Medicare Advantage Preferred Provider Organization (MA PPO)

Applicable to enrollees from other Blue Cross Blue Shield Medicare Advantage Plans who obtain health care services within the 5-county Philadelphia service area.

Title:

Care Management and Care Planning Services

Policy #:

MA00.006n

Policy

ELIGIBLE

TRANSITIONAL CARE MANAGEMENT
Transitional Care Management (TCM) services are covered and eligible for reimbursement consideration by the Company when ALL the following requirements are met:

The individual has medical and/or psychosocial problems that require moderate- or high-complexity medical decision making.
Communication with the individual or the individual's caretaker occurs within 2 business days of discharge by either direct (face-to-face), or indirect (telephonic or electronic) means.
- If the individual is not reached within 2 business days, the provider may still be able to furnish TCM services provided the individual is reached in enough time for a face-to-face visit to occur within the established time frame (see face-to-face requirements below).
- The provider must document all unsuccessful attempts in reaching the individual, beginning at a minimum of 2 business days postdischarge, until contact is eventually established.
The face-to-face visit must occur within either 7 calendar days postdischarge (for an individual whose condition requires high-complexity decision making) or 14 days postdischarge (for an individual whose condition requires moderate-complexity decision making).
- If the face-to-face visit occurs outside this period (e.g., because the member could not be reached in enough time for a face-to-face visit to occur within either 7 or 14 days), then the provider has NOT provided TCM services. In such cases, the provider should report the appropriate Evaluation/Management (E/M) service furnished based on medical necessity if and when the member is eventually reached.
Medication reconciliation and management occurs no later than the date of the face-to-face visit.

ADVANCE CARE PLANNING

Advance care planning (ACP) services are covered and eligible for reimbursement consideration by the Company when the following requirement is met:

The individual has a face-to-face or telehealth encounter with a professional provider or other qualified healthcare professional to discuss the advance directives.

Telephone audio-only conversations with the family members and/or healthcare surrogates, without the individual's presence, are not considered as ACP services.

When ACP service is reported more than once in a calendar year, a change in the individual’s health status and/or wishes about end-of-life care must be documented.

For information related to ACP as preventive services, refer to the Preventive Services policy located in the Cross Reference section of this policy.

NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT

The Company covers the following care management and care planning services; however, these services are not eligible for separate reimbursement whether billed alone or in conjunction with other services. Participating professional providers may not bill members for these services.

Chronic Care Management (CCM) and Complex Chronic Care Management (CCCM)
Comprehensive Management and Care Coordination for Advanced Illness (CMCCAI)

BILLING REQUIREMENTS

WHEN TO REPORT TCM SERVICES
TCM services should only be reported once per individual within 30 days of discharge from an inpatient hospital, outpatient hospital, or skilled nursing facility stay, and are only eligible to a single professional provider. TCM services should not be reported until all criteria have been met. If the provider furnishes a medically necessary face-to-face service following the 7- or 14-day visit during this 30-day period, the provider should bill the appropriate E/M service.

WHEN NOT TO REPORT TCM SERVICES

When the professional provider reports a procedure with an assigned global period (e.g., 10 days, 90 days); in this instance, TCM services are included in the postoperative payment for the procedure.
When the individual is discharged from the hospital to a skilled nursing facility.
E/M services performed on the day of discharge as part of the discharge management services cannot be considered the TCM face-to-face visit.

WHEN REPORTING ACP SERVICES

Telephone audio-only conversations with the family members and/or healthcare surrogates, without the individual's presence, should not be included in time calculations for ACP services and should not be reported for reimbursement.

REQUIRED DOCUMENTATION

There is no frequency limitation on ACP services in a calendar year period. When an ACP service is reported more than once, a change in the individual’s health status and/or wishes about end-of-life care should be clearly documented.

The Company may conduct audits for individuals with multiple ACP claims. Documentation would be expected to support the reasonable and necessary use of ACP as evidenced by the following:

The content and the medical necessity of the ACP-related discussion
Voluntary participation in ACP by the individual, or in the case of absent decision-making capacity, by the family member or surrogate
A change in health status or advance care wishes in order to support repetitive provision of ACP services
The scenario for the service: face to face, by phone, as a telehealth service including audio and/or video communication
The time spent solely for provision of ACP services
The names of participants involved in the discussion

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, Care Management and Care Planning Services are covered under the medical benefits of the Company's Medicare Advantage products.

Description

Care management and care planning services use a multidisciplinary team approach to assist individuals in managing their medical, mental, or behavioral health conditions more effectively.

ADVANCE CARE PLANNING

Advance care planning (ACP) is the the face-to-face service between a professional provider or other qualified healthcare professional and the patient/individual discussing advance directives, with or without completing relevant legal forms. ACP services are time-based services. No other active management of the individual’s health conditions should be undertaken for the time recorded when ACP service codes are reported. Brief conversations of a few minutes (performed during an Evaluation and Management [E/M] service) related to wishes concerning potential emergent resuscitation do not represent ACP services. The face-to-face time is defined as only that time spent face-to-face with the individual with or without the presences of surrogate(s) such as a healthcare agent, designated decision maker, family member, or caregiver.

An advance directive is described as a written document that an individual uses to appoint a representative and/or to record the individual's wishes as it relates to future medical treatment in the event the individual is incapacitated and unable to make decisions on their own. Types of written advance directives include, but are not limited to:

Healthcare proxy
Durable power of attorney for healthcare
Living will
Medical orders for life-sustaining treatment (MOLST)

CHRONIC CARE MANAGEMENT AND COMPLEX CHRONIC CARE MANAGEMENT

Chronic Care Management (CCM) and Complex Chronic Care Management (CCCM) refer to care coordination services provided to individuals with two or more chronic conditions expected to last at least 12 months or for the remainder of an individual's life. These chronic conditions place the individual at significant risk of death, acute exacerbation/decompensation, or functional decline.

CCM services have the same criteria and components as (CCCM) services. According to the Centers for Medicare & Medicaid Services (CMS), CCM and CCCM differ in the amount of clinical staff service time directed by a professional provider or other qualified healthcare professional; the involvement and work of the billing professional provider or other qualified healthcare professional; and the extent of care planning performed. The estimated work time for CCCM services is 60 minutes per month, while the work time for CCM services is at least 20 minutes.

In furnishing CCCM services, the professional provider or other qualified healthcare professional and clinical staff develop a holistic care plan that addresses all aspects of the individual's healthcare needs, including all medical conditions, psychosocial needs, and activities of daily living. Whereas the professional provider or other qualified healthcare professional might not singly furnish all the included components of a CCCM care plan, the provider is nonetheless expected to coordinate all of the included components and update the plan as needed to address any changes in an individual's health needs.

A CCCM plan is typically implemented by clinical staff under the direct supervision of the professional provider or other qualified healthcare professional. In implementing the plan, the staff members typically perform many, if not all, of the following tasks:

Communicate and engage with the individual, family members, guardian or caretaker, surrogate decision makers, and/or other professionals regarding aspects of the individual's care.
Communicate with home health agencies and other community services utilized by the individual.
Collect and document health outcomes data.
Provide individual and/or family/caretaker education to support self-management, independent living, and activities of daily living.
Assess and support the individual's treatment regimen adherence and medication management.
Identify available community and health resources for the individual and facilitate access to care and services needed by the individual and/or family.
Develop, communicate, and maintain the individual's comprehensive care plan.

COMPREHENSIVE MANAGEMENT AND CARE COORDINATION FOR ADVANCED ILLNESS

Comprehensive management and care coordination for advanced illness (CMCCAI) refers to the management of members with one chronic condition, rather than multiple (two or more) chronic conditions.

CMCCAI includes the following services for members with ONE chronic condition:

Assess for the presence of symptoms on at least a monthly basis
Develop a treatment plan to manage symptoms
Educate about cause and management of symptoms
Assess for psychosocial and spiritual distress and refer for support
Provide information regarding prognosis consistent with the individual's preferences
Establish goals of care that are consistent with the individual's values and preferences
Maintain an advanced care plan that is consistent with the individual's goals and preferences
Coordinate care with other health care providers and across sites of care
Educate the individual and caregivers about role of specialist palliative care and hospice
Assess need for specialist palliative care and hospice
Coordinate referral to hospice when appropriate
Educate and support caregivers providing care to the individual

TRANSITIONAL CARE MANAGEMENT

Transitional Care Management (TCM) refers to care coordination services provided to an individual whose medical and/or psychosocial condition(s) require moderate- or high-complexity medical decision making during transitions in care from an inpatient hospital setting (including acute hospital, long-term acute care hospital), partial hospital, observation status in a hospital, or skilled nursing facility/nursing facility, to the individual's community setting (home, domicile, rest home, or assisted living).

References

Centers for Medicare & Medicaid Services (CMS). Frequently Asked Questions about Billing the Physician Fee Schedule for Advance Care Planning Services. July 2016. Available at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/FAQ-Advance-Care-Planning.pdf. Accessed July 20, 2022.

Centers for Medicare & Medicaid Services (CMS). MLN Fact Sheet. Advance Care Planning. October 2020. Available at:
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/AdvanceCarePlanning.pdf. Accessed July 30, 2022.

Centers for Medicare & Medicaid Services (CMS). MLN Fact Sheet. Chronic Care Management Services. December 2019. Available at: https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/chroniccaremanagement.pdf Accessed July 30, 2022.

Centers for Medicare & Medicaid Services (CMS). MLN Fact Sheet. Transitional Care Management Services. July 2021. Available at:
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Transitional-Care-Management-Services-Fact-Sheet-ICN908628.pdf. Accessed July 30, 2022.

Centers for Medicare & Medicaid Services (CMS). MLN Matters® Number MM10000. Billing for Advance Care Planning. May 2017. Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10000.pdf. Accessed July 30, 2022.

Novitas Solutions. Provider specialty: Care management services. [Novitas Web site]. Revised: 07/07/2022. Available at: https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00170702. Accessed July 30, 2022.

Coding

CPT Procedure Code Number(s)

ELIGIBLE
99495, 99496, 99497, 99498

NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT

99424, 99425, 99426, 99427, 99437, 99439, 99487, 99489, 99490, 99491

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

N/A

HCPCS Level II Code Number(s)

NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT

G0506	Comprehensive assessment of and care planning for patients requiring chronic care management services (list separately in addition to primary monthly care management service)
G0511	Rural health clinic or federally qualified health center (RHC or FQHC) only, general care management, 20 minutes or more of clinical staff time for chronic care management services or behavioral health integration services directed by an RHC or FQHC practitioner (physician, NP, PA, or CNM), per calendar month
G0512	Rural health clinic or federally qualified health center (RHC/FQHC) only, psychiatric collaborative care model (psychiatric COCM), 60 minutes or more of clinical staff time for psychiatric COCM services directed by an RHC or FQHC practitioner (physician, NP, PA, or CNM) and including services furnished by a behavioral health care manager and consultation with a psychiatric consultant, per calendar month
S0257	Counseling and discussion regarding advance directives or end of life care planning and decisions, with patient and/or surrogate (list separately in addition to code for appropriate evaluation and management service)
S0311	Comprehensive management and care coordination for advanced illness, per calendar month

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From MA00.006n:

01/02/2024

This policy has been identified and updated for the CPT/HCPCS code update effective 01/02/2024

The Following CPT codes have been added to this policy:

G0019, G0022, G0023, G0024, G0136, G0140, and G0146

Revisions From MA00.006m:

01/01/2024	This AmeriHealth New Jersey Medicare Advantage policy will become effective 01/01/2024.
01/01/2023	This policy has been identified and updated for the CPT/HCPCS code update effective 01/01/2023 The following CPT codes have had narrative revisions: 99495 and 99496

Revisions From MA00.006l:

11/07/2022

This version of the policy will be effective 11/07/2022.

The Company’s reimbursement position for Advanced Care Planning services has changed from not eligible for separate reimbursement to eligible for reimbursement.

Revisions From MA00.006k:

05/31/2022

This version of the policy will be retro-actively effective 05/30/2022. The policy has been reviewed and reissued to communicate the Company’s continuing position on Care Management and Care Planning Services.

The following CPT codes have been removed from this policy and are being communicated in the Policy - MA00.052 Psychiatric Collaborative Care Management (CoCM):
99484, 99492, 99493, 99494

The following HCPCS code has been removed from this policy and is being communicated in the Policy - MA00.052 Psychiatric Collaborative Care Management (CoCM):
G2214

Revisions From MA00.006j:

04/01/2022

This version of the policy will become effective 04/01/2022. The policy has been reviewed and reissued to communicate the Company’s continuing position on Care Management and Care Planning Services.

Revisions From MA00.006i:

01/01/2022

This policy has been identified and updated for the CPT/HCPCS code update effective 01/01/2022

The Following CPT codes have been added to this policy:

99424, 99425, 99426, 99427, 99437

The following HCPCS codes have been removed from this policy:

G2064 and G2065

The following CPT codes have had narrative revisions:

99484, 99487, 99489, 99490, 99491, 99492, 99493

Revisions From MA00.006h:

01/04/2021

This version of the policy will become effective 01/04/2021.

The following criteria regarding when not to report Transitional Care Management services has been deleted from policy:
The member is established and not new to the provider's practice.

HCPCS code S0257 has been added to this policy

HCPCS code G0507 has been deleted from this policy due to a 1/1/2018 Quarterly Code Update

Revisions From MA00.006g:

01/01/2021

This policy has been identified and updated for the CPT/HCPCS code update effective 01/01/2021

CPT code 99430 has been added to the policy.

HCPCS code G2214 has been added to the policy.

HCPCS code G2058 has been removed from the policy.

Revisions From MA00.006f:

01/01/2020

This policy has been identified and updated for the CPT/HCPCS code update effective 01/01/2020.

The following HCPCS codes have been added to the policy: G2058, G2064, G2065.

Revisions From MA00.006e:

01/01/2019

This policy has been identified and updated for the CPT code update effective 01/01/2019.

The following CPT code has been added to the policy:

99491

Revisions From MA00.006d:

04/30/2018

This policy was updated to include information on; General Behavioral Health Integration and Psychiatric Collaborative Care Management Services; as as not eligible for separate reimbursement.

The following CPT codes were added to this policy: 99492, 99493, 99494.

The following HCPCS Codes were added to this policy: G0511, G0512

Revisions From MA00.006c:

01/01/2018

This policy has been identified for the CPT code update effective 01/01/2018.

The following CPT code has been added to this policy: 99484

Revisions From MA00.006b:

01/01/2017

The description section was updated.

CPT codes 99497 & 99498 were added to the coding table.

HCPCS codes G0506 & G0507 were added to the coding table

Revisions From MA00.006a:

07/01/2016

This policy has been identified for the CPT code update effective 07/01/2016.

The following HCPCS code has been added to the policy:

S0311 Comprehensive management and care coordination for advanced illness, per calendar month

Revisions From MA00.006:

07/08/2015	MA00.006 has been reissued with minor changes to the company's coverage statement on Chronic Care Management services (CCM).The company's coverage position on CCM remains unchanged.
01/01/2015	This version of the policy will become effective 01/01/2015. The following new policy has been issued to communicate the Company’s position on transitional care management (TCM), complex chronic care coordination (CCCC), and chronic care management (CCM).

Version Effective Date:

1/2/2024

Version Issued Date:

1/16/2024

Version Reissued Date: