Conundrums Transitional Care Management Thomas Weida M D

Conundrums: Transitional Care Management Thomas Weida, M. D. Associate Dean for Clinical Affairs College of Community Health Sciences The University of Alabama, Tuscaloosa

Nothing to Disclose http: //ak-hdl. buzzfed. com/static/2014 -03/enhanced/webdr 05/18/17/enhanced-24336 -1395177770 -9. jpg 7/28/2015 © 2015, Thomas J. Weida, M. D. 2

Objectives • Implement proper use of Transitional Care Management Codes in the office; • Demonstrate appropriate documentation for Transitional Care Management Codes. • Differentiate the two levels of payment for Transitional Care Management Codes. • Improve quality and decrease cost by implementing Transitional Care Management

Medicare Data • 90% of hospital readmissions within 30 days of discharge are unplanned • One fifth of Medicare patients rehospitalized within 30 days of discharge • 60% experience medication errors • Cost Medicare $15 billion annually • Contributes to deterioration of function, reduced symptom-free days and decreased satisfaction with health care

Readmission Risk Factors • • • >80 with other factors Moderate to severe functional deficits Inability to manage daily tasks or self-care Depression 4 or more active coexisting health conditions • 6 or more prescribed standing medications

Readmission Risk Factors • 2 or more hospitalizations within the past 6 months • Hospitalization within the past 30 days • Baseline dementia • Treatment during hospitalizations for delirium • Lack of family caregiver support • Low health literacy • Social issues

Results of TCM • 20 of 21 studies of TCM assessed reported positive results in at least 1 outcome – Health Outcomes – Quality of Life – Patient Satisfaction/Perception of Care – Resource Use (including readmissions) – Costs Naylor, Mary; Aiken, Linda; et al, “The Importance of Transitional Care in Achieving Health Reform, ” Health Affairs, Vol. 30 no. 4, 746 -754, April 2011

Positive Outcomes • Nine studies • Positive effect on – Total all-cause readmissions – Time to first readmission – Length of readmission stay • Statistically significant positive effects Naylor, Mary; Aiken, Linda; et al, “The Importance of Transitional Care in Achieving Health Reform, ” Health Affairs, Vol. 30 no. 4, 746 -754, April 2011

Positive Outcomes of the 9 • 8 of 9 reduced all cause readmission for at least 30 days after discharge • 3 of 9 reduction effect lasted 6 -12 mo. – 2 of 3 used comprehensive discharge planning and home visits • 2 studies reported cost savings per Medicare patients of $3, 000 at 6 months and $5, 000 at 12 months Naylor, Mary; Aiken, Linda; et al, “The Importance of Transitional Care in Achieving Health Reform, ” Health Affairs, Vol. 30 no. 4, 746 -754, April 2011

Transitional Care Management (TCM) Services • Services required during transition to the community following certain discharges • No gap in care provided during transition • Medical or psychosocial problems of moderate or high complexity decision making • Takes responsibility for patient’s care • Can be used for new or established patients 7/28/2015 © 2015, Thomas J. Weida, M. D. 10

Who may provide TCM service • Physicians (any specialty) • Non-physician practitioners (NPP) – Physician assistants – Nurse practitioners – Clinical nurse specialists – Certified nurse-midwives 7/28/2015 © 2015, Thomas J. Weida, M. D. 11

Transitional Care Management Services include discharges from all of the below except: 1. Inpatient Acute Care Hospital 2. Emergency Room 3. Inpatient Rehab Facility 4. Hospital Outpatient Observation 5. Skilled Nursing Facility 7/28/2015 © 2015, Thomas J. Weida, M. D. 12

Includes Discharges From: • • • Inpatient Acute Care Hospital Inpatient Psychiatric Hospital Long Term Care Hospital Skilled Nursing Facility Inpatient Rehab Facility Hospital Outpatient Observation or Partial Hospitalization • Partial Hospitalization at Community Mental Health Center 7/28/2015 © 2015, Thomas J. Weida, M. D. 13

TCM Services include transition to all of the following except: 1. 2. 3. 4. Home Domiciliary Rest Home Partial Hospitalization 5. Assisted Living 7/28/2015 © 2015, Thomas J. Weida, M. D. 14

Returning To: • • Home Domiciliary Rest Home Assisted Living 7/28/2015 © 2015, Thomas J. Weida, M. D. 15

Communication (direct contact, telephone, electronic) must be made with a response with the patient and/or caregiver within 2 days of discharge 1. True 2. False 7/28/2015 © 2015, Thomas J. Weida, M. D. 16

99495: Moderate Complexity • Communication (direct contact, telephone, electronic) with response with patient and/or caregiver within 2 business days of discharge • Medical decision making of at least MODERATE complexity during the service MODERATE period • Face-to-face visit within 14 calendar days of 14 discharge • Ongoing care management (Non-face-to-face services) for 30 days post discharge 7/28/2015 © 2015, Thomas J. Weida, M. D. 17

High Complexity TCM code (99496) includes all of the following except: 1. Communication (direct contact, telephone, electronic) with response with patient and/or caregiver within 2 business days of discharge 2. Medical decision making of HIGH complexity HIGH during the service period 3. Face-to-face visit within 10 calendar days of 10 discharge 4. Ongoing care management (Non-face-to-face services) for 30 days post discharge 7/28/2015 © 2015, Thomas J. Weida, M. D. 18

99496: High Complexity • Communication (direct contact, telephone, electronic) with response with patient and/or caregiver within 2 business days of discharge • Medical decision making of HIGH complexity HIGH during the service period • Face-to-face visit within 7 calendar days of discharge • Ongoing care management (Non-face-to-face services) for 30 days post discharge 7/28/2015 © 2015, Thomas J. Weida, M. D. 19

Post Discharge Communication Within 2 Days of Discharge • Must be interactive: document patient or caregiver’s response • Can be face-to-face or non-face-to-face • Voicemail not adequate • Attempts to communicate should continue after the first 2 attempts within the required 2 business days until they are successful • Rules unclear if this meets criteria 7/28/2015 © 2015, Thomas J. Weida, M. D. 20 DOCUMENT

Non-face-to-face Services by Physicians or NPP’s • Obtain and review discharge info • Review need for or follow-up on pending tests and treatments • Interact with other health care professionals • Provide education to patient, family, caregiver • Establish referrals and arrange community services • Assist in scheduling follow-up services DOCUMENT 7/28/2015 © 2015, Thomas J. Weida, M. D. 21

Non-face-to-face Services by Licensed Clinical Staff • Under Physician or NPP direction • Communication with agencies and community services • Education to support self-management • Identify available community and health resources • Assist patient/family in accessing needed care and services DOCUMENT 7/28/2015 © 2015, Thomas J. Weida, M. D. 22

Medical Decision Making • 2 of 3 Elements meet or exceed level Decision Making # of Possible Diagnoses and/or Management Options Amount and/or Complexity of Data Risk of Significant Complications, Morbidity and/or Mortality Moderate Multiple Moderate High Extensive High 7/28/2015 © 2015, Thomas J. Weida, M. D. 23

Medication Reconciliation and Management • Furnished no later than the date of the Face-to-Face Visit DOCUMENT 7/28/2015 © 2015, Thomas J. Weida, M. D. 24

Initial Transitional Care Contact Note Need to send to clinician 7/28/2015 © 2015, Thomas J. Weida, M. D. 25

Clinician note • Documentation must include timing of initial contact, date of face-to face visit, complexity of medical decision making 7/28/2015 © 2015, Thomas J. Weida, M. D. 26

Transitional Care Visit Plan: Clinician Note Discharge Date: _ Initial transitional care contact documentation reviewed and was made on _ (if documented patient contact not made within 2 business days of discharge, TCM does not apply) Medical Decision Making: _ Moderately or Highly Complex (seen within 14 days of discharge) (99495) _ Highly Complex (seen within 7 days of discharge) (99496) Medication Reconciliation: _ Medication list reconciled _ Medication list given to patient/family/caregiver at discharge Referrals: _ None _ Care manager _ Referred to: _

Community Resources identified for patient/family: _ None needed _ Home health agency for: _ _ Office of aging _ Assisted living _ Hospice _ Support group for: _ _ Physical therapy for: _ _ Occupational therapy for: _ _ Education program for: _ _ Other: _ Durable medical equipment: _ None _ DME ordered: Type: _ Duration: _

Additional communication delivered or planned to: _ Family/caregiver: _ _ Home health agency: _ _ Specialists: _ _ Other: _ Patient Education: _ Topics discussed: _ _ Handouts given: _ Other: _ Follow-up visit: _ days _ weeks _ months Other plans: _

After face to face visit • Nurse care manager needs to document ongoing care management activities and ideally time spent doing care coordination/managing activities. • Note needs to be sent to clinician to review 7/28/2015 © 2015, Thomas J. Weida, M. D. 30

TCM: An Example Ø Location: UMC Ø Clinic: Outpatient Ø Day: Thursday am Ø Number of patients 5 -8 patients every week.

Transitional care team Ø Ø Ø Ø Transitional care coordinator: Kim Mc. Millian Nurse: Amy Yourbrought Social Services: Robert Mc. Kinney Dietitian: Susan Henson Clinical pharmacology: Danna Caroll Behavioral medicine fellow: Calia Torres Residents: Upper level resident and an Intern Faculty: Tamer Elsayed, MD

Our Service Ø Comprehensive medical management. Ø Early access: within 48 hours a phone call to check on patient, confirm appointment and assess need for transportation. Ø Medication reconciliation. Ø Address cost and affordability of medication. Ø Psychological and behavioral support.

Our Service Ø Review of discharge summary. Ø Follow up on pending tests and labs. Ø Health education. Ø Open access to our clinic, patient may walk in, evening clinic. Ø 24/7 Answering service. Ø Dedicated transitional care nurse.

Our Service Ø Social services: transportation, meals on wheels, home condition, medical supplies, social support. Ø Community resources utilization: Home health, physical therapy. Ø Follow up phone call, after visit. Ø Appointment with PCP within 2 weeks. Ø Home visit as needed.

Aim of TCM Ø Patient wellbeing, health promotion and maintenance. Ø Comprehensive patient care as a part of patient centered medical home. Ø Providing community resources. Ø Reduction of ER utilization. Ø Reduction of hospital readmission.

Billing TCM • Reported once during the TCM period with reported date of service on the 30 th day post discharge (discharge day counted as day 1) • Only one clinician can bill per TCM period within 30 days of discharge • If readmitted within 30 days, can bill, but cannot bill a second TCM if second discharge within 30 days of first discharge, or can bill regular E&M for first post discharge visit and restart TCM after the second discharge

Billing TCM • Place of service site of face-to-face • Can bill additional E&M services if needed during 30 day period • Can bill in postoperative global period if clinician did not do the operation • Cannot do TCM face-to-face visit on same day as discharge. • Cannot bill if patient dies before 30 days

TCM • Cannot use the following with TCM: – – – Care plan oversight (99339, 99340, 99374 -99380) Prolonged without direct patient contact (99358, 99359) Anticoagulation management (99363, 99364) Medical team conferences (99366 -99369) Education and training (98960 -98962, 99071, 99078) Telephone (98966 -98968, 99441 -99443) End-stage renal disease (90951 -90970) Online medical evaluation (98969, 99444) Preparation of special reports (99080) Analysis of data (99090, 99091) Complex chronic care coordination (99487 -99489) Medication therapy management (99605 -99607) 7/28/2015 © 2015, Thomas J. Weida, M. D. 39

TCM – RVU’s for 2015 • 99495 – Work RVU: 2. 11 • Non Facility RVU: 4. 63, Payment $165. 54 • Facility total RVU: 3. 13, Payment $111. 91 • 99496 – Work RVU: 3. 05 • Non Facility RVU: 6. 50, Payment $232. 41 • Facility total RVU: 4. 51, Payment $161. 25 • For comparison • 99214 – Work RVU: 1. 50 • Non Facility RVU: 3. 03, Payment $108. 34 • Facility total RVU: 2. 21, Payment $79. 02 • Codes billed 30 days after discharge 7/28/2015 © 2015, Thomas J. Weida, M. D. 40

The Challenges for TCM Billing • Connecting with the patient within 2 business days – If you’re discharging the patient, inform them that you will be calling • Holding the bill for 30 days after discharge when a face to face visit is done before 14 days post discharge – Keep a manual 30 day file folder for bill submission

References • http: //www. aafp. org/dam/AAFP/documents/practi ce_management/payment/TCM 30 day. pdf • http: //www. aafp. org/dam/AAFP/documents/practi ce_management/payment/TCMFAQ. pdf • http: //www. cms. gov/Outreach-and. Education/Medicare-Learning-Network. MLN/MLNProducts/Downloads/Transitional-Care -Management-Services-Fact-Sheet. ICN 908628. pdf

References • Naylor, Mary, Sochalski, Julie, Scaling Up: Bringing the Transitional Care Model into the Mainstream, Commonwealth Fund pub 1453, Vol. 103, November 2010 • Bixby, M. Brian, Evidence-Based Transitional Care for Chronically Ill Older Adults and Their Caregivers, New Journal of Geriatric Care Management, Winter 2011 • Naylor, Mary; Aiken, Linda; et al, “The Importance of Transitional Care in Achieving Health Reform, ” Health Affairs, Vol. 30 no. 4, 746 -754, April 2011