Transitional Care Management

Transcription

1 Transitional Care Management Jill Young - CPC, CEDC, CIMC East Lansing, Michigan 1 Disclaimer This material is designed to offer basic information for coding and billing. The information presented here is based on the experience, training, and interpretation of the author. Although the information has been carefully researched and checked for accuracy and completeness, the instructor does not accept any responsibility or liability with regard to errors, omissions, misuse, or misinterpretation. This handout is intended as an educational a guide and should not be considered a legal/consulting opinion 2 1

2 What is TCM? Providing or overseeing the management and coordination of services, as needed All medical conditions Psychosocial needs Activity of daily living supports Requiring moderate or high-complexity medical decision making during the transition 3 CMS Comments Physicians should not undertake TCM services unless they are capable and willing to assume comprehensive responsibility for a patient's care during the period of the service We believe the lengthy list of services is quite appropriate to the nature of the service. 4 2

3 Transition From Where to Where? Patient Discharged From: Inpatient hospital setting Including acute hospital, rehabilitation hospital, longterm acute care hospital Partial hospitalization Observation status in a hospital Skilled nursing facility/nursing facility, Patient Discharged To: The patient s community setting Home Domiciliary Rest home Assisted living 5 Transition From Where to Where? TO a Skilled Nursing Facility (SNF) Cannot bill TCM Use codes for initial, subsequent, discharge care and annual facility assessment 6 3

4 Transition From Where to Where? FROM Skilled Nursing Facility (SNF) to Community or Nursing Facility May bill TCM Even when the SNF and nursing facility are part of the same entity or located in the same building 7 Code Description Transitional Care Management Services with the following 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 Transitional Care Management Services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge Medical decision making of high complexity during the service period Face-to-face visit within 7 calendar days of discharge 8 4

5 Medical Decision Making 9 Who is eligible to bill? Provider Types MDs and DOs (regardless of specialty) Physician assistants Nurse practitioners Clinical nurse specialists Certified nurse midwives 10 5

6 Who Initiates TCM Is Appropriate No specific mention in final rule Discharging Physician is referenced in communications Discharge Planner by default seems appropriate Is NOT Appropriate Phone call from hospital for patient appointment Phone call from patient/family for post discharge appointment 11 Day of Discharge Care Discharging Physician or NPP Billing discharge care 99217, , , or MAY NOT use visit on date of discharge as required E&M MAY provide and bill TCM subsequently 12 6

7 Day of Discharge Care Non Discharging Physician or NPP (Community Physician) May be primary care physician or NPP Maybe other physician or NPP Pt new or established to practice May perform the required TCM face-to-face E&M visit on date of discharge May provide remainder of TCM services subsequently 13 Discharging Physician vs Community Physician Discharging physician Expectation they would communicate with the community physician As necessary As part of billing for discharge day management services. 14 7

8 Discharging Physician vs Community Physician Community physician Responsible for reviewing the discharge summary, Can decide whether standard clinical practice indicates the need for further communication with the discharging physician. 15 Initial Contact Interactive contact with the patient or caregiver required Within 2 business days of discharge May be direct (face-to-face), telephonic, or by electronic means. telephonic, or by electronic means Who performs? Any exceptions??? 16 8

9 Business Days Per Final rule normal business days Monday Friday 17 Medication Reconciliation Medication reconciliation and management must occur no later than the date of the face-to-face visit. 18 9

10 Face-To-Face Visits First face-to-face visit Part of the TCM service May not be reported separately. Additional reasonable and necessary E/M services * If required for managing the beneficiary's clinical issues May be reported separately. 19 Face-To-Face Visit When 7 days or 14 days after discharge TCM Code is determined by patient s MDM at that visit How Medical decision making during the service period At least moderate complexity during the service period Of high complexity during the service period 20 10

11 Medical Decision Making (MDM) Moderate Complexity Multiple possible diagnoses and/or the management options Moderate complexity of the medical data (tests, etc.) to be reviewed Moderate risk of significant complications, morbidity, and/or mortality as well as comorbidities High Complexity Extensive number of possible diagnoses and/or the management options Extensive complexity of the medical data (tests, etc.) to be reviewed High risk of significant complications, morbidity, and/or mortality as well as comorbidities 21 Face To Face Visit Appointment Challenges If provider unavailable or does not have any openings in the required timeframe for the face-toface visit Cannot bill TCM Not an excuse No wiggle room 22 11

12 Place of Service Typically the required face-to-face visit is in the physician office May also be in home or other location where patient resides Home Domiciliary Rest home Assisted living 23 Other E&M Services In CMS s final rule Emergency Department visits are allowed when billing TCM Medically necessary E&M s are allowed and are billed as per traditional guidelines for service* Modifier 25? Diagnosis may or may not be same as for facility stay Other members of same group may bill for E&M services that are not part of TCM within the 30 days 24 12

13 Other Services Lab, X-ray, Testing, Injections May be done & billed same day as initial face-toface TCM visit Bill on date of service performed 25 Non-Face-to-Face Services by Clinical Staff Under direction of a physician or other qualified health care professional Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge. Regarding aspects of care Communication with home health agencies and other community services utilized by the patient. Patient and/or family/caretaker education to support self-management, independent living, and activities of daily living

14 Non-Face-to-Face Services by Clinical Staff Under direction of a physician or other qualified health care professional cont d Assessment and support for treatment regimen adherence and medication management. Identification of available community and health resources. Facilitating access to care and services needed by the patient and/or family. 27 Non-Face-to-Face Services by Provider Obtaining and reviewing the discharge information (for example, discharge summary, as available, or continuity of care documents). Reviewing need for or follow-up on pending diagnostic tests and treatments. Interaction with other qualified health care professionals who will assume or reassume care of the patient's system-specific problems

15 Non-Face-to-Face Services by Provider Education of patient, family, guardian, and/or caregiver. Establishment or reestablishment of referrals and arranging for needed community resources. Assistance in scheduling any required follow-up with community providers and services. 29 Who Can Provide Service Elements? CPT describes services by the physician's staff and/or licensed clinical staff under his or her direction Medicare encourages practitioners to follow CPT guidance in reporting TCM services. Medicare requires that when a practitioner bills Medicare for services and supplies commonly furnished in physician offices, the practitioner must meet the incident to requirements described in Chapter 15 Section 60 of the Benefit Policy Manual

16 Licensed Clinical Staff Regulations at Services and supplies incident to a physician s professional services: Amend (b) Services and supplies must be furnished in accordance with applicable State law. Require that the individual performing incident to services meets any applicable requirements to provide the services, including licensure, imposed by the State in which the services are being furnished. 31 Date of Service TCM begins on the date of discharge Continues for the next 29 days Report date of service as day 30 Do not submit bill until 31st day Date of discharge entered into Box

17 Diagnosis Use diagnosis code that best reflects the patient s condition Should support medical necessity of medical decision making level chosen 33 Services in the Global Period Physicians providing services that have either a 010 or 090 day global CANNOT BILL Transitional Care Management AMA RUC recommends working to develop an appropriate code for these services 34 17

18 Once Per Patient within 30 Days Only one individual may report these services Only once per patient within 30 days of discharge Same individual or group may NOT report TCM for any subsequent discharge(s) within the 30 days. May report hospital or observation discharge services and transitional care management 35 Patient s Re-admission TCM Service is for a 30 day period If 30 days not met because of re-admission Restart service New contact within 2 business days of discharge New Face to face visit within 7 or 14 days of discharge Report the TCM required face-to-face visit under traditional outpatient E&M service codes at the level of care provided/documented 36 18

19 Patient s Death If care is less than 30 days CANNOT BILL TCM codes What can you bill Report face-to-face visit under traditional outpatient E&M service codes at the level of care provided/documented 37 Patient Co-Pay TCM could not be classified as an additional preventive service. Cannot waive copay Face-to-face visit gives meaning to copay Reduce the possibility of increased bad debt for physicians

20 Multiple TCM Care Codes Submitted for Payment Medicare pays only the first eligible claim submitted (rush to bill) Other practitioners may continue to report other reasonable and necessary services, including other E/M services, to beneficiaries during those 30 days 39 Care Plan Oversight If billing TCM code may not report: Care plan oversight services Home health care oversight Hospice care plan oversight 40 20

21 Other Services Edited Out Education & Training for patient self management Non face-to-face Non physician services Special services procedures reports (educational supplies, education in group) Prolonged care Anticoagulation management Medical Team conference Telephone services Online medical evaluation Medication Therapy management services 41 Documentation Suggestions Document the date, time and content of the initial communication with the patient and/or caregiver. Identify who provides this care. Summarize the inpatient course, based on the discharge summary, if available, and conversations with the patient, caregiver and others involved in the care. The purpose of this would be to establish the anticipated complexity of the services

22 Documentation Suggestions Document the face-to-face visit as you would any E&M visit, making sure that the medication reconciliation is adequately documented, as well as the plan of care. Although the face-to-face visit does not need to meet the requirements for existing E&M codes, documentation should support the medical necessity and complexity of the overall transitional care management services. 43 Documentation Suggestions Document all communications with home health agencies, qualified healthcare providers and other individuals and agencies involved in the patient s care. Have clinical staff document the date, time, duration and content of any of their communications involving the patient

23 Template for TCM Documentation Name DOB Discharging Physician Date of Discharge Discharge summary Discussion with discharging physician Summarize hospitalization Diagnosis Medications on discharge Noting reconciliation done Notation of interactive contact Date, who, service or method 45 Template for TCM Documentation Diagnostic tests Services Community Other care givers and agencies Education 46 23

24 Template for TCM Documentation Documentation of Medical Decision Making Use MDM template from HGSA Audit tool Notations of follow up care instructions and follow up visits 47 Myths TCM is only for established patients Medicare has a G code for TCM not CPT Patient must have been seen by provider in prior 30 days TCM can only be provided by a primary care physician There are specific chronic conditions that a patient is required to have to be eligible for TCM services 48 24

25 Recap of Claim Details Date of service 30 th day Place of service Location of face to face visit Service code Moderate MDM High MDM Additional E&M services as medically necessary 49 Transitional Care Management Reimbursement Moderate Complexity 4.58 RVU = $ High Complexity 6.47 RVU = $ Patient has 20% co-pay - $ $

26 References FAQ CMS March 13, 2013 Individual Medicare Carrier FAQ WPS 51 QUESTIONS??? Thank you! 52 26