Description: Initiation of care management services (Comprehensive Assessment) and comprehensive (focused) care plan
Delivery Method: Face-to-face or via video
Who Can Bill? Per BCBSM, an licensed care-team member who has completed Introduction to Team-Based Care within 6 months of billing. Per PH, a clinical staff member working under supervision of a physician, NP, or PA and who is allowed by law, regulation and facility policy to perform or assist in the performance of a specified professional service, but who does not individually report that professional service.
| Payer | Billing Allowance | Requirement |
| BCBSM/BCN/BCN Advantage | Once per patient, per day, per practice Can be done via telephone (note: telephone can only be utilized if video was declined by patient) On 9/20/23, BCBSM communicated providers recognized as registered dietitians with the education to support that recognition can bill in person PDCM codes (as if they are licensed). | For groups not participating in the PDCM program, if claim is submitted, it will deny as MEMBER liable. For all other groups, a claim is submitted and denies, it will deny as PROVIDER liable.
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| Priority Health | Limited to once per practice annually | Must include patient. Work must encompass a minimum of 30 minutes, some of which maybe without the patient present |
| Medicaid (varies by HMO) | Limited to once per year with same diagnosis; cannot be billed in the same month as G9002 | Must be a face-to-face encounter |
Billing opportunities and reimbursement may vary depending upon organization's specific payer value-based contracts. All services should be billed in accordance with CPT and Center for Medicare & Medicaid service guidelines.
MICMT does not have expertise related to the Centers for Medicare and Medicaid services coverage decisions related to billing. The information contained on this site comes from publicly available sources of CMS information. Any needed clarification should come from CMS or their representatives/contractors.
Recommended Documentation
- Identify care manager responsible for overall care plan, his/her credentials, and patient’s provider and contact information
- Date, duration, and modality of contact (face-to-face or video)
- Name and relationship of person contacted if other than patient
- All active diagnoses assessed (and reported on claim)
- Current physical and mental/emotional status
- Current medical treatment regimen and medications
- Risk factors
- Available resources and unmet needs
- Level of patient’s understanding of condition and readiness for change
- Perceived barriers to treatment plan adherence
- Individualized long and short-term desired outcomes and target dates
- Anticipated interventions and timeframe for follow-up
- Patient consent to engage/participate in care management
G9001 FAQs
For additional PDCM FAQs, please click here
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?
A: Yes.
Q: Can the initial assessment (G9001) be billed if the patient decided not to proceed with care management services?
A: Yes.
Q: Can a pharmacist bill a G9001?
A: Yes, a pharmacist is a licensed care-team member in the state of Michigan
G9001 Scenario
- Mr. Paxton presents to office for face-to-face follow-up with Eric, care manager. Eric completes a comprehensive assessment.
- Eric provides Mr. Paxton with two screenings to complete: Social Determinants of Health Screening (SDOH), as well as a Patient Health Questionnaire -2 (PHQ-2) Screening
- His SDOH screening is positive for difficulty reading and understanding medical language as well as transportation issues, as he does not drive and relies on family/friends to take him to appointments.. Mr. Paxton’s PHQ-2 screening was negative for depression.
- His CHF management is discussed further, and Mr. Paxton identifies a SMART goal to reduce his salt intake.
- They also discuss Advance Care planning, and he has an advance directive and living will in place.
- Eric connects Mr. Paxton with various resources to help address his identified barriers.
- Patient and care manager agree on a follow-up plan. Mr. Paxton will meet with PharmD/Stacey via phone in 2 weeks to follow-up on his identified goals.
- Total time of visit 45 min