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; (For example, LPN and LBSW). If individual is non-licensed and working under their scope of service document, 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.