BCBSM PDCM/MiPCT Program Discussion Session

1. BCBSMPDCM/MiPCT ProgramDiscussion Session November 15, 2012

2. Care Management Automated Tools • MiPCT Care Managers should use care management software or other automated tools (e.g., electronic medical records, patient registries) in their work with patients: • Maintain list of active patients, both follow-up and new •   Document information from care management visits, including diagnoses, self-management goal-setting, and transitions of care information •   Create and maintain patient care plans •   Generate care manager activity reports and align the health information tools with existing care management workflows at your organization

3. Care Management Automated Tools • In some cases, patients who drop off the monthly list may still be eligible for care management services • Under our attribution  methodology, a patient could drop off the list if they are seen by a provider in a different PO.  If the patient is still considered a current patient with the original provider, and has active BCBSM coverage, the patient will remain eligible for care management services. •  To verify eligibility when a patient has been dropped from your list, submit an inquiry through the PGIP Collaboration Site, including the patients’ name and contract number. •  Please note that if a patient has been dropped from the list because they are no longer eligible for PDCM/MiPCT (for example, if a patient changes jobs and their new employer does not participate in Provider Delivered Care Management), future claims for these patients will not be payable

4. Code Updates • PDCM • Add new code for Care Manager care coordination: 99489 • Add new code for physician for team conferences: G9007 • Oncologists will use same PDCM codes • Home-based care management: TBD • New care transition codes payable for all providers: 99495 and 99496

5. PDCM Current Billing/Coding • PDCM currently pays for 7 services delivered by qualified non-physician practitioners to approved practices or POs • PCP is generally identified as the Rendering Provider on the claim (and E&M fee uplifts for which they qualify are applied to these codes) • No cost-share is applied (except for groups with high deductible plan products with HSAs) • If any of these services are billed for members that are not PDCM eligible (i.e., the group does not participate) the service is rejected with provider liability • PCP visits are billed as regular office-visits and the member’s OV coverage/cost-share applies * Limit of one per year

6. New CPT Codes for 2013-Complex Chronic Care Coordination Complex Chronic Care Coordination—Clinical staff time, directed by a physician or other qualified health care professional • Billed by care manager for care coordination with providers that are NOT the PCP, the primary caregiver or the patient • Two options for claim reporting: (1) on the date of service (ignore “per calendar month”) or (2) total up the time spent and quantity bill at the end of the month (i.e. 3 hours = quantity of 6) • Does this proposal meet your request from the PGIP Quarterly Meeting? • What do you think of criteria for payment for this procedure code?

7. Team Conferences • Proposed paying G9007 to physicians (e.g. $30) to encourage physicians and care management staff to formally discuss care plans • Billed by physicians only, not the care manager • Does this proposal meet your request from the PGIP Quarterly Meeting? • What type of criteria for payment would you recommend for this procedure code?

8. Under Development: Home-based Complex Care Management • Home-based PDCM • Providers would include Care Managers and Physicians • Codes already exist for Physicians, exploring options for clinical model • Current PDCM codes do not account for additional complexity/travel for home-based delivery • New CCCC codes could be adopted for home based care distinct from office-based delivery • Potential model of PDCM practices/POs contract with HHAs/Hospices (and their services are paid indirectly, i.e., reimbursement goes to the practice/PO) • How do we want to integrate with other existing home based care delivery providers? For example: HHAs and Hospice • Pay in person PDCM services at 150% when done in the home

9. New CPT Codes for All Providers in 2013Transitional Care Management • Transitional Care Management—Services with the following required elements: • Communication (direct contact, telephone, electronic within two business days of discharge) • Medical decision making of defined complexity (see below) during the service period • Face-to-face visit, within defined days of discharge (see below) • Payable to all MD/DO, CNP & PA’s – not just PDCM • Treat as office visit, with cost-share applied • Fee Uplift applicable • Continue to use current G-codes to pay nurse care manager encounters (face-to-face or phone) which may occur post-discharge or pre-discharge (using location of service 1)

10. Questions?