Primary Care Physician - Provider Delivered Care Management


Engrained in the Blue Cross Blue Shield of Michigan (BCBSM) patient centered medical home (PCMH) program, Provider Delivered Care Management (PDCM) is a model where care management is provided within the primary care physicians’ practice by trained care managers. Multi-year studies demonstrated positive outcomes with care manager engagements within the practices. For example, those patients who engaged with care managers had reductions in costs, risk score, and readmissions.

The Physician Alliance (TPA) aims to provide the necessary support to practices to ensure success in mainstreaming the integration of care managers into primary care practices, billing of the 12 PDCM codes and 3 PDCM-related codes, and building additional program criteria to increase revenue growth and improving the quality of care and patient satisfaction.

PDCM is the mechanism used by BCBSM to reimburse for care management and care coordination activities for BCBSM members through the billing of care management codes. Each PDCM patient must have a care plan- either focused or comprehensive. The practice must be able to provide sample care plans upon request. PDCM participation is available to all Patient Centered Medical Home (PCMH) designated practices and Comprehensive Primary Care+ (CPC+) participants.

PDCM care management billing has been available since July 1, 2015 and is the payment methodology that supports the CPC+ and SIM initiatives.

  • For PCMH designated practices to receive an additional 5% PDCM-PCP valued based reimburse (VBR):
    • TPA must attest each fall/winter on the practices’ behalf that the practices have met the eligibility requirements listed below:
      • The practice must have at least one physician that supports care management, and understands the PDCM program (A physician champion must be named).
      • The practice must have either:
        • A lead care manager who has successfully completed the BCBSM approved care manager training within 6 months of beginning to bill the PDCM codes. The care manager must receive the designated care management and self-management training and completed a mandatory online BCBSM billing webinar in addition to obtaining an additional 12 hours of care management training annually.
        • A lead care manager must be either a registered nurse, licensed social worker, physician assistant and/or a nurse practitioner.


  • A qualified healthcare professional who has successfully completed online PDCM training and 8 hours of additional clinical educational webinars annually.
    • The qualified healthcare professional must be either a clinical pharmacist, LPN, certified diabetes educator, registered dietician, masters of science-trained nutritionist, respiratory therapist, certified asthma educator, certified health educator specialist (bachelor’s degree or higher in health education), licensed professional counselor or licensed mental health counselor.
    • The qualified healthcare professional does NOT need to be supervised by an on-site by a lead care manager to bill care management codes however they must have access to a lead care manager.
    • QHP is not considered a lead care manager and therefore will not be able to bill for code G9001.
  • The practice must have a practice panel manager or PO clinical lead that will actively work to close gaps in care across the practice’s population (panel manager or PO clinical lead name must be provided to TPA as part of the attestation process). A panel manager is a clinical team member trained in panel management - the primary contact person for running gaps in care in the practice.
  • The practices must submit claims for a specific percentage per year of BCBSM commercial and Medicare Advantage (MA) PDCM-eligible patients (January 1st –December 31st).
    • In 2018:  At least two paid claims for services provided on separate dates are processed for 3% of the eligible BCBSM Michigan members (In 2018 Blue Cross will count commercial and MA patients in its denominator.)
    • In 2019:  At least two paid claims for services provided on separate dates are processed for 3% of all eligible BCBSM Michigan members (Attributed membership in the Commercial and Medicare Advantage programs.)
  • Practices should strive to engage all high complexity patients flagged in the monthly eligible lists as Blue Cross may soon require practices to engage a specific percentage of high complexity patients to qualify for the PDCM 5% VBR.
  • Codes included in the analysis are: HCPCS codes G9001, G9002, G9007, G9008, S0257 and CPT codes: 98961, 98962, 98966, 98967, 98968, 99487, 99489 and PDCM -related codes: 99495, 99496 and 1111F.
  •  The 5% PDCM-PCP VBR will be assessed annually and will continue, start, or stop based on performance and reaching the required touch rate for the year. Only PCMH designated practices are eligible.



  • More money – earn an additional 5 % PDCM-PCP VBR (PCMH designated practices only)
  • Increased revenue through reimbursement for care management services
  • Improve quality and increase the capture of pay for performance dollars
  • Reduce cost with care being provided in the lower cost settings
  • Add a trained care manager to expand the practice’s care team
  • Prepare your practice to manage risk

There is the potential to earn an additional 5% VBR if the practice qualifies as an advanced practice beginning in 2018. Qualification criteria include:

  • PCMH designation
  • Receipt of the PDCM VBR
  • Capability 13.11 in place (Participating in ADT)
  • Engage in one of the following medication reconciliation activities: capability 13.1 in place or capability 4.10 in place or submitting claims for 1111F
  • Meets 4% touchpoint for attributed Blue Cross population
  • One lead care manager per 2500 members
  • Engage in one of the following telehealth activities: Capability 12.14 in place; or claims data for delivery of telehealth services (codes 99444 with modifier 99441, 99442, or 99443, or codes 98966, 98967, 98968; or telephonic follow-up within 7 days after ED or IP admission for every patient who does not have an in-person follow-up office visit.


Learn more about Provider Delivered Care Management, the benefits to your primary care practice and more : View the presentation

Additional resources:
Care management/PDCM billing and coding webinar presentation
BCBSM PDCM data dictionary information
PDCM updates and eligibility information (2019)
How to open and reply to an encrypted email tip sheet

*Training information PDCM-PCP can be located here.


For more information on the Provider Delivered Care Management program, contact Fran Burley MSN RN CPHQ at (586) 498-3588 or email This email address is being protected from spambots. You need JavaScript enabled to view it..