How To Bill Medicaid For Case Management

Targeted Case Management Monthly Limit

11/12/2020

Dear Provider and Staff,

WellCare of Kentucky has some important information to share with you regarding targeted case management billing and payment.

WellCare has discovered that some providers are billing multiple units of targeted case management per member, per month. As a reminder, reimbursement for targeted case management is a monthly, all-inclusive rate consisting of one unit.

Depending upon the type of targeted case management , the provider must have four to five TCM contacts with the recipient to quality for reimbursement.

This notice is to remind you that WellCare will only pay for one unit of targeted case management per member per month and will deny any claims exceeding one unit.

Additionally, if you were erroneously paid for more than one unit of TCM for a member for a given month, WellCare intends to recover any such overpayment in accordance with KRS 304.17A-714.

If you have any question regarding this notice, please contact your Provider Relations representative.

Sincerely,

Billable Activities: Definitions And Sample Tasks

Assessment Activities

Facilitation of Transition Options Team process to complete a comprehensive community needs and risk assessment and periodic reassessment of member needs to determine the need for community-based supports and services.

Assessment – Sample Tasks

• Gathering information from a member regarding his/her needs, preferences and concerns related to community living
• Identifying the member’s community living goals in community living
• Gathering information from other sources such as family members, medical providers, and/or social workers to form a complete community needs assessment of the member and
• Completing related documentation.
• Facilitate transition options team meetings and discussions to complete community needs and risk assessments
• Obtain and review any relevant and/or required information needed for the completion of the community needs and risk assessments
• Reassess risk mitigation needs based on new information, change in condition or the occurrence of an incident related to identified risk factor.

Development of Transition and Risk Mitigation Plans:

Service and Support Coordination

Coordination of the non-Medicaid services and supports being provided as identified in the Transition Plan and the Risk Mitigation Plan to ensure continuity of service and support provision.

Service Planning/Coordination Sample Tasks

Risk Mitigation Plan Review:

Discharge Planning:

Child Health Services Targeted Case Management

Medicaid reimburses for services under the Child Health Services Targeted Case Management program for recipients from birth up to 3 years of age who are receiving services through the Department of Health Childrens Medical Services Early Steps program or recipients up to 21 years of age who are receiving services through the Department of Health Childrens Medical Services foster care contractors. These services assist Medicaid recipients in gaining access to medical social, educational, and other support services.

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Advocate For Services Identified In The Service Plan

• Provide counsel and support to the person receiving services and other appropriate parties as necessary to prepare them for entry, transfer or termination from a program
• Provide information on Medicaid State Plan benefits
• Contact with members family members or informal supports to assist member with accessing community-based supports.
• Advocate for the members preferences regarding community living options/resources
• Promote of members self-advocacy
• Promote person-centered practices

Cpt Codes For Case Management Patient Education And Other Miscellaneous Services

The following Current Procedural Terminology codes represent supportive or miscellaneous services that supplement or are adjunct to direct patient care. Supportive services, such as case management or patient education services, are designed to enhance or assist a patient with treatment goals or to monitor treatment effectiveness. Miscellaneous services generally provide a means to report the completion of special services that are adjunct to basic treatment and evaluation services, such as completing special reports or providing medical testimony. For virtual services, such as e-visits, virtual check-ins, telephone assessments, and remote monitoring, see ASHA’s web page on communication technology-based services.

Medicare does not recognize these codes for billing by audiologists and speech-language pathologists . However, other payers may elect to cover them. Before initiating services, always verify coverage directly with the payer and notify patients that they may be responsible for payment of non-covered services.

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See also: Virtual Services

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Medicaid Targeted Case Management

The Social Security Act, § 1915, defines case management services as those assisting individuals eligible under the State plan in gaining access to needed medical, social, educational, and other services. Case management services do not include the direct delivery of an underlying medical, educational, social, or other service for which an eligible individual has been referred. Payments for case management services may not duplicate payments made to public agencies under other program authorities for the same service. Prior OIG work in one State identified 18 percent of such claims as unallowable, with an additional 20 percent as potentially unallowable. We will determine whether Medicaid payments for targeted case management services in selected States were made in accord with Federal requirements.

Education And Training For Patient Self

Use these codes to report educational and training services to an individual or a group of patients for the purpose of teaching the patient how to self-manage their condition or disorder.

98960 Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient each 30 minutes individual patient

98961 24 patients

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Targeted Case Management Transition Coordination Procedure Code Table

Providers may bill procedure codes for Targeted Case Management Transition Coordination as follows:

Medicaid Definition Of Covered Case Management Services Clarified

MEDICAID DEFINITION OF COVERED CASE MANAGEMENT SERVICES CLARIFIED

The Centers for Medicare & Medicaid Services interim final rule with comment period implementing section 6052 of the Deficit Reduction Act of 2005 clarifies the Medicaid definition of covered case management and targeted case management services. The rule includes measures to address concerns about improper billing of non-Medicaid services to the Medicaid program by some states, while also including significant beneficiary protections that ensure comprehensive and coordinated services to meet the needs of beneficiaries.

Case management consists of services which help beneficiaries gain access to needed medical, social, educational, and other services. Targeted case management services are those aimed specifically at special groups of enrollees such as those with developmental disabilities or chronic mental illness.

Widespread improper billing by states of the Medicaid program for services mandated by other programs helped prompt Congress to address the problem in the DRA, which redefined the scope of allowable case management services, strengthened state accountability, and required that CMS issue regulations.

Defines case management

o the IFC reiterates the definitions of case management and targeted case management services contained in sections 1905 and 1915 of the Social Security Act and

o are an integral component of another Medicaid service

o constitute the administration of foster care programs

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