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.
BCBSM distinguishes between licensed and non-licensed individuals. If an individual is licensed, and they are working within their scope of licensure, then they can bill all the PDCM codes; (i.e., LPN and LBSW). If individual is non-licensed and working under their scope of service document, (i.e., MA and CHW) then they can bill the telephonic and care coordination codes only.
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 Z-codes be the primary diagnosis for billing care management codes?
A: Yes, if the appropriate unspecified code is selected. (excludes 99487,99489).
Q: Can PDCM and CCM codes be furnished during the 30-day TCM service period?
A: Yes, 99487, 99489, 99490, 99491 by the same practitioner for services furnished during the 30-day TCM service period (CPT99495, 99496).
Q. Is it required to have a physicians co-signature on all EMR encounter types when submitting PDCM codes?
Q: Is there only one charge per encounter? For example, If a care team member is contacting a patient multiple times, should that care team member wait until everything is completed before billing, or am I supposed to adjust the code as a person goes or are would we create a new encounter?
A: This depends on the code and if one person is doing all the work within a single day. If that individual is using (98966-98968) telephonic codes, then they should add up the total minutes throughout the day and bill one phone call code. Care-team members should only bill one phone call code per day, per patient. If this work goes to a subsequent day, then the care team member would bill a phone call code on each of those days. If you are doing a video visit, then you can follow up with a phone call code in the same day. If you perform a team conference, then you can do both a G9007 and the appropriate phone call code.
Q: If a care team member speaks to a patient for 10 minutes and submits the code (98966) then communicates with the physician requesting follow-up on the care plan, then another care team member contacts the patient with a phone call lasting 10 min. Would the original charge still be there? How would the other care team member bill?
A: Phone call codes should be billed once per day, per patient. So, if the 2nd care-team members bill’s for service the two calls should be a combination of 20 minutes and the first charge would be removed. Overall, this would be a 98968.
BCBSM-related answers reviewed and approved by Blue Cross Blue Shield of Michigan as of September 7, 2022.
Priority Health-related answers reviewed and approved by Priority Health as of November 7, 2021.