MiPCT/PDCMBilling Road Show

July 2013

Agenda

MiPCT/PDCM Procedure Codes Why should I bill G/CPT Codes? Case Studies Quiz Patient List Blue Care Network What is a typical day for a Care Manager? Resources Questions Break Out Time

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MiPCT/PDCM Procedure Codes

Effective 4/1/2012G9001 - Initiation of Care Management (Comprehensive Assessment)G9002 - Individual Face-to-Face Visit98961 - Education and training for patient self-management for 2–4 patients; 30 minutes98961 - Education and training for patient self-management for 5–8 patients; 30 minutes98966 – 5-10 minutes of medical discussion98967 – 11-20 minutes of medical discussion98968 – 21-30 minutes of medical discussion

Effective 4/1/201399487 - First hour of clinical staff time directed by a physician or otherqualified health care professional with no face-to-face visit, per calendar month.99489 - Each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month. (An add-on code that should be reported in conjunction with 99487)G9007 - Coordinated care fee, scheduled team conferenceG9008 - Physician Coordinated Care Oversight Services (Enrollment Fee)

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Why should we bill G/CPT Codes?

• Instrumental to the success of MiPCT/PDCM and the CMS demo overall (Michigan has the largest number of members participating in the demo nationally)

• We need to be able to show customers that PDCM has high engagement rates

• We need a large enough “n” to have a successful evaluation • Long-term viability of PDCM

– If we are successful in MiPCT, more customers will join the program– If we can’t demonstrate impact and value to customers, PDCM program will

end• G/CPT codes are the BCBSM mechanism for paying for PDCM (make-

whole payments were intended to be for start-up, and will not be paid to POs whose practices are not engaging BCBSM members and billing G/CPT codes)

• Comparative report that shows year-to-date G/CPT code BCBSM billing volume at a summary level for all Physician Organizations in MiPCT is now available.

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SPECIAL NOTE

• PGIP philosophy is that PCMH infrastructure and care processes should be implemented for all patients– But payable services can only be provided to patients who

have the benefit– PDCM is a payable service and should NOT be provided to

patients who do not have the benefit– Delivering PDCM to patients who do not have the benefit will

contaminate the control group and distort the evaluation results• If the evaluation doesn’t find a difference between patients with the

PDCM benefit and those without, the PDCM program will not continue

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MiPCT Care Management - Case Presentations

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Case 1

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Case 1: Care Manager Post Hospital Follow-up

• 59 year old male s/p digit amputation, discharged from hospital– Other Diagnoses: Diabetes, HTN, Hyperlipidemia, Neuropathy

• Pre-assessment– Right foot dressing, not weight bearing – I/D consult in the hospital– Appears that no changes in medications were made in the hospital– MRSA on inpatient culture (pending results at DC)– A1C 6.2; LDL 98 BP: 132/78

• Care giver support – At time of discharge lives with wife, who has macular degeneration and DM– Unemployed, not working due to foot ulcer

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Care Manager - First Office Visit with Patient

CM completes office visit with patient and wife

Medication reconciliation:Patient brought in all pills to visit. He reports taking Bactrim for wound infection.

Medication reconciliation identified patient on Bactrim without known reason- not clear on discharge plan

Care Coordination:– I/D specialty appointment in mid April– Questions on his follow-up visits

Self Management Support:– Patient questions on control ranges– Patient self-regulating Lantus doses based on

his HS blood sugars

• Patient agrees to participate in care management

• This office visit contributes to

G9001

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Care Manager Office Visit (cont.)

Risk Assessment– Patient and wife report inability

to “see” the wound and are uncomfortable with wound changes.

– Fear of wound not healing and their skill in managing the wound care

Depression Assessment– PHQ2 negative

• Patient agrees to participate in care management (20 min)

• This office visit contributes to G9001

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Day 1 Care Coordination – Closing the Gap

CCM reviews inpatient hospital stay information and discharge plan directly in record

Determines that Bactrim doses will be out on Saturday, and pt. lab report show MRSA—unknown to I/D, Hospitalist and PCP as culture report was not available at time of discharge

Contacts I/D specialist to obtain an earlier appointment—patient not set to go until 3 weeks later

Speaks with I/D directly and receives refill on Bactrim and appointment for upcoming Monday

Sets up homecare to monitor wound at home (not in place at DC). Wife not able to do dressing changes due to macular degeneration

Speaks directly with Home Health Agency RN, reviewed history, meds and treatment plan

Care Coordination time with medical neighborhood:

60 min - Bill 99487 (at end of the month)

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Week 1 - Care Manager Phone Visit

Self Management Support

• Addressed patient and spouse concern regarding wound care

•Education and teach back of ranges of blood sugar

•Educated on contacting office for medication adjustment for blood sugar out of range

•Follow-up phone scheduled for the following week

•Assessment completed, self management goal agreed upon

• Check Blood sugar daily, record results

Completion of Comprehensive Assessment (30 min) - Bill G9001

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Week 1: Care Manager follow-up call

CCM conducts first weekly phone visit with patient

– Patient states he is doing better, still not ambulating.

– Worried about getting his medications as he is not able to drive and he is due for refills.

– Homecare nurse has been out and visits are every 2 days—wound healing nicely.

– Contacted I/D specialist to review treatment plan, ongoing ABX. Reinforced this plan with the patient.

– Still has questions about his meal planning and the best foods for he and his wife.

– Mentions he has some swelling in his legs.

Phone visit with patient 20 min - Bill 98967

Care Coordination with medical neighborhood – 20 min (need to track total Care Coordination minutes (60 min + 20 min) – 99489

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Week 2: Care Manager Phone Visit, Care Coordination

Ongoing Care Coordination

• More in--depth history on swelling.

• Contacted Homecare to coordinate plan of care– arrange for collaborative call at the time of the home

visit to review findings and discuss necessary treatment changes.

• Contacted pharmacy– Arranged for home delivery of refills.

• Contacted dietician– Arranged for phone education to support

healthier food choices.

Care Coordination: Day 1 = 60 minWeek 1 = 20 minWeek 2= 30 minTotal cumulative time Care Coordination = 110 minutes. Now able to quantity bill 99489.

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Week 2: Care Manager Phone Visit (cont.)

Follow up phone visit– medication reconciliation

• Reviewed with patient current diuretic meds and dosing.

– assess swelling– assess wound healing– progress of self

management goal

Phone visit 10 min Bill 98966

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Case 2

Case 2: Transition of Care - Post Hospital Discharge

• 65 year old woman history of breast cancer 25 years ago• Admitted to hospital after a syncopal episode at church • Suffered skull and finger fracture• During hospital course patient was found to have severe Mitral

Regurgitation and under went heart catheterization

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Transition of Care – 24 hr. Post Hospital Care Manager Phone visit

Care manager reviews hospital discharge summary

– Post discharge phone call made within 24 hours post discharge

• Patient’s concern identified– pressure dressing in place with

no patient instructions– patient is confused about how to

take her medications

• Assessment• Provide education

– after hours access to PCP practice

– wound care – HHA Care Manager will assist

– Red flags – shortness of breath, weight gain, dizziness, fever, redness/swelling around wound

Phone visit is 20 min = Bill 98967

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Transition of Care

• Care Manager actions (cont.)– Completed medication reconciliation

• Patient has a new prescription for Toprol but did not start to take this medication

– Contact daughter who is able to pick up from pharmacy and bring to patient

– Verified that patient received oxygen and understood use and care of oxygen

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Transition of Care

• Care Manager actions 24 post hospital visit: – Coordination of care

• Referral for home care visit that day

• Spoke directly with Home Health Agency Care Manager

– shared phone visit assessment findings, patient’s concern

– Follow up call with HHA RN• Discussed HHA RN visit plan (i.e.

wound, med rec, patient education, and patient to take daily weights)

• HHA RN visit is scheduled weekly

– Verified that patient had follow up appointments with PCP, cardiothoracic surgeon

Care Coordination = 20 minutes (need to track cumulative care coordination minutes) Do not bill for Care coordination at this time.NOTE: when total Care Coordination adds up to 31 minutes you may bill 99487 (at end of the month).

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Transition of Care: Day 2 Follow up Phone visit

• Care Manager actions:– Follow up phone visit two days

post discharge

– Medication reconciliation

– Assess weight, HF symptoms, wound healing

• Patient’s weight is stable, no swelling, no shortness of breath

– Then weekly times 4 phone visits

– Verified PCP appointment day 3 post hospitalization, will see Care Manager face to face same day

Phone visit 10 min = Bill 98966

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Case 3

Case 3: Moderate Care Management Ms. H

• 53 yr. old female• History:

– diagnosed at age 11 yrs. with “chronic bronchitis”

– persistent asthma

– asthma exacerbation

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Ms. H – First Care Manager phone visit

• Care Manager phone visit– Ms. H was not convinced

that she “needed” asthma education

• Approach: Respect Ms. H’s current knowledge about her asthma

• Patient agrees to participate in care management

Patient agrees to participate in Care Management.Phone visit 10 minutes – this will be added toward the G 9001

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Ms. H – Care manager face to face visit

• Face to Face CM visit – Patient’s peak flow 250

– Discuss • triggers – mold, cold weather • current use of medications patient uses inhaled corticosteroid PRN and also

uses albuterol PRN• Patient completes Asthma Control test – result 6/25

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Asthma Control Test

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Ms. H: Care Manager face to face visit

• Assessment completed• Education: purpose of controller

inhaler and importance of daily use• Visual Tools

– Poster of controller and rescue inhalers

– Asthma Booklet - Normal airway, inflamed airway, airway under attack

• Reference tool• Patient’s peak flow was 250 • looked up predicted peak

flow based on ht and age = 430

• Self management goal: Patient will compete the peak flow and record result 3 to 4 days in the next week

Face to Face Care Management visit 20 minutes (20 minute face to face and the 10 minute phone visit = 30 minutes: Bill G9001

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Ms. H – Follow up Phone Visits

CM phone visit week 1– Tools, self management goals, home

work for Patient:• Asthma Action Plan• Revisit Self management goal:

Patient will compete the peak flow and record result 3 to 4 days in the next week

CM phone visit week 2– Discuss Peak Flows (range, look at

several days)– After 2 weeks patient’s peak flow = 420

(improved!)– Discuss use of medications– Patient reports marked improvement!!– Follow up phone visit in 2 weeks agreed

upon

Week 1 Phone visit 20 minutes - Bill 98967. Week 2 Phone visit: 14 minutes - Bill 98967

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Case 4

Case 4: Moderate Care Management: Mr. J

• 50 yr. old male, married, 3 children, occupation – cement truck driver

• Ht. 5’9”, wt. 337 lbs.• Diagnoses: Diabetes, HTN, Hyperlipidemia, Morbid

obesity• Medications: metformin, glipizide, lisinopril-HCTZ,

simvastatin and actos• Labs: HgA1c 9.9, T Cholesterol 152, Trig. 81, HDL 37,

LDL 99• BP 125/70

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J’s First Care Manager visit – Face to Face

Care Manager heard patient’s concern • Patient’s goal: Lose weight• J has a large ventral hernia

• surgeon advised patient to lose weight • currently not a candidate for surgery due to weight

•Patient agrees to participate in care management

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J’s First Care Manager visit – Face to Face

• Assessment, individualized plan of care, patient’s self-management goal

– exercise at least one hour everyday after work

• Identified preferred method of visits and frequency of follow up

• Plan: monthly phone call visit by Care Manager (monthly phone visits x 3 completed) – address self management goal, barriers, solutions

Face to face visit with Care manager 40 minutes, Bill G9001

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J’s PCP visit

• 28 lb. weight loss over 3 mos. period• BP 124/70, hgA1c 6.5 (3 mos. prior hgA1c 9.9 )• Assessment

– significant lifestyle modifications leading to wt. loss

– vast improvement in DM and HTN

– discontinue Actos

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J’s Barriers and Plan of Care

Barrier Actions

Weight loss plateau Dietary modifications, Care manager placed referral to dietician

Getting through social events, Holidays etc.

Drink water before going to the parties, smaller portions of sweets

Knee pain Started Physical Therapy (PT), Care Manager discussed with PCP and placed referral for PT

Decreased motivation—not working much—after work habit changed, loss of exercise buddy

Develop a new routine, Find a buddy. Care Manager discussed with J – “what would work for him?”

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Care Manager interventions

• Care Manager phone visit 1 with patient– Discuss with patient to explore

patient’s ability and willingness to follow up with PT, Dietician

– Follow up on self management goal, modify self management goal

• Coordination of care - Referral to PT, Dietician

• Discuss case with PCP.

Care Management Phone visit – 15 minutes, Bill 98967Care Coordination- 35 minutes, Bill 99487

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Team Conference – Bill G9007

Once a Month Care Management Phone visits: J’s - Accomplishments

•50 pound weight loss over 12 months

•HgA1C down to 6 from 9.9

• Two medications discontinued: Actos, HCTZ

Care Manager phone visits, once per month, each visit ranges 8 to 10 minutes: Bill 98966

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J’s Current Status

• Gained “back” some weight• Still struggling but remains motivated• Care Manager phone visits “help more than you know”

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Quiz

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Answers to Quiz

1. I can render care management services to any BCBSM, BCN, or Medicare Advantage member. False

2. Medical Assistants can serve as Care Managers. False3. I should contact Michigan Data Collaborative (MDC) if I have questions about the

Patient List. True4. The patient list is the only place I need to check eligibility, for members of a High

Deductible Health Plans with Health Savings Account. False5. My Physician indicates a patient needs care management; however, the patient

is not on the patient list. It is still appropriate to render the service. False6. There is no cost to patients for care management. False7. Procedure codes G9001 (Initiation of Care Management) and 99487 (First hour

of clinical staff time…) may be billed more than once. False8. Once I receive the patient list, there is nothing further I need to do. False9. I can bill a telephone assessment (98966-98968) before a G9001 (Initiation of

Care Management) or G9002 (Face to Face Care Management). True10. I can bill G9001 (Initiation of Care Management) without a face to face visit and

the completion of the assessment. False11. I should bill all active diagnoses on every claim. True

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All Payer Patient List

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All-Payer Patient Lists

• Available on the MDC MiPCT Dashboards– On the Download PO Reports tab

• Distribution: Monthly– Target release date is the 3rd week of each month (dependent upon

data availability)

– Notifications:• Email announcement to dashboard users• Notice on the MDC Website (What’s New section)• Notice in the MiPCT FLASH newsletter

• BCBSM Medicare Advantage Patient List available in a separate file– Uses same file layout as the All-Payer Patient List

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All-Payer Patient Lists

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•See All-Payer Patient List Information document on the MDC Website Support page•https://www.michigandatacollaborative.org/MDC/#/support

•Provides details of the content in each month’s files:

•Also Includes attribution assignment schedules and a list of available data fields

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

BCN MiPCT PDCM Billing

James H. Haskins IV, MPH

Administrative Manager Clinical Affairs

Blue Care Network

BCN Eligible Members

• While BCN offers multiple products, only the commercial underwritten population is eligible for PDCM service– Self-funded customers must agree to participate

– Currently, one customer has agreed to participate and another customer will be joining this month

• BCN members belonging to an other product are not eligible– These members are not appearing on the patient list

– The claims will deny and BCN data shows over 1000 claims for these products have been billed since April 1, 2012

• BCN Medicare Advantage HMO-POS• Blue Cross Complete (Medicaid)• BCN 65 (Medicare Supplemental)

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BCN Clinical Edits

• BCN has diverged slightly from BCBSM for billing guidelines on these codes

• Any procedure code that includes a global post-surgery follow up, the PDCM service will deny

• For the phone calls, 98966-98968, the codes contain language about the service being within 7 days– So if the date of service on this code is less than 7 days from the

previously billed code, the claim will deny

– 98966 billed with date of service 7/1 pays, 98967 billed with date of service 7/7 will deny

– 98966 billed with date of service 7/1 pays, 98967 billed with date of service 7/9 will pay

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BCN System Challenges: Right Now

• BCN has recently run a denied claims report and we have discovered some claims that probably should have paid

• The claims system was denying for services rendered in the outpatient hospital setting (location 22)

• As an HMO, everything is structured around the member’s assigned PCP– PDCM services are denying when billed by a PCP who is not the

member’s PCP

– BCN is evaluating how to fix this issue

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Care Manager Typical Day

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MDC: Sample Report Member List

• Physician Level attribution list, by Practice• Includes information on Risk Scores, Visits, and Conditions

Member Information

NameDOBAge

Age GroupGenderPayer

Attribution Information

PhysicianPractice

PO

Risk Score

Risk ScoreRisk Group

VisitCounts

# Inp. Visits# Readmits# PC visits

# Care Coord. Encounters# Maint. Rx Scripts

ChronicConditions

AsthmaCOPDCHFCAD

DiabetesHTN

ADHDCKD

Obesity48

Care Management - Building a Patient Case load

• Care manager and PCP review MiPCT list sorted by risk and payer– Target moderate and complex

patients that are in need of care (based on medical record review and CM/PCP clinical judgment)

– Recent hospital/ED discharges (and other high risk transitions)

– Just-in-time office visits

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MiPCT Patient Lists – Key Steps

–New potential patients• Review reports and identify patients with high ER utilization,

inpatient stays, complexity, …• Meet with PCP to determine if identified patients are

moderate or complex and would benefit from Care Management

–Current patient’s already enrolled in Care manager’s caseload• Review pharmacy, ER visit, hospitalizations (will have this

data starting 4/13)

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PO distributes MiPCT patient list to Care Managers

Care Management Patient Screening - MiPCT Patient List

REFERRAL/ SCREENING

ENROLLMENT/ ENGAGEMENT

MANAGEMENT/INTERVENTION

CLOSURE (as appropriate)

Review patients scheduled the next day for PCP visit

Admit/discharge notifications for

transition of care calls

Yes = identify patient is eligible

for G9001

Discuss with PCP : Is patient

recommended for care management?

PCP, team referralCompare to

MiPCT member list; assess

appropriateness

Outreach with patient (visit,

phone)

Assess, develop care plan, implement

interventions, monitor and

update care plan

Submit G CPT code billing if appropriate

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CCM / HCM/MCM Role - Building a Patient Caseload

* Note: patient selection is made in partnership with the physician52

MiPCT Dashboards

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PopulationMembership•Attributed members by PayerRisk Information•# of members by Risk LevelPopulation Information•# patients by Chronic Condition (Asthma, CKD, CHF, etc)

Quality MeasuresScreening and Test Rates •Diabetes tests, Cancer Screens, etcPrevention•Immunization Rates, Wellness Visits, etc.Comparison to Benchmarks

Utilization Measures (avail in Jan. ‘13)

Rates •ED Use, Admissions, Re-admissions, etcComparison to Benchmarks

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PLEASE REMEMBER

– Payable services can only be provided to patients who have the benefit

– PDCM is a payable service and should NOT be provided to patients who do not have the benefit

– Delivering PDCM to patients who do not have the benefit will contaminate the control group and distort the evaluation results

• If the evaluation doesn’t find a difference between patients with the PDCM benefit and those without, the PDCM program will not continue

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Patient List – michigandatacollaborative@med.umich.edu

Claims and Billing – log an issue through PGIP Collaboration Site or mipctdemo@michigan.gov

Clinical – mipctdemo@michigan.gov

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Where do I send questions?

Resource Packet

• MiPCT/PDCM Billing Road Show Slide Deck

• MiPCT/PDCM Quiz• PDCM Payment Policy & Billing

Guidelines for Medicare Advantage

• MDC – All Payer Patient List Information

• MDC – All Payer Patient List FAQ• Transitional Care Management

Procedure Codes FAQ• PGIP SharePoint Collaboration

Site Quick Reference Guide

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• Qualified non-physician practitioners on the PDCM Team –MA Article

• What is an HSA (HDHP)?• Provider Delivered Care

Management: FAQ• MiPCT/PDCM-BCBSM/BCN/MA

Resource Page• BCBSM MiPCT/PDCM

Reimbursement Policy and Billing Guidelines

• MiPCT/PDCM Codes: April 2013 – All

• MiPCT/PDCM Codes: April 2013- Physician Only

Questions

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Break Out Time

• Claims• Billing• Clinical• Patient List

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