Code Who can provide Payers PDCM BCBSM Documentation G9001: Initiation of Care Management (Comprehensive Assessment) BCBSM RN, LMSW, CNP or PA who meet the conditions of a lead care manager BCBSM MA Same as above, but RNs and LMSWs must be direct physician supervision Priority Health QHP Medicare Advantage, Priority Health Y All Payers Description: Comprehensive assessment and care plan development with patients, prior to enrollment in care management (and annually thereafter) G9001 is not required to be billed for the other PDCM codes to be payable (though it is an expectation that a G9001 be completed). Conditions of payment: Contacts must add up to at 30 minutes of discussion with the member or member’s representative/caregiver. Must include a face-to-face visit. Patient/caregiver must formally agree with care plan and this must be documented in the medical record. Claims Reporting Requirement: Date of service should be the date the assessment is completed for patients entering into care management. If patient Description: Comprehensive Assessment and Care Plan Development with Patients, Prior to Enrollment in Care Management (and annually thereafter). Documentation: Lead Care Manager Name, Licensure. BCBSM Only payable when service is delivered by a RN, LMSW, CNP or PA who meet the conditions of Lead Care Manager. Priority Health: RN, RD, MSW, CDE, CAE, Pharmacist, PA, NP Identify Primary Care Physician and Contact Information Date of service = date assessment is completed. Duration, and Modality of Contact (face-to-face required, or can be combination of the face-to-face and phone). Visit, Face-to-Face Visit Visit Duration: 30 min BCBSM- Contacts must total at least 30 minutes in duration with at least one face to face encounter with patient. Priority Health- Work must encompass minimum of 30 minutes, some of may be without the patient present. Specific Assessments such as depression, functionality, urologic, etc. Medical Treatment Regimen Risk Factors Physical Status Emotional Status (PH)(BCBSM) Unmet Needs/Available Resources Perceived Barriers to Treatment Plan Adherence Anticipated interventions to help patient achieve goals Self-Management Activities
Code Who can provide service? Payers PDCM BCBSM Notes Documentation G9002: Individual Visit BCBSM Lead Care Manager and Other Care Team Members Priority Health QHP BCBSM Medicare Advantage, Priority Health Y All payers Description: Individual face-to-face care management intervention visits Conditions of payment: Only conducted/billed when patient circumstances and/or the nature of the service require person-to- person interaction to be successful. May include the patient’s caregiver/family Must include focused discussion of patient’s care plan Can also include treatment plan, self-management education, medication therapy, risk factors, care, physical status, emotional status, community resources, readiness to change and ongoing care plan development MA Code may be billed one time per day. If multiple members of the care team provide this service on the same date, to the same patient, this procedure code can be quantity billed. For example: 1-45 minutes (1), 46-75 minutes (2), 76-105 minutes (3), or 106-135 minutes (4). Priority Health Code may be billed one time per day. Description: Individual face-to-face care management intervention visits Documentation: Name/credentials of team member performing the service Date of Service Duration of Face-to-Face Visit All Diagnoses pertinent to encounter Medication reconciliation Focused discussion pertinent to the patients Care Plan (BCBSM) - progress, changes Short-Term Goal, including target date Long-Term Goal, including target date Time Frame for Follow Up Name of Individual(s) in Attendance, Relationship to Patient Nature of the Discussion and Pertinent Details Updated Status on Patient’s Medical Condition, care needs and progress to goal Care Needs and progress to goal(s) Any revisions to the Care Plan Interventions, and Target Dates Patient/Care Giver’s Level of Understanding Readiness for Change Priority Health- include documentation fields listed in "all payer" section plus the following: Diagnosis Discussed, Treatment Plan, Self-Management Education, Risk Factors, Unmet Care, Emotional Status, Community Resources Name of Patient’s PCP Physician coordination activities and approval of Care Plan Patients agreement with care plan
Code Description Who can provide service? Payers PDCM BCBSM Notes Documentation 98961, 98962: Group Education and Training 98961: Education and training for patient self- management for 2–4 patients; each 30 minutes BCBSM/BCBSM MA Lead Care Manager and Other Care Team Members Priority Health QHP BCBSM Commercial, BCBSM Medicare Advantage, Priority Health all plan with the exception of Medicaid Y All Payers Description: Formalized educational sessions led by qualified non-physician personnel delivered in a group setting Conditions of Payment: At least two, but no more than 8 patients present There must be some level of individualized interaction included in the session Must use a standardized curriculum. Claims Reporting Requirements: Family members should not be counted as patients All active dx should be reported Bill separately for each individual patient Quantity Limits: None. May be quantity billed. Description: Formalized educational sessions led by qualified non-physician personnel delivered in a group setting Documentation: Name, Licensure of Group Visit Facilitator(s) Primary Care Physician Date of Number of Patients in Attendance: 2-4 patients or 5-8 patients Visit Duration: 30 min 60 min 90 min if >90 min, indicate total minutes Diagnoses Relevant to the Group Visit Location of Class Nature and Content of Group Visit Objective(s) of the Training Status Update: Medical Condition, Care Progress to Goal, Interventions, and Target Dates Have some level of individualized interaction(BCBSM) All active diagnosis 98962: Education and training for patient self- management for 5–8 patients; each 30 minutes
Code Description Who can provide service? Payers PDCM BCBSM Notes Documentation 98967, Telephone Services: Telephone assessment and management services provided by a qualified non- physician health care professional 98966: 5-10 minutes of medical discussion MA Lead Care Manager and Other Care Team Members Priority Health QHP BCBSM BCBSM Medicare Advantage, Priority Health (all PH plans) Y All payers Description: Non-face-to-face care management services provided to a patient or patient’s representative/caregiver using the telephone or by other real-time interactive electronic communication Conditions of Payment: Not for reminder about appointments or conveying test results. For substantive discussions focused on the patient’s care plan and goal achievement. Claims Reporting Requirements: Code selection depends on time spent in discussion with the patient Report all active dx BCBSM/BCBSM MA Documented consent from patient agreeing to phone contacts initiated by the care manager You may not quantity bill these codes Only one of these codes may be billed per day. Priority Health Codes cannot be quantity billed Description: Non-face-to-face care management services provided to a patient or patient’s representative/caregiver using the telephone or by other real-time interactive electronic communication Documentation: Lead Care Manager Name, Licensure (payable when delivered by any of the qualified allied personnel approved for PDCM) Date, Time, and Duration of Call Phone Visit All active diagnoses relevant to the encounter Medications Short-Term Goal, target date Long-Term Goal, target date Care and Progress to Goal(s) Nature of the Discussion and Pertinent Details Updated Status on Patient’s Medical Condition Care Needs and Progress to Goal Any revisions to the Care Plan Interventions, and Target Dates Patient/Care Giver’s Level of Understanding Readiness for Change Name of Individual(s) in attendance, relationship with patient 98967: 11-20 minutes of medical discussion 21-30 minutes of medical discussion
Code Description Who can provide service? Payers PDCM BCBSM Notes Documentation 99358, 99359: Prolonged E/M Service 99358: Prolonged E/M service before and/or after direct patient care, first 60 minutes Physicians; Practitioners; Physician Assistants Medicare [except CPC+ patients] N Medicare CCM and complex CCM reimburse providers for clinical staff time spent providing care management services, not time spent by physicians. For those cases in which a physician spends a significant amount of time outside the usual office visit addressing an individual patient’s needs, CMS will make payment under these two codes beginning in 2017. In discussing services, CMS warns the time counted toward these codes must be separate and distinct from time spent providing any other service reimbursable under the MPFS including, but not limited to, new and established patient office visits, transitional or chronic care management services or care plan development. The CPT prefatory language and reporting apply for the Medicare billing of these codes, for example, CPT codes 99358 and 99359: Description: CCM and complex CCM reimburse providers for clinical staff time spent providing care management services, not time spent by physicians. For those cases in which a physician spends a significant amount of time outside the usual office visit addressing an individual patient’s needs Documentation: Duration of visit Content of the medically necessary evaluation and management service and prolonged services that you bill Direct face-to-face time with the patient Start and end times of the visit Date of service. For details and complete listing of Prolonged E/M service elements: 99359: Prolonged E/M service before and/or after direct patient care, each additional 30 minutes (listed separately with 99358)
Medicare Add-on code to 99487, for each increment that does beyond 60 minutes utilizing the last encounter date Quantity Limits: 99487 may only be billed once per calendar month, per patient 99489 may be quantity billed Medicare The billing rules for CCM (CPT 99490) and complex CCM are the same, except complex CCM requires 60 minutes of non-face- to-face care management services per month, as compared to 20 minutes for CCM. CMS also will pay for an add-on code for complex CCM, CPT 99489, for each 30- minute increment that goes beyond the initial 60 minutes. Medicare- Include documentation fields listed above in "all payer" section, plus the following: Verbal consent is documented in the medical record, and information must be explained to the patient for transparency Comprehensive Care Plan for all health issues Problem list Expected outcome and prognosis Measurable treatment goals Symptom management Planned interventions and identification of the individuals responsible for each intervention Measurable treatment goals Medication management Community/social services ordered A description of how services of agencies and specialists outside the practice will be directed/coordinated Schedule for periodic review and, when applicable, revision of the care plan “Incident to applies” For details and complete listing of CCM service elements: 1) https:// MLN/MLNProducts/Downloads/ChronicCareManage ment.pdf 2)
Code Who can provide service? Payers PDCM Notes Documentation G9007: Coordinated care fee, scheduled team conference Primary Care Practitioner MA Lead Care Manager and Other Care Team Members Priority Health Physician BCBSM Commercial, BCBSM Medicare Advantage, Priority Health Y All Payers Description: Scheduled meetings between PCP and care manager to discuss a patient’s care plan (without the patient present). Can be conducted face-to-face, by telephone or by secured video conference. Conditions of Payment: To be billed by the primary care practitioner and payable only to the primary care practitioner. Based on a change in the patient’s care plan Discussions must be focused on the patient’s individualized care plan (including significant change in patient status and/or unresolved barriers) and goal achievement Outcomes and next steps for each patient must be agreed upon and documented Documentation can be completed by the physician or the care manager Claims Reporting Requirements: Bill separately for each patient discussed Quantity Limits: Limit of one G9007 paid per primary care practitioner, per practice, per patient, per day. This limit does not apply across specialty types; for example, when a patient is being managed by both a PCP care manager and an oncology care manager, both care managers may conduct a team conference as needed and Description: Scheduled meetings between Primary Care Practitioner and care manager to discuss a patient’s care plan (without the patient present). Can be conducted by telephone or by secured video conference. Documentation: Date of Team Meeting Duration of discussion for individual Patient Name and credentials of allied professionals present for Team Conference Nature of the discussion and pertinent details Any revisions to the Care Plan Goals, Outcomes, Interventions, and Target Dates. Outcomes and next steps for each patient must be agreed upon and documented. Priority Health- Include documentation fields listed above in "all payer" section, plus the following: Diagnoses discussed Treatment Plan, Self-Management Education, Medication Therapy, Risk Factors, Unmet Care, Physical Status, Emotional Status, Community Resources, Readiness to Change. Tip: self- management goals. Physician coordination activities and approval of Care Plan Billed under the physician and is payable only to the physician Physician approval of care plan face-
Code Who can provide service? Payers PDCM BCBSM Notes Documentation Transitional Care Management MD and DO of any specialty, NP, PA, CNS, or CNM. Provider does not need to have an established relationship with the patient. BCBSM, Medicare (including CPC+ patients), Medicare Advantage, Medicaid, Priority Health (all plans), Managed Medicaid Health Plans, Medicaid *”Incident to” applies. N All Payers Description: Transitional care management services for patients whose medical and/or psychosocial problems require moderate complexity medical decision making during transitions in care from an inpatient hospital setting (including acute hospital, rehabilitation hospital, long-term acute care hospital), partial hospital, observation status in a hospital, or skilled nursing facility/nursing facility, to the patient’s community setting (home, domicile, rest home, or assisted living). Conditions of Payment: The practitioner must communicate with the patient by the end of the day on the second business day following the day of discharge. Communication can be face-to-face, phone, or email. Face–to-face visit is required within 14 days of discharge The first face-to-face visit is not reported separately, though E&M services provided after the first to-face visit can be billed (with some exceptions) Description: Transitional care management services for patients whose medical and/or psychosocial problems require moderate complexity medical decision making during transitions in care from an inpatient hospital setting (including acute hospital, rehabilitation hospital, long-term acute care hospital), partial hospital, observation status in a hospital, or skilled nursing facility/nursing facility, to the patient’s community setting (home, domicile, rest home, or assisted living). Documentation: Date of visit Date of interactive contact with the beneficiary and/or caregiver Electronic, telephone or face to face Place of service Complexity of medical decision making moderate. Documentation of any medical or psychosocial problems. Testing ordered, reviewed. Consultations with other providers. Indication of number of problems (established or new) Diagnosis: Report the diagnosis(s) for the conditions requiring TCM services. General conditions the patient at the time of discharge. Medication reconciliation and management no later than the date of the face-to face visit
Quantity Limits and other Limitations: Medicare and Priority Health will only pay one physician or qualified practitioner for TCM services per beneficiary per 30-day period following a discharge The provider who reports a service with a global period of 010 or 090 days may not also report the TCM service CMS-Include documentation fields listed above in "all payer" section, plus the following: Date of beneficiary discharge Applicable physical exam findings For details and complete listing of TCM service elements: