Blue Cross Blue Shield of Michigan Medicare Plus Blue SM and BCN Advantage SM High Intensity Care Model

Transcription

1 Blue Cross Blue Shield of Michigan Medicare Plus Blue SM and BCN Advantage SM High Intensity Care Model Version 2.0 June 2015 Billing Frequently Asked Questions

2 High Intensity Care Model Billing Frequently Asked Questions Blue Cross Blue Shield of Michigan Medicare Plus Blue SM and BCN Advantage SM Patient participation and eligibility 1. Does BCN Advantage use the Provider Automated Response System (interactive voice response system) for providers to check contract eligibility? Yes 2. What is the eligibility period, and if a member is discharged from the program does HICM program authorization end? BCN has an authorization that will pay based on the target patient list and member add process (refer to applicable procedures). Authorization for BCN members participating in HICM is valid through the end of the calendar year, and it could be renewed again in January. If a member is discharged partway through the calendar year, the authorization remains open for the remainder of the calendar year. Authorization periods are not applicable to the Blue Cross Medicare Plus Blue process. 3. Will having an NP or PA deliver medical services in the home change the patient s attribution to the primary care physician (or regular doctor) and affect the patient s HICM eligibility? Nurse practitioners and physician assistants aren t included in the Physician Group Incentive Program attribution model. Patients are attributed to the primary care physician (or regular doctor) seen most recently within the past two years. If the patient is homebound and does not see his/her doctor in person for two years, as long as the NP or PA bills an in-home evaluation and management () code with the doctor as rendering provider, the patient will continue to be attributed to that doctor. 4. What needs to be documented for patient consent? Patient consent is ALWAYS required to participate in the HICM program. A practitioner must inform eligible patients of the availability of and obtain consent for the service before furnishing or billing any HICM service. You must document that the program has been explained and that the patient agreed to participate in the patient s medical record 2

3 Provider requirements and expectations 5. Do our currently employed care managers have to take the Geriatric Resources for Assessment and Care of Elders Training program? Only specific team members/practitioners must take GRACE Training. This includes the licensed Master Social Worker, the NP, PCP-care team supervisor, a PCP who conducts home visits, pharmacists, RN, RN coordinator and RN care manager. Registration for the upcoming GRACE training is currently open. Physician organizations coordinate these registrations. 6. Does the primary care physician or regular doctor also have to go through GRACE Training? No, but if a geriatrician is on the care team in the role of the PCP-care team supervisor or if he/she is conducting home visits, the geriatrician would need to attend GRACE Training. 7. What GRACE training is required for the lead physician (the PCP or geriatrician) who supervises the care management? The HICM geriatrician or PCP team lead (responsible for clinical supervision of the HICM team) must attend the first four hours of in-person GRACE training on the first day and view a one hour HICM billing webinar. Other PCPs (i.e., PCPs in a practice participating in the HICM program) can choose to participate in the introductory HICM one hour recorded webinar with CME credit and the one hour HICM billing webinar. Participation is voluntary for other PCPs. Payment methodology 7. We would like to offer additional services in the home. What procedures are billable and do copays and/or deductibles apply? The following services can be provided in the home: Blood glucose by glucometer Blood a1c by meter Urinanalysis (stick test) Pulse oximetry Peak flow Questions regarding medical and other services that are not specific to HICM should be directed to your provider consultant or Provider Inquiry. Such services could be subject to deductible, copay or coinsurance depending on the member s coverage. 3

4 8. What services don t have a copay, coinsurance or deductible? Only the care management procedure codes that are part of the HICM program do not have a copay, coinsurance or deductible. Specifically, G9001*, G9002*, G9007*, G9008*, 98961*, 98962*, 99487*, 99489*, 98966*, 98967*, 98968*, S0280*, S0281*, S0316*, and S0257*. If another procedure is billed on the same day as a HICM procedure code, it s subject to the member s deductible or coinsurance. 9. If the geriatrician sees the patient in the office, can they bill an E&M procedure? And, if so, will the patient have a copay for that visit? Yes. The patient would be responsible for the copay, coinsurance or deductible related to the E&M procedure and any additional tests that may have been performed as part of that E&M evaluation. 10. Are there any Blue Cross or BCN Medicare Advantage members who have a high deductible health plan with a health savings account where cost-share would apply? No, due to federal regulations, Medicare beneficiaries aren t eligible to enroll in a HDHP with an HSA. As a result, Blue Cross and BCN Medicare Advantage members aren t eligible for a HDHP with a HSA. 11. The GRACE model has a two-person approach with two clinicians delivering care. If there are two practitioners delivering care in the home, for example, and they are both simultaneously working, can they bill quantity of four? No, only a quantity of two should be billed. Diagnosis capture 12. What are the requirements for ensuring the diagnosis capture meets the Centers for Medicare & Medicaid Services criteria? Diagnoses must be made by a physician, nurse practitioner, or physician assistant, and documented in a medical record that was based on a face-to-face health service encounter between a patient and a healthcare provider. If the provider is making a new diagnosis, he/she can bill either comprehensive assessment code G9001 or S0280. If the physician will treat and manage the new diagnosis, use an E&M code for billing. During medical record review, the certified coder will check for the following: The service was provided by an acceptable risk adjustment provider type and physician specialty 4

5 A provider signature and credentials for each note Acceptable documentation based on documentation guidance Diagnoses supported by medical record documentation 13. If the certified nurse practitioner was in the office and captures a new diagnosis, should he/she bill under the physicians NPI or their own? The CNP can bill for new diagnosis codes, but the encounter will be under the CNP rate of 85 percent reimbursement. The patient will not have a copay as long as it is billed with a HICM procedure code. 14. Are there any HICM procedure codes that don t qualify for diagnosis capture? No. However, all billing is subject to CMS audit and the medical record must sufficiently support the diagnosis (the medical record is the source of truth). The diagnosis captured must be signed by a physician, PA, or CNP. Others could recommend diagnoses, but it must be signed by those listed. For more information, please consult current CMS billing guidelines at cms.gov regarding risk adjustment. 15. Can NP bill for HICM visits, regardless of location of service? If the NP is the rendering practitioner, using his/her NPI or billing PIN, will be reimbursed at 85 percent regardless of location of service. General HICM billing guidelines 16. Can a NP bill directly under the physician s NPI or can/should they bill under their own NPI? Nurse practitioners can bill for HICM services under the physician s NPI in the home or office locations. However, if the NP makes a new diagnosis in a home location not previously documented in the medical records, then the NP needs to bill directly using his/her own NPI. 17. When a nurse practitioner conducts the comprehensive care management assessment in the home, should they bill a medical house call (E&M code) and G9001*/S0280*? No. Only G9001*/S0280* should be billed for the HICM comprehensive care management assessment. An E&M code should only be billed if a medical issue arises, medical services are provided and the requirements for billing an E&M (separate from care management services) are met. 5

6 18. Is there a place of service modifier for G9001* and G9002* when services are rendered in the home? Effective April 1, 2015, we added two new codes for in-person care management interactions in the home. This allows us to pay a higher fee for home-based services. S0280* will be for home-based comprehensive care management assessment. All G9001* rules will apply to S0280*. S0281* will be for home-based care management services. All G9002* rules will apply to S0281*. 19. If more than one HICM care team member conducts a comprehensive care management assessment, can they both bill G9001*/S0280*? No. G9001*/S0280* can be billed only once per patient per year for assessments conducted for the HICM program. Both care team members may contribute to the assessment but it should be billed only once. If the patient gets reattributed to a new PCP, a new assessment can be conducted. 20. If a patient refuses a home visit, is it appropriate to bill a G9001 for an outpatient visit? Yes. 21. If the patient who initially refused the home visit was billed as a G9001 and now consents to a home visit, can I bill a S0280? No, only one G9001/S0280 is allowed per patient per calendar year. 22. If more than one HICM care team member delivers care management services on the same day, can they both bill G9002*/S0281*? Yes, each care team member can bill G9002*/S0281* for the time they spend delivering care management services to the patient. If the total time spent by one or more team members exceeds 45 minutes, on the same date, to the same patient, the provider should quantity bill this procedure code. 23. For procedure code G9001*/S0280*, does this go by calendar year or date of service? Bill this code based on calendar year. 24. Can a limited license MSW perform G9001*/S0280*? No, only a fully licensed MSW is eligible to perform and bill the G9001*/S0280*. 6

7 25. When a comprehensive assessment is completed, do I have to include the entire care plan in the medical record or EMR or some other method accessible to the primary care physician/care team members? Yes. 26. Can I bill procedure code G9002* on the same day as G9001*? G9002* can be billed if the billing guidelines for the code are met. This means that care management services related to the care plan are delivered in a face-to-face encounter with the patient. We don t expect this to be a common occurrence. 27. For procedure code G9002*, if you bill a quantity, does the amount you get reimbursed change? Yes, your quantity will determine the reimbursement amount. 28. Can the physician bill G9007* for time spent conferring with the HICM care team by phone? Yes, if the care management for the patient is taking place primarily in the home, and the phone conversation (or Skype or FaceTime conversation) between the physician and the HICM care team is substantive and focused on discussing the patient s care plan. is not acceptable for G Is G9007 limited to 10 minutes? No, there is no minimum time limit for the G Can both the patient s primary care physician (or regular doctor) and the HICM supervising geriatrician bill G9007* for time spent conferring with the HICM care team? Yes. 31. Can both the patient s primary care physician (or regular doctor) and the HICM supervising geriatrician bill G9008* for physician-coordinated care? No, only the primary care physician (or regular doctor) can bill G9008* and there must be a face-toface component with the patient to be payable. 7

8 32. For procedure codes G9007* and G9008*, can the care manager submit the claim with the rendering physician s NPI? Yes, the care manager may submit the claim on behalf of the physician. 33. Is BCN Advantage now reimbursing procedure code S0257*? Yes, it is only payable for HICM by BCN Advantage. 34. Can we bill 99487*/99489* for each team member in a GRACE Team conference? No. These codes should only be used only for work done within the medical neighborhood working with other providers and/or community agencies. 35. Can we bill a telephone code for outreach? No. Telephone codes (98966*, 98967*, 98968*) should NOT be billed for outreach or leaving messages. They should only be used for care management activities. 36. How does hospice affect ongoing HICM participation? Can we provide ongoing services once hospice starts? Can we bill for coordination and patient support? Once hospice starts, you should transition the patient to hospice and stop billing for HICM care management services. For billing questions: Blue Cross Blue Shield of Michigan Medicare Plus Blue, please submit an issue through the PGIP Collaboration Site or send an to ValuePartnerships@bcbsm.com. BCN Advantage practices with questions should contact their provider consultants. For Provider Organizations with questions, please contact your PO consultant. 8