1. Coordination of Care: How to Implement in Practice Melissa Gaines MD Assistant Professor October 4, 2013

2. Purpose

3. Care Transitions

5. Barriers to Safe Transitions

6. Case Example 56 yo female with CAD, CHF and BiVAICD presents for hospital follow-up 6 days after dismissal Discharge summary is not available She presented with syncope after taking nitroglycerin for chest pain. She remained hypotensive and Valsartan was discontinued. She needs scheduled for her BiVAICD battery replacement She reports increased anxiety because she is losing her medical card

7. Case Example Labs – TSH 1.36 – FT4 2.3 – Chol 147 – LDL 75 – HDL 33 – TG 194 – Troponin <0.01 x3 Radiology – CT Head negative – CXR emphysematous changes

8. Case Challenges No discharge summary Potential missed intervention with battery change in BiVAICD Medication change CHF patient with syncope Insurance change

9. Care Coordination Codes Transitional Care Management (TCM) Codes – 99495 – 99496

10. TCM Codes Once in a 30 day period after discharge – Acute hospital – Rehabilitation hospital – Long term acute care hospital – SNF/NF

11. TCM Codes Requirements – Initial patient/caregiver contact Phone Electronic Face-to-face – Within 2 business days after discharge – Physician, mid-level, licensed clinical staff Capacity to address medical concerns related to care of the patient

12. TCM Codes 99495 – Contact 2 business days – Face-to-face visit within 14 calendar days – Medication reconciliation at time face-to-face – MDM moderate complexity (level 4) – Medicare reimbursement $154.52

13. TCM Codes 99496 – Contact 2 business days – Face-to-face visit within 7 calendar days – Medication reconciliation at time face-to-face – MDM high complexity (level 5) – Medicare reimbursement $218.26

14. TCM Codes

15. Documentation – Must document initial contact occurred – 2 separate attempts in a timely manner if unsuccessful – MDM only component required

16. TCM Codes Billing – Bill TCM code at day 30 from discharge – Only 1 TCM code per 30 days – Regular E/M codes for return visits

17. Team Based Care KU Adult Medicine Providers Debbie APRNLisa RN Dr. Gaines

18. Call arrives for hospital follow-up appointment Front Office Confirm date discharge & record appointment scheduled within 7 days with PCP or APRN Send list of pts to nurse at end of day Nursing Patient phoned next morning to review meds, order labs, answer questions Pull discharge med reconciliation EMR updated Day 1Day 2 Day 3-7 Provider Patient arrives for appointment with appropriate pre-visit planning & documentation available EMR codes 99495 99496 See screen shots

19. Receive Discharge documents Provider Appointment scheduled within 7 days with PCP or APRN Forward documents to RN Nursing Patient phoned review meds, order labs, answer questions Pull discharge med reconciliation EMR updated Day 1Day 2 Day 3-7 Provider Patient arrives for appointment with appropriate pre-visit planning & documentation available Bill 99495 99496 Nursing

20. EMR Documentation Pre-visit Planning Auto text phrasing – Patient's hospital records with history, d/c summary, labs, and x-rays were requested and reviewed. Time spent face-to-face – 25 Minutes Level 4 (MDM) – 40 Minutes Level 5 (MDM)

21. EMR Documentation

22. Contact Meds

23. TCM Code Results January 1-July 30 – 49 TCM visits – Payment for 42 visits

24. Insurance and TCM – Paid Aetna Coventry Medicare Humana Advantra – Unpaid BCBS – Requesting notes and explanation of code

25. Insurance and TCM ChargeAverage Reimbursement Highest Reimbursement 99495 (14 day)$270$140$218.60 99496 (7 day)$385$205$327.25

26. Conclusion Care transitions are valued with higher reimbursement Proper documentation of initial contact is essential Visit must be within 7-14 days after discharge

27. References http://www.acponline.org/running_practice/p ayment_coding/coding/tcm_codes.htm http://www.acponline.org/running_practice/p ayment_coding/coding/tcm_codes.htm http://www.aafp.org/dam/AAFP/documents/ practice_management/payment/TCMFAQ.pdf

28. Questions?