Transitional Care Codes New Codes, New Requirements

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1 Transitional Care Codes New Codes, New Requirements Karen W. Foster, MSA, RN Project Facilitator New Jersey Academy of Family Physicians NJAFP This presentation and content shared during this session can not be copied, shared or disseminated without prior written approval from NJAFP; doing so is in violation of copyright laws and regulations. What is Transitional Care Management (TCM) TCM includes services provided to a patient whose medical and or psychosocial problems require moderate or high complexity medical decision making during the transition in care from an inpatient setting Slide 2 Background of TCM No clear consensus on how many readmissions may be preventable Studies show readmission rates vary from 5-70% 2005 claims data showed ¾ of readmissions within 30 days were potentially preventable 2009 CMS began public reporting of hospital readmission rates US government estimates avoidable readmissions cost Medicare 17 Billion/Yr Slide 3 NJAFP Advanced Topics - June 12,

2 Period of Handoff and Timely Notification Transitional codes address the handoff period when risks for errors are the highest Work with local hospitals or hospitalists request fax or secure or call Work with your patients- educate them to notify you when admitted Pay close attention to those discharge faxes Slide 4 Medication 1 in 5 patients have adverse event transitioning from hospital to home 2 out of 3 adverse events are related to prescriptions List should include when to take and how much and for how long Possible side effects and whether new ones replace old ones that are to be discarded Slide 5 Care Outside the Hospital ¾ of patients that leave hospital with chronic conditions wouldn t need return trip if they had follow up plan of care In 2009 less than half of patients saw a primary care physician within 2 weeks of leaving the hospital Slide 6 NJAFP Advanced Topics - June 12,

3 Discharge Plans Creating a detailed written discharge plan before they leave the hospital Discharge Plans should include, medications any new equipment that they will need at home, follow up office appointment When caregivers have the copy of discharge sheet, test results and plan of care they can assist in the recovery Slide 7 Codes for TCM Required Elements * Communication ( direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge * Medical Decision making of at least moderate complexity during the service period * Face to Face visit within 14 calendar days of discharge Slide 8 TCM Codes (cont) Required Elements * Communication ( direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge * Medical Decision making of at least high complexity during the service period * Face to Face visit within 7 calendar days of discharge * Medication Reconciliation no later than the face to face meeting. Slide 9 NJAFP Advanced Topics - June 12,

4 Interactive contact Services can be furnished by Physician or non-physician providers Educating Family or patient about independent living and self management Interact with other health care professionals Review need for follow up on diagnostic tests and treatment Establish or re-establish referrals and arrange for community resources Assist in scheduling required follow up with community providers and services Slide 10 Interactive Contact Services furnished by Licensed Clinical staff under the direction of Provider of Mid Level Communication with agencies and community services Provide education to the patient and family to support self management Review Discharge Information Access and support treatment regimen and med management Identify available community and health resources Assist the patient and or family in accessing needed care and service Slide 11 Documentation Date the patient was discharged Date you made the interactive contact Date you furnished the face to face Complexity of medical decision making (moderate or high) Slide 12 NJAFP Advanced Topics - June 12,

5 How much are these services worth Payment allowances will vary by payer and Medicare will vary by geographic location. Also Medicare s allowance will vary on the conversion factor in force at the time the claims are paid. Based on the current 2012 conversion factor in a physicians office is about $ 163 and $135 in a facility setting and is about $231 in a physician office and $197 in a facility setting Slide 13 Tricky Aspect Only one practitioner may bill for TCM services during the 30 days after the discharge Mostly expected this will be Primary Care Provider Specialist can bill, Hospitalist cannot bill Only the first practitioner to bill will be reimbursed for it. Coordination to decide who is responsible for the TCM services with providers and specialist Slide 14 TCM Billing Time Frame TCM commences on the day of discharge and continues for the next 29 days. The bill for these services should be submitted on the 30 th day after discharge as TCM covers 30 days of management. The date on the claim should be the 30th day following discharge The diagnosis code billed typically will be the condition that the patient had at the time of discharge Slide 15 NJAFP Advanced Topics - June 12,

6 Challenges Catching codes before they drop MA s remembering to link visit to the episode to cue the provider to use or code Tracking re-admission within the episode Varying levels of understanding of process by staff and providers Knowing when the patient is discharged from the hospital Hospitalist can add a wrinkle to discharge communications. Slide 16 TRANSITIONAL CARE MANAGEMENT (TCM) PROCESS FACE-TO-FACE must show TCM content. Not combined with other billing codes that day (except relevant labs, imaging, etc.). Does not exclude most additional services provided outside day of face-to-face. INITIAL CONTACT must show TCM content. If unsuccessful, 2 documented attempts counts, and then keep trying. DISCHARGED from: IP acute, rehab, SNF Observational, day-treatment No ED discharges TCM INITIAL CONTACT INPATIENT DISCHARGED Provider Monitor discharge reports Care Coordinators Obtain hospital records Non-Licensed Staff Document TCM initial contact (using Tel Encounter) Advise on F/U urgency and pre-visit planning Tel Encounter Pre Visit Planning labs, imaging, referrals Anticipate problems Prep patient ed Prep shared decision aids Schedule face-to-face. Add reason: Transitional Care. Add billing note: D/C date (i.e. D/C 10/25/13 ). TCM FACE-TO-FACE Document TCM face-to-face with med rec. If visit is within 7 days, use code (High MDM) or (Moderate MDM). If within 8-14 days, use only HUDDLE Administer patient experience survey Post Visit Planning Referrals DME, home health Community resources Planned follow-up Care plan CODING AND BILLING Provide/Bill additional services as needed Coders: Hold TCM code until after 30 th day postdischarge. Record Date of service as day 30 10/29/13 Developed by Braden Duncan, LMSW, St Vincent Health System, Little Rock. Practitioners may copy or adapt for use in their own practices Practice Sharing Woodbridge Internal Medical Associates Woodbridge, New Jersey Lillian Greco, Practice Administrator Water Street Physicians Toms River, New Jersey Donna Pino, Practice Administrator Slide 18 NJAFP Advanced Topics - June 12,

7 Questions??????? Slide 19 Slide 20 NJAFP Advanced Topics - June 12,

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