Notification



Notification Issue Date:



Claim Payment Policy


Title:Care Management and Care Planning Services

Policy #:00.01.59e

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.

Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract

NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT

The Company covers the following care management and care planning services; however, these services are considered not eligible for separate reimbursement, whether billed alone or in conjunction with other services. Participating professional providers may not bill members for this service.
  • Advanced Care Planning (ACP)
  • Chronic Care Management (CCM) and Complex Chronic Care Management (CCCM)
  • Comprehensive Management and Care Coordination for Advanced Illness (CMCCAI)
  • General Behavioral Health Integration (BHI)
  • Psychiatric Collaborative Care Management (CoCM)

ELIGIBLE FOR SEPARATE REIMBURSEMENT

TRANSITIONAL CARE MANAGEMENT (TCM)
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 two business days of discharge by either direct (face-to-face), or indirect (telephonic or electronic) means.
    • If the individual is not reached within two 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 two business days post-discharge, until contact is eventually established.
  • The face-to-face visit must occur within either seven calendar days post discharge (for an individual whose condition requires high-complexity decision making) or 14 days post-discharge (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 seven or 14 days), then the provider has NOT provided TCM services. In such cases, the provider should report the appropriate 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.


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 (eg, 10 days, 90 days); in this instance, TCM services are included in the post-operative payment for the procedure.
  • When the individual is discharged from the hospital to a skilled nursing facility.
  • Evaluation & Management (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.
  • The member is established and not new to the provider's practice.

REQUIRED DOCUMENTATION

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 benefit contract, Care Management and Care Planning Services are covered under the medical benefits of the Company's products.

Description

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

ADVANCE CARE PLANNING (ACP)

Advance care planning (ACP) is the the face-to-face service between a professional provider and the patient/individual discussing advance directives, with or without completing relevant legal forms. An advance directive is a document appointing an agent and/or recording the wishes of a patient/individual pertaining to his/her medical treatment at a future time should he/she lack decisional capacity at that time.

CHRONIC CARE MANAGEMENT (CCM) AND COMPLEX CHRONIC CARE MANAGEMENT (CCCM)

CCM and CCCM refers 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 of Medicare and Medicaid (CMS), CCM and CCCM differ in the amount of clinical staff service time provided; the involvement and work of the billing professional provider; and the extent of care planning performed. The estimated work time for CCCM services is 60 minutes, while the work time for CCM services is 20 minutes.

In furnishing CCCM services, the professional provider 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. While the professional provider 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. 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 (CMCCAI)

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

GENERAL BEHAVIORAL HEALTH INTEGRATION (BHI)

General Behavioral Health Integration (BHI) are monthly services provided using BHI models of care other than Psychiatric Collaborative Care Management (CoCM) that similarly include “core” service elements such as systematic assessment and monitoring, care plan revision for individuals whose condition is not improving adequately, and a continuous relationship with a designated care team member. General BHI may be used to report models of care that do not involve a psychiatric consultant, nor a designated behavioral health care manager, although these providers may perform General BHI services.

General Behavioral Health Integration (BHI) refers to the integration of behavioral health with primary care as a strategy for improving outcomes for individuals with mental or behavioral health conditions.

PSYCHIATRIC COLLABORATIVE CARE MANAGEMENT (CoCM)

Psychiatric CoCM refers to services provided to an individual seen in a primary care setting who is diagnosed with a mental health or substance abuse disorder. CoCM is a model under BHI services that utilizes regular psychiatric inter-specialty care for individuals receiving BHI treatment. Psychiatric care services are provided through the primary care professional provider in collaboration with a psychiatric professional provider, who reviews the clinical status of the individual and makes recommendations. The primary care team weekly reviews the individual's treatment plan and status with the psychiatric consultant and maintains or adjusts the treatment plan with referrals to specialities in behavioral health as needed.

TRANSITIONAL CARE MANAGEMENT (TCM)

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 and Medicaid (CMS). MLN Fact Sheet. Chronic Care Management Services. December 2016. Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdf. Accessed March 12, 2018.

Centers for Medicare and Medicaid (CMS). Frequently Asked Questions about Billing Medicare for Behavioral Health Integration (BHI) Services. January 2018.
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/Behavioral-Health-Integration-FAQs.pdf. Accessed March 12, 2018.

Centers for Medicare and Medicaid (CMS). MLN Fact Sheet. Advance Care Planning. August 2016. Available at:
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/AdvanceCarePlanning.pdf. Accessed March 12, 2018.

Centers for Medicare and Medicaid (CMS). MLN Fact Sheet. Transitional Care Management Services. August 2016. Available at:
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Transitional-Care-Management-Services-Fact-Sheet-ICN908628.pdf. Accessed March 12, 2018.

Frequently Asked Questions about Billing Medicare for Behavioral Health Integration (BHI) Services January 3, 2018. Available at:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/Behavioral-Health-Integration-FAQs.pdf. Accessed February 22, 2018.

OptumCoding. The Challenge of Coding Complex Chronic Care Coordination. Available at:https://www.optumcoding.com/CodingCentralArticles/?id=1544. Accessed February 23, 2018.




Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

99484, 99487, 99489, 99490, 99491, 99492, 99493, 99494, 99495, 99496, 99497, 99498


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)



G0506 Comprehensive assessment of and care planning for patients requiring chronic care management services (list separately in addition to primary monthly care management service)

G0507 Care management services for behavioral health conditions, at least 20 minutes of clinical staff time, directed by a physician or other qualified health care professional, per calendar month, with the following required elements: initial assessment or follow-up monitoring, including the use of applicable validated rating scales; behavioral health care planning in relation to behavioral/psychiatric health problems, including revision for patients who are not progressing or whose status changes; facilitating and coordinating treatment such as psychotherapy, pharmacotherapy, counseling and/or psychiatric consultation; and continuity of care with a designated member of the care team

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

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


Revenue Code Number(s)

N/A

Coding and Billing Requirements



Policy History

Revisions from 00.01.59e
01/01/2019This 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: Chronic care management services, provided personally by a physician or other qualified health care professional, at least 30 minutes of physician or other qualified health care professional time, per calendar month, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; comprehensive care plan established, implemented, revised, or monitored


Revisions from 00.01.59d
05/07/2018This policy was updated to include information on; General Behavioral Health Integration and Psychiatric Collaborative Care Management Services; 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 00.01.59c
01/01/2018This policy has been identified for the CPT code update effective 01/01/2018.

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

Effective 10/05/2017 this policy has been updated to the new policy template format.
Version Effective Date: 01/01/2019
Version Issued Date: 01/04/2019
Version Reissued Date: N/A

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2017 Independence Blue Cross.
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.