Coming soon: We’re changing how we issue value‑based reimbursements for PDCM outcomes

Effective Jan. 1, 2022, Blue Cross Blue Shield of Michigan will change the way it issues value-based reimbursements for outcomes related to Provider-Delivered Care Management.

No action is required from provider organizations or health care providers at this time. We simply want to make them aware of the process. 

Eligibility for value-based reimbursements for PDCM outcomes has already been determined, and changes in the process started Sept. 1, 2021.

Through Dec. 31, 2021, value-based reimbursements for PDCM outcomes will continue to be paid as they are today. Starting January 2022, and for each month thereafter, Blue Cross will produce a claim on behalf of eligible providers for each attributed member. The attribution will include:

• Members who have Blue Cross Blue Shield of Michigan coverage and live in Michigan
• Members who have coverage through another Blue plan

This value-based reimbursement claim for PDCM outcomes will be represented by one procedure code and not spread across multiple codes (as with the percentage VBR).

Keep the following in mind:

• Each month, Blue Cross will produce a claim on behalf of the eligible physician. The claim will include procedure code S0281, diagnosis code Z0289 and modifier 3P. 

• The value-based reimbursement amount is dependent on the VBR percentage the provider earned as of Sept. 1. 

• The dollar amount varies from $0.40 to $1.60 per attributed member per month, based on the chart below. 

• This change only affects value-based reimbursements for PDCM outcomes. All other value-based reimbursements will remain unchanged.

See the below charts for additional details:

Adults

Pediatric

Measure	Composite measure	Performance threshold	Potential rate	Improvement percent	Value-based reimbursement amount
Emergency department encounters (per 1,000 members per year)	N/A	164	55	10%	$0.40 per attributed member per month
Inpatient encounters (per 1,000 members per year)	N/A	13.5	1	9%	$0.40 per attributed member per month
Follow-up after emergency department visit for mental illness	PEDCOMP1	56%	N/A	N/A	$0.80 per attributed member per month
Follow-up care for children prescribed ADHD medication — continuation and maintenance phase	PEDCOMP1	47%	N/A	N/A
Asthma medication ratio — 5 to 11 ratio > 50%	PEDCOMP1	44%	N/A	N/A
Asthma medication ratio — 12 to 17 ratio > 50%	PEDCOMP1	65%	N/A	N/A

If you have any questions, send an email to ValuePartnerships@bcbsm.com.

None of the information included in this article is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with all applicable state and federal laws and regulations.