Coordination of Care: How to Implement in Practice

Melissa Gaines MDAssistant Professor

October 4, 2013

Purpose

Care Transitions

Care Transitions

Care Transitions

• Barriers to Safe Transitions

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

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

Case Challenges

• No discharge summary• Potential missed intervention with battery

change in BiVAICD• Medication change• CHF patient with syncope• Insurance change

Care Coordination Codes

• Transitional Care Management (TCM) Codes– 99495– 99496

TCM Codes

• Once in a 30 day period after discharge– Acute hospital– Rehabilitation hospital– Long term acute care hospital– SNF/NF

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

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

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

TCM Codes

TCM Codes

• Documentation– Must document initial contact occurred– 2 separate attempts in a timely manner if

unsuccessful– MDM only component required

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

Team Based Care

• KU Adult Medicine Providers

Debbie APRN Lisa RN Dr. Gaines

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 1 Day 2 Day 3-7

Provider

Patient arrives for appointment with

appropriate pre-visit planning &

documentation available

EMR codes 9949599496

See screen shots

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 1 Day 2 Day 3-7

Provider

Patient arrives for appointment with

appropriate pre-visit planning &

documentation available

Bill9949599496

Nursing

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)

EMR Documentation

EMR Documentation

Contact

Meds

TCM Code Results

• January 1-July 30– 49 TCM visits– Payment for 42 visits

Insurance and TCM

– Paid• Aetna • Coventry • Medicare• Humana• Advantra

– Unpaid• BCBS

– Requesting notes and explanation of code

Insurance and TCM

Charge Average Reimbursement

Highest Reimbursement

99495 (14 day) $270 $140 $218.60

99496 (7 day) $385 $205 $327.25

Conclusion

• Care transitions are valued with higher reimbursement

• Proper documentation of initial contact is essential

• Visit must be within 7-14 days after discharge

References

• http://www.acponline.org/running_practice/payment_coding/coding/tcm_codes.htm

• http://www.aafp.org/dam/AAFP/documents/practice_management/payment/TCMFAQ.pdf

Questions?