Provider Delivered Care Management: Frequently Asked Questions

1 Prepared by: Lisa Rajt, Senior Health Care Analyst Value Partnerships Program Date Submitted: 2/20/12 Date Revised: 10/8/12 Provider Delivered Car...
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Prepared by: Lisa Rajt, Senior Health Care Analyst Value Partnerships Program Date Submitted: 2/20/12 Date Revised: 10/8/12

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 Medicare Advantage ............................................................................................................................................................... 8 Pediatric Practices ................................................................................................................................................................... 9 Program Evaluation ................................................................................................................................................................ 9 BlueHealthConnection........................................................................................................................................................... 10 Linkage to Interpretive Guidelines/PCMH ............................................................................................................................. 11 Additional Information .......................................................................................................................................................... 11

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.

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Prepared by: Lisa Rajt, Senior Health Care Analyst Value Partnerships Program Date Submitted: 2/20/12 Date Revised: 10/8/12

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, 2012. 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 three years in a row (2010, 2011 and 2012), 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 in 2012. 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 2012; when receiving information that says “PDCM” or “Provider Delivered Care Management, know that it relates to the MiPCT program.

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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), 179-189.

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.

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Prepared by: Lisa Rajt, Senior Health Care Analyst Value Partnerships Program Date Submitted: 2/20/12 Date Revised: 10/8/12

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 plans 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 BCBSM will send Physician Organizations 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? Physician Organizations will obtain the list – which includes information on both commercial and Medicare Advantage members – from their EDDI folders once they receive an email from BCBSM indicating the list is available. The list should then be distributed to participating practices as soon as possible. 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, which uses data from the previous month, 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. Once a patient has been identified as being eligible for care management, they can be contacted by phone or mail to set up appointments for in-person meetings at the office. 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 What are the qualifications of the providers delivering care management?

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.

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Prepared by: Lisa Rajt, Senior Health Care Analyst Value Partnerships Program Date Submitted: 2/20/12 Date Revised: 10/8/12

The providers delivering care management services are specially trained care managers and other clinical team members 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.

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 the BCBSM Provider Consulting area at Blue Cross Blue Shield for more information on the enrollment and registration process. 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.

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.

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Prepared by: Lisa Rajt, Senior Health Care Analyst Value Partnerships Program Date Submitted: 2/20/12 Date Revised: 10/8/12

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. 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 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

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? The following chart shows the fees paid to physicians as of July 2012 (net of the physician organization component) — payable at 100 percent of our approved amount — for each of the care management codes. The dollar amounts listed reflect the amount indicated in the payment voucher BCBSM remits for each service. Code

Fee

G9001

$112.64

Coordinated Care Assessment (limited to one per year per pt)

G9002

$56.32

Coordinated Care Fee, maintenance rate

98961

$14.08

Face-to-face with the patient, each 30 minutes; 2-4 patients

98962

$10.46

Face-to-face with the patient, each 30 minutes; 5-8 patients

98966

$14.48

Phone: 5-10 minutes of medical discussion

98967

$27.81

Phone: 11-20 minutes of medical discussion

98968

$41.16

Phone: 21-30 minutes of medical discussion

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.

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Prepared by: Lisa Rajt, Senior Health Care Analyst Value Partnerships Program Date Submitted: 2/20/12 Date Revised: 10/8/12

Provider Delivered Care Management codes are among those subject to the enhanced compensation provisions of the Physician Group Incentive Program. For example, if the provider is a PCMH-designated physician — and therefore is eligible for an additional evaluation and management fee — the additional amount will be applied to our fee for the Provider Delivered Care Management service. 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). CPT codes 98961, 98962, 98966, 98967, 98968 (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. Please note that telephone calls with the patients’ caregiver, if they include a substantive, focused discussion pertinent to the patient’s care plan and goal achievement, warrants the reporting of 98966 or 98967, even if the patient was not directly spoken to during the encounter. 2. Please also note that phone calls to specialists and/or other health care facilities for the purposes of coordinating patient care are not billable at this time. Billing should take place for the total time per day per patient, and not each individual call.

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.

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.

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Prepared by: Lisa Rajt, Senior Health Care Analyst Value Partnerships Program Date Submitted: 2/20/12 Date Revised: 10/8/12

How is patient eligibility determined? Currently, BCBSM underwritten business is automatically included in Provider Delivered Care Management; ASC (self-funded) groups are excluded from the program, but have a choice about whether or not to participate. BCBSM Account Managers are reaching out to self-funded groups to educate them about Provider Delivered Care Management. Who pays for Provider Delivered Care Management services? 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?

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.

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Prepared by: Lisa Rajt, Senior Health Care Analyst Value Partnerships Program Date Submitted: 2/20/12 Date Revised: 10/8/12

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. 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 http://mipctdemo.wordpress.com/.

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? The amount paid for Provider Delivered Care Management services delivered to Medicare Advantage members, as of April 2012, is reflected in the chart below. Code

Fee

G9001

$129.37

G9002 98961 98962 98966 98967 98968

$64.69 $16.17 $12.02 $16.59 $31.93 $47.28

Coordinated Care Assessment (limited to one per year per pt) Coordinated Care Fee, maintenance rate Face-to-face with the patient, each 30 minutes; 2-4 patients Face-to-face with the patient, each 30 minutes; 5-8 patients Phone: 5-10 minutes of medical discussion Phone: 11-20 minutes of medical discussion Phone: 21-30 minutes of medical discussion

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  Functional assessment

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.

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Prepared by: Lisa Rajt, Senior Health Care Analyst Value Partnerships Program Date Submitted: 2/20/12 Date Revised: 10/8/12

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. It is performed by a physician for planning and preventive care purposes • 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 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? The Michigan Care Management Resource Center is currently working with a pediatrician in the state to develop a training curriculum for care managers in pediatric practices. Education – which will include separate breakout sessions at the MiPCT Care Manager training sessions - will begin in fall 2012. 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:

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Prepared by: Lisa Rajt, Senior Health Care Analyst Value Partnerships Program Date Submitted: 2/20/12 Date Revised: 10/8/12



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 2013. 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 will be available in 2012; program results, including impact on use and cost, will be available in 2013.

BlueHealthConnection What is BlueHealthConnection®? 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?

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.

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Prepared by: Lisa Rajt, Senior Health Care Analyst Value Partnerships Program Date Submitted: 2/20/12 Date Revised: 10/8/12

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? 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 each of the 130 Patient Centered Medical Home capabilities. The guidelines are available at www.bcbsm.com.

Additional Information Where can I learn more? http://mipctdemo.wordpress.com/ - 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 emails, 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

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.