3 Systematically track patients across all care settings Capability 13.4 Flags for time-sensitive health issues Capability 13.5 Transition plans Capability 13.6 Coordination of care for patients with complex/catastrophic conditions Capability 13.7 Coordination care process 14.0 Specialist referral process Capability 14.1 Defined parameters for referral process from PCPs Capability 14.2 Documented procedures for referral process Capability 14.3 Specialist directory Capability 14.5 Makes specialist appointments on behalf of patients Capability 14.7 Completion of referral by patient Capability 14.8 Staff training on referral process Capability Physician to physician pre-consultation How will BCBSM know which capabilities are fully in place for oncology practice units? With the roll out of the BCBSM PGIP Self Assessment Data tool August 2013, POs will be able to report the capabilities of each of their oncology PUs. Reporting of capabilities in August are based on those that went into effect 1/1/13 through 9/30/13. What procedure codes will oncologists bill for PDCM services? Please refer to the codes listed in the Billing and Coding section earlier in this document What training is required for PDCM-Oncology nurses? PDCM oncology nurses will be required to complete a nurse care management training session offered through the Care Management Resource Center (CMRC) and required to complete a CMRC-approved self-management program.

11 How will PDCM Oncology be evaluated? Although the evaluation plan for PDCM oncology is not yet complete, the following summarizes a preliminary outline: Track use of all PDCM codes Track use of S0257 for advanced care planning conversations (total volume and percent of members receiving the service) and evaluate patients that received one or more S0257 service and its impact on hospital deaths, chemotherapy use in the last two weeks of life, and IP use Exclude inpatient admissions for cancer care that is commonly rendered in an inpatient setting Review scheduled/planned vs unscheduled/unplanned IP stays Review data based on distance traveled for care (i.e., greater distances may result in hospital stays) Chemotherapy in the last 14 days of life when not used for palliative care purposes Symptom frequency and functional status Medicare Advantage Will the program work the same way for Medicare Advantage members as it does for patients covered under our commercial plans? If a patient is a BCBSM Medicare Advantage member with the BlueHealthConnection benefit, the patient is eligible to receive Provider Delivered Care Management services from an approved provider, and BCBSM will pay for these services. However, if a Medicare Advantage member is not eligible for these services, any Provider Delivered Care Management claims will be denied. What is the reimbursement for Medicare Advantage patients who receive Provider Delivered Care Management Services? You will be able to view the fees paid to physicians for each of the care management codes in our fee schedules on web-denis. The dollar amounts listed reflect the amount indicated in the payment voucher BCBSM remits for each service. To view our fee schedules: Log in to web-denis. Click on BCBSM Provider Publications and Resources. Click on Entire Fee Schedules and Fee Changes. Note: Medicare Advantage claims are not subject to the physician organization component or the additional evaluation and management fees. Therefore, the fees are slightly different than those of the commercial plan. Is there anything else I should know about G9001 for Medicare Advantage patients? G9001, the initial Provider Delivered Care Management visit, should include the following components for Medicare Advantage patients in order to be compliant with the Medicare Star program: Review of all active diagnoses with reporting back to BCBSM on the claim form

12 Functional assessment Review of all medications Urinary Incontinence screen Do the services provided differ for Medicare Advantage patients? It is expected that Medicare Advantage patients will receive an annual Wellness Visit (code G0438), and a comprehensive assessment if needed. The wellness visit (code G0438) is mandatory for MA patients for planning and preventive care purposes, regardless of whether the members are eligible for Provider Delivered Care Management services who are no longer within the first twelve months of their first Part B coverage period. It may be performed by qualified non-physician practitioners who are members of the health care team: a physician (doctor of medicine or osteopathy), physician assistant, nurse practitioner, clinical nurse specialist or other medical professional (including a health educator, a registered dietitian, nutrition professional, or other licensed practitioner), or a medical professional team working under the direct supervision of a physician (doctor of medicine or osteopathy). Note: The listing of eligible AWV providers is an update to the BCBSM Medicare Advantage Provider Delivered Care Management Billing Guidelines webinar presented on June 2012, in which we stated the AWV can only be offered by a physician. The comprehensive assessment (code G9001) is optional for MA patients. It is performed by a non-physician care manager to determine whether care management is appropriate for the patient CMS Initial Preventive Physical Exam and Annual Wellness Visit Frequently Asked Questions document contains a link to a quick reference documents for the AWV and defines: Who is eligible for AWV How to find out if a beneficiary has previously had o An AWV o When these services were performed Required elements of the exam Do all diagnosis codes need to be included when billing claims for Medicare Advantage patients (including acute illnesses, such as strep throat or sinus infections)? Yes Are all Medicare Advantage patients eligible for the comprehensive assessment, regardless of their eligibility for PDCM, or are they only eligible if they show up on the MiPCT patient lists? Only the patients who are on the monthly MiPCT patient list are eligible for the comprehensive assessment. Pediatric Practices If I work in a pediatric practice, is there anything I need to do differently?

13 The Michigan Care Management Resource Center works with a pediatrician in the state to develop training curriculum for care managers in pediatric practices. Educational opportunities, tools and resources are available please visit mipctdemo.wordpress.com and micmrc.org for more information. Does the child need to be present at their appointment? When evaluating pediatric patients, the child must attend at least a portion of the initial assessment, regardless of their age. Program Evaluation Are there any results from the Provider Delivered Care Management Pilot? Preliminary results of the two-year Provider Delivered Care Management pilot program show that patients were more likely to engage with a nurse care manager aligned with a practice. That means that they were more motivated to improve their health. Specifically: Between 40 and 50 percent of patients contacted about the program decided to participate. Each patient participating in the pilot had, on average, six to seven care management encounters. o The encounters were primarily in-person, but some were by telephone. The program had a positive impact on patient health, based on initial clinical indicators. When will additional results from the pilot be available? Researchers at Michigan State University are conducting a comparative effectiveness evaluation of the two-year pilot program under a grant from the Agency for HealthCare Research and Quality (AHRQ). Findings from that evaluation, along with early results of the expanded PDCM program, will be available in late How will Provider Delivered Care Management be evaluated? BCBSM will track patient experience in the program based on claims submitted by providers for care management/care coordination services. Reporting on program activity was available starting in 2012 on a limited basis; program results, including impact on use and cost, will be available in late What is BlueHealthConnection? BlueHealthConnection

14 BlueHealthConnection is Blue Cross Blue Shield of Michigan s suite of wellness and care management programs. The disease management piece of BlueHealthConnection focuses on adults with one or more of the five most common chronic conditions and provides primarily telephonic services. How does Provider Delivered Care Management differ from BlueHealthConnection? Provider Delivered Care Management is intended for anyone with a condition that would benefit from care management services, including children, and includes group and in-person interventions. Is there overlap between Provider Delivered Care Management and BlueHealthConnection? In some cases, individuals receiving care management through Provider Delivered Care Management may also receive care or case management services through BlueHealthConnection. These patients will be co-managed, and their Provider Delivered Care Management provider and BlueHealthConnection Case Manager will ensure that interventions are coordinated. How will I know if a patient is being co-managed? If a patient is already being managed by a BlueHealthConnection Case Manager, they will be flagged as bcbsm_cm or bcbsm_dm on the monthly MiPCT member list. If a patient is in Provider Delivered Care Management, can they still receive BlueHealthConnection services? Individuals who are engaged in Provider Delivered Care Management are still eligible to receive other BlueHealthConnection services, including wellness, Quit the Nic, and Complex Care Management. In addition, individuals who need extra-contractual benefits will receive services through BlueHealthConnection as they do today. Linkage to Interpretive Guidelines/PCMH How does Provider Delivered Care Management fit with Patient Centered Medical Homes? Provider Delivered Care Management is a core component of the Patient-Centered Medical Home model. What is the Patient Centered Medical Home Program? BCBSM s award-winning Patient Centered Medical Home (PCMH) program is a collaborative effort with physician organizations and providers across Michigan. Our program is the largest in the country, with approximately 6,700 Primary Care Physicians participating, of which over 3,000 are PCMH Designated. What is the goal of the Patient Centered Medical Home Program? The Patient Centered Medical Home Model transforms primary care practices in Michigan; providers focus on improving quality and patient care. Does the Patient Centered Medical Home Model Work?

15 A growing number of studies report that the PCMH model reduces inpatient admissions (16-40%) and emergency department use (29-50%). 3 In 2012, PGIP PCMH Designated providers had 24% fewer ambulatory care sensitive condition admissions compared to non-designated providers. What are the Interpretive Guidelines? The Interpretive Guidelines contain collaboratively developed, detailed information about how to implement over 130 Patient Centered Medical Home capabilities. The guidelines are available at Additional Information Where can I learn more? - This is the website for the Michigan Primary Care Transformation Project. You can sign up for care management training, link to the Care Management Resource Center, sign up for the weekly Flash s, obtain payment updates, and access all the latest information about the program. 3 Kevin Grumbach, MD, Paul Grundy, MD, MPH; Outcomes of Implementing Patient-Centered Medical Home Interventions: A Review of the Evidence From Prospective Evaluation Studies in the United States; Updated November 16, 2010