Description: Physician care oversight service
Delivery Method: Face-to-face, telephone, or via video
Who Can Bill? Physician only
No quantity limits
Cannot be conducted via email exchange or EMR messaging
Code can be used when physician is coordinating care with the team or interacting with another healthcare provider seeking guidance or background information to coordinate and inform the care
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.
|Priority Health||Code can be billed once per practice during the time the patient is a member of the practice||Service must include patient face-to-face: this can include face-to-face with PCP or face-to-face with patient/care manager|
|Medicaid (varies by HMO)||
Limited to once per month
Not used unless beneficiary requires recurring supervision of therapy
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.
Coordination with Care Team Member/Care Manager
- Date(s) or duration of visit
- Person with whom coordination is occurring
- Care-team member credentials
- Name of caregiver and relationship to patient (if applicable)
- Treatment Plan
- Self-management education, medication management, risk factors, physical/emotional status, community resources, and referrals
- Readiness of change
Coordination with External Consultant * BCBSM only *
- Date(s) or duration of visit
- Reason for consultation (must be meaningful, not just a referral)
- Patient's current state and desired goal/outcome
- Outcome of discussion and guidance resulting from consultation, such as determination for testing, development of a coordinated care plan
- Examples include but are not limited to: pathologists, ED providers, and paramedics
For additional PDCM FAQs, please click here
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 Advanced Practice Practitioner (APP) bill the G9008?
A: No, the nomenclature specifically identifies physicians (MD/DO) only.
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.
Primary care physician calls a pulmonologist to discuss a joint treatment plan for a patient with diagnosis of severe pulmonary hypertension.