It is expected that all team members act within their scope of licensure, certification, or authorization by the physician, physician assistant or advanced practice nurse.
Payer-specific information is indicated in the answers below.
Q: Where can I locate the BCBSM PDCM codes, descriptions, and billing guidelines?
A: Blue Cross Blue Shield of Michigan or our current billing guide.
Q: Is training required for care team members to bill PDCM CPT Codes?
A: Yes, must be completed within 6 months of submitting codes. Information regarding required courses can be found here.
Q: Can unlicensed care-team members bill PDCM codes?
A: Yes, unlicensed care-team members such as medical assistants or community health workers can bill for telephonic services (98966-98968) and care coordination codes (99487-99489).
Q: Can all 12 PDCM codes be conducted telephonically?
A: Due to the pandemic, BCBSM allows all 12 PDCM codes to be conducted via telephone or virtual (via secure video conferencing). Although, not always possible, in-person or secured video conferencing is the preferred. If a patient is unable or does not want to return to office; this information should be clearly documented within the medical record.
Q: Can care management services be rendered via secure video conferencing with a submission of the 12 PDCM codes?
A: Yes, services identified as virtual may require a modifier for the Commercial PPO members only.
Q: If I interact with a patient's caregiver, can I bill care management codes if the patient is not present?
A: Yes, if the name of the caregiver, relationship to patient and appropriate consent is provided and documented within the medical recorded.
Q: Can a care team member bill a G9002 without a preceding G9001?
A: Yes, care team members are not required to bill a G9001 prior to billing G9002.
Q: Does submitting a G9001 or G9002 require a time limit?
A: No; however, if you’re submitting a G9002 and a coordinated care visit is >45 minutes, you may quantity bill. A G9001 cannot be quantity-billed.
Q: Can the G9001 and G9002 be billed on the same day?
Q: Can the initial assessment (G9001) be billed if the patient decided not to proceed with care management services?
Q: Are CPT codes 98966, 98967 and 98968 appropriate for contacting members for emergency department visits or hospitalizations when not part of transition of care services?
A: Yes, these codes can be submitted based upon duration of time spent on the telephonic outreach with patient/caregiver.
Q: Can the PDCM codes be billed simultaneously?
A: Yes, each of the codes maybe billed alongside the other codes. As an example, G9002 can be billed on the same day as a telephonic service (98966, 98967 and 96968).
As a reminder, care coordination services (99487/99489) is time accumulated over a course of a month, not time spent within a specific day. The best practice is to bill at the end of the month, adding up all the minutes.
Q: Can a group visit (98961 or 98962) and a phone visit (98966, 98967, 98968) be billed on the same day?
A: These codes should only be billed on the same day if contact is completed as a distinct service. (e.g., Patient attends group education in the morning and the care team member contacts patient as a follow up in the afternoon).
Q: Historically, many forms were completed as phone outreach however many organizations have converted to online. Would time spent completing online forms such as CPS intake, court and/or school documents be considered as care coordination?
A: Yes, as the care-team member would be spending the same amount of time on the telephone as he/she would be online.
Q: How can I get reimbursed for time spent coordinating services with other providers/services (i.e., home health, specialty offices, community resources, etc.)?
A: When providing non-face-to-face clinical coordination with the patient-centered medical neighborhood, a care team member must accumulate at least 31 minutes of time spent within a calendar month and submit code: 99487 or 99489. Individual organizations will need to develop internal workflows for capturing and tracking each contact until the total time is collected.
Q: What constitutes a care team conference? What code(s) can I use to bill for a care-team conference?
A: A care-team conference constitutes a face-to-face or telephonic conversation between the primary provider (physician or APP if acting as primary provider) and one or more care-team members regarding a patient status. A team conference does not include the patient. The code used to bill for a care team conference is G9007.
Q: Can the G9007 be billed if two team members are discussing a potential patient for care management prior to the patient coming onto service, or can this only occur with the physician?
A: No, this is a physician/provider code. It can only be billed when discussing with the physician/APP.
Q: Can an educational visit be conducted via telephone?
A: Yes, with appropriate documentation within medical record clearly stating that patient can’t or will not present for face-to-face visit.
Q: Can a physician bill a 98961 or 98962?
Q: If a family member attends a training, can a care-team member submit claim on behalf of the patient?
Q: Does a physician need to bill a G9008 prior to a care-team member submitting subsequent PDCM codes?
Q: When a physician coordinates care or interacts with another health care provider (specialist, paramedic, and/or care manager) seeking guidance or additional background information on a patient, is this billable?
A: Yes, a physician-delivered service may be billed when coordinating care or engaging patients in care management services. A physician would utilize code G9008 for services rendered. Note: This is not applicable for APPs.
Q: Can a G9008 be billed for unsuccessful attempts to engage patients in care management?
Q: Can a G9008 be billed with a Medicare Wellness Exam?
Q: If the care manager speaks with the physician and the physician decides to make a change in the plan of care, can the G9008 be billed for that conversation?
A: This would be a G9007.
Q: Can a care team member bill for advance care planning conversations?
A: Yes, care team members who conduct end-of-life (advance care planning) conversations with either the patient or “surrogate” can bill S0257.