1. Michigan Primary Care
Transformation
Demonstration Project
March 7, 2012
Webinar #2

2. Agenda
 Patient Identification
 Patient Eligibility
 Funding
 Care Management Training
 PDCM Policy Design
 General Conditions of Program Delivery
 Billing Guidelines
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3. Patient Identification and
Eligibility
 Attributed
 Assigned
 All patients and all payers
 Begin to build patient file
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4. Practice Transformation, Care
Manager and P4P Payments
 Medicare
 Medicaid
 Blue Cross
 Blue Care Network
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5. MiPCT Meetings
 March 20, 2012 (9am-12noon or 5pm-8pm)
 March 28, 2012 (9am-3pm)
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6. Care Manager Training
 Moderate Care Manager
• Self Management Training
• Completed by June 30, 2012
• Approved learning organization that provides
Certificate or CEU
 Complex Care Manager
• Geisinger Model Training
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7. Care Manager Training
Classroom
 25 hour curriculum
• Pre-work
• Care Manager Project
 Options
• Group Orientation: March 27 or 29 (9am – 12noon)
• April 7, 14, 21, 28
• May 5, 12, 19, June 2
• April 3, 10, 24, May 1, 8, 15, 22, 29, June 5, 12, 19
• April 5, 12, 19, 26, May 3, 10, 17, 24, 31, June 7, 14
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8. Care Manager Training
Virtual
 25 hour curriculum
• Pre-work
• Care Manager Project
 Options
• Group Orientation: March 27, 28 or 29 (9am – 12noon)
• Web based interactive
•April 2, 9, 16, 23, 30, May 7, 14, 21, June 4, 11
•April 4, 11, 18, 25, May 2, 9, 16, 23, 30, June 6
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9. Care Manager
Final Assessment
 Two hour final assessment
 June 7, 8, 9, 10 or 17 (9am-10am or 6pm-8pm)
 Morning or evening meeting
 Enrollment dependent
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10. Care Manager Assignment
 Care Managers available
• Dawn Carroll**
• Dawn D’Allesandro
• Margaret Kucinski**
• Deb Kobayashi
• Ilene Latasiewicz
• Kim Roberts (Pediatrics Only)
• Angie Siegmon
• Deb Slocum
• Pam Vaccarelli
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11. PDCM Payment Policy
 7 codes for services performed by qualified non-
physician practitioners
 Payable to approved providers only
 BCBSM will pay the lesser of provider charges or
BCBSM’s maximum fee
•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
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12. PDCM Payment Policy Design
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
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13. 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
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14. General Conditions of Payment
 For billed services to be payable, the following
conditions apply:
•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
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15. 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 (further detail
forthcoming)
Services billed for non-eligible members will be rejected with provider liability.
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16. Patient Eligibility
 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 participant in the
care plan
Services billed for non-eligible members will be rejected with provider liability.
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17. Patient 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.
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18. 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 professiona
•LPN, CDE, RD, nutritionist, clinical pharmacist, respiratory therapist,
certified asthma educator, certified health educator specialist
(bachelor’s degree or higher), licensed professional counselor, licensed
mental health counselor, certified health educator specialist (bachelor’s
degree or higher), licensed professional counselor, licensed mental
health counselor
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19. Provider Requirements: Care
Management Team
 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
Only lead care managers may perform the initial assessment services
(G9001)
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20. Provider Requirements: Billing
and Rendering Provider
Rendering Billing
Provider Provider
Practice-based Physician, CNP or PA within the Physician practice
PDCM-approved practice
Physician Organization-based PO-based billing entity
• 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
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21. 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
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22. Billing and Documentation:
General Guidelines
• 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
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23. 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.
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24. Individual, Face-to-Face 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.)
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25. 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
 No quantity limits
 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
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26. Telephone-based Services
98966 Telephone assessment and management, 5-10 minutes
98967 Telephone assessment and management, 11-20 minutes
98968 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
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27. Comments
Issues
in 3 x 5
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