·:{iC0Fp'16ACOFP 53rd Annual Convention & Scientific Seminars

Transition of Care Management

Danielle Cooley, DO

3/18/2016

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Transition of Care

ManagementDanielle Cooley, DO

Associate Professor, RowanSOM

© 2016 by Danielle Cooley, DO

Background1,2,3,4

January 1, 2013 Centers for Medicare and Medicaid Services

introduced new CPT codes

Care management codes following discharge from inpatient

setting

Transition of Care Management (TCM) Codes

Enhance reimbursement for more complicated case

management

What are the Codes?1,2,3,4,5

99495

99496

There are several key requirements for use of these codes

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When Can You use these Code?1,2,4

Discharge from any of the following settings:

Hospitalization (inpatient or admission or observation

status)

Long term care hospital

Inpatient rehabilitation facility

Skilled nursing facility

Partial hospitalization at a Community Mental Health

Center

Mental health hospitalization

Who Can Provide TCM Services?1,2,4

Physicians (any specialty)

Non-physician practitioners

Certified nurse-midwives

Clinical nurse specialist

Nurse Practitioners

Physician assistants

Resident physicians- patient must be seen by supervising

attending and complied with Medicare requirements

-GC modifier must be used

1st Requirement- Interactive Patient

Contact1,2,3,4

One of the hardest requirements

You must be informed that you patient is being discharged

The patient must be contacted within 48 hours (2 business

days) of discharge, except holidays

However, documentation of 2 unsuccessful attempts to

contact the patient will allow this requirement to be waived

Contact can be telephone, email or face-to-face

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2nd Requirement- Medication

Reconciliation1,2,3,4,6

Medication reconciliation must be completed no later than

the day of face-to-face follow up appointment

Can be completed prior to appointment

Must be documented in the medical record

Allows time to proactively obtain relevant information

3rd Requirement- Face to Face

Encounter1,2,3,4

The physician or appropriate health care provider (PA, NP,

etc) must see the patient within 7 or 14 days of discharge

Services can be provided at a Federally Qualified Health

Center (FQHC) or Rural Health Clinic (RHC)

This can occur in the office, in the patient’s home, or another

location where the patient resides

Non Face-To-Face Services1,5

May be furnished by licensed clinical staff under your

direction

Must be provided, unless they are not medically indicated or

needed

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Services by Physicians or Non-

Physician Providers1,2,5

Obtain and review discharge information

Review need for or follow up on pending diagnostic tests and treatments

Interact with other health care professionals who will assume or re-assume care of the patient’s problems

Provide education to the beneficiary, family, guardian and/or caregiver

Establish or re-establish referrals and arrange for community resources

Assist in scheduling required follow up and with community providers and services

Services Furnished by Licensed

Clinical Staff1,2,5

Communicate with agencies and community services used

by the beneficiary

Provide education to the beneficiary, family, guardian,

and/or care giver to support activities of daily living

Assess and support treatment regimen adherence and

medication management

Identify available community and health resources

Assist the beneficiary and/or family in accessing needed care

and services

The Billing Codes1,2,4,5

99495- visit within 7 or 14 days of discharge with moderate

complexity medical decision making

99496- visit within 7 days of discharge with high complexity

medical decision making

Codes apply to both new and established patients

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Diagnosis Codes with TCM1

Report diagnosis (es) codes for the conditions that require

TCM services

Typically these will be conditions the patient had at the time

of discharge

Medical Decision Making1,2,4

Number of possible diagnoses and/or number of

management options available

Amount and complexity of medical records, diagnostic tests,

and other information that must be obtained, reviewed and

analyzed

Risk of significant morbidity and/or mortality associated

with the patients problems, diagnostic procedures and/or

selected possible management options

Medical Decision Making1,2,3,4

Type of Decision

Making

Number of

Possible

Diagnoses

and/or

Management

Options

Amount and/or

Complexity of Data

to be Reviewed

Risk of Significant

Complications,

Morbidity, and/or

Mortality

Straightforward Minimal Minimal or None Minimal

Low Complexity Limited Limited Low

Moderate Complexity Multiple Moderate Moderate

High Complexity Extensive Extensive High

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Understanding TCM Codes1,3,4,5,6,7

TCM period- Medicare considers it a 30 day length

Discharge day- considered Day 1

Date of Service when billing is 29 calendar days after discharge

Place of service- should be site of face-to-face encounter

Other services can be rendered during the TCM period and

billed as appropriate E/M codes

New option- can bill TCM code immediately but if it gets

denied, will need to re-submit – this may take longer than

waiting the 30 days to submit

Re-admission during TCM

period1,2,3,4,5

If a patient gets re-admitted during the TCM period, a TCM

code can be billed

Previous initial face-to-face visit reverts to appropriate E/M

code with the DOS being the date the patient was seen

TCM code can then be used for the follow up visit following

the 2nd discharge

One TCM per 30 day period1,3,4,5

Only one practitioner can bill for a TCM code during the 30 days

following discharge

Medicare only recognizes only the first eligible claim in the event that

multiple TCM claims are received

Ineligible TCM codes can be converted to appropriate E/M codes

based on services rendered

If a patient dies during the 30 day period, TCM code is ineligible

because the TCM covers the full 30 day period

Ineligible TCM codes due to death can also be converted to

appropriate E/M codes

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Limitations of TCM

Codes1,3,4,5

Same healthcare provider may discharge the patient, report

hospital or observation discharge services and bill TCM

services

Required face-to-face cannot take place on the same day as

discharge

TCM services and services that are within a post-operative

global period cannot be billed by the same practitioner during

the same time period

Coding Limitations with TCM codes2,3,5

G0181 (home health care plan oversight) or G0182 (hospice care plan

oversight)

End Stage Renal Disease Services – 90951-90970

Prolonged services without direct patient contact (99358, 99359)

Anticoagulation management (99363, 99364)

Medical tram conferences (99366-99368)

Education and training (98960-98962, 99071, 99078)

Telephone services (98966-98968, 99441-99443)

Online medical evaluation services (98969, 99444)

Preparation of special reports (99080)

Analysis of data (99090, 99091)

Complex chronic care coordination services (99481X-99483X)

Medication therapy management service (99605-99607)

Other medically necessary billable services can be reported during the

30-day period

Physician Assistants and Nurse

Practitioners1

May provide TCM services but must bill under the CMS

“Incident to” requirements

Residents may provide care for TCMs but must have direct

involvement of a supervising attending physician

Must be billed with GC modifier- indicating that the

supervising physician was present for “key and critical

components” of the service

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Reimbursement for TCMs1,4,5

Code RVU Allowable Charge

99214 1.5 $117.80

99495 2.11 $179.24

99496 3.05 $253.21

Billing Requirements1,2,3,4

Billing requirements- need an internal system

Date of service should be the 30th day

Place of service- should be place of the required face-to-face

visit

Challenge of Billing for TCM6

Finding out quickly that the patient has been discharged

Work with local hospitals

Work with your patients

Work with you hospitalists

Pay close attention to those discharge faxes

Physician portals

Tracking system for billing for the service at the end of the 30 day period

Develop an internal workflow!!!!

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TCM Form for EMR

Put example of our EMR form

TCM Form in EMR

Documentation1

Date of discharge

Date of interactive contact with the beneficiary and/or

caregiver

Date of face to face visit

Complexity of medical decision making

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References 1Medicare learning network. http://go.cms.gov/MLNProducts. Accessed 1/7/16.

2TCM. American Medical Association. http://www.sccma-mcms.org/Portals/19/assets/docs/TCM-CPT.pdf. Accessed 1/7/16.

3Frequently Asked Questions about Billing Medicare for Transitional Care Management Services. https://www.cms.gov/medicare/medicare-fee-for-service-payment/physicianfeesched/downloads/faq-tcms.pdf. Accessed 2/2/16.

4Billing for Transitional Care Management. Medical Economics. http://medicaleconomics.modernmedicine.com/medical-economics/news/billing-transitional-care-management?page=full. Accessed 2/2/16.

5Frequently Asked Questions: Transitional Care Management. AAFP. http://www.aafp.org/dam/AAFP/documents/practice_management/payment/TCMFAQ.pdf. Accessed 2/2/16

6What Practices Need to Know about Transition Care Management Codes. American College of Physicians. http://www.aafp.org/fpm/2013/0500/p12.html accessed 1/7/16.

7http://www.primarycarecoding.com/tcm-date-of-service/?ur=1C3CDCH3