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TRANSITIONAL CARE MANAGEMENT Codes 99495; 99496 CMMI September 2015

TRANSITIONAL CARE MANAGEMENT Codes 99495; 99496 CMMI September 2015. Transitional Care Management Codes. What are Transitional Care Management Codes 99495 and 99496? What are the Requirements and Services? What is Necessary to Bill TCM?. Transitional Care Management. CMS Definition:

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TRANSITIONAL CARE MANAGEMENT Codes 99495; 99496 CMMI September 2015

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  1. TRANSITIONAL CARE MANAGEMENTCodes 99495; 99496CMMISeptember 2015 www.flhsa.org

  2. Transitional Care Management Codes • What are Transitional Care Management Codes 99495 and 99496? • What are the Requirements and Services? • What is Necessary to Bill TCM? www.flhsa.org

  3. Transitional Care Management CMS Definition: “The management of (Medicare) patient’s transition from an inpatient to a community setting. Contact with the patient within 2 business days following discharge, and a face-to-face visit within either 7 or 14 calendar days of discharge depending on the complexity of the medical decision-making involved in the patient’s care.” • Code 99495 - for moderately complex cases seen within 14 days ~ $160 reimbursement • Code 99496 - for highly complex cases seen within 7 days~$225 reimbursement • 20% patient coinsurance and deductible apply www.flhsa.org

  4. Transitional Care Management Requirements TCM period begins on the date of discharge and continues for 29 days: There are three required elements: • An interactive contact (telephone, portal, email or face-to face) with patient and/or caregiver within 2 business days of discharge, M-Fexcluding holidays • Prompt interactive communication • Clinical staff under general supervision1 • Medication reconciliation and management performed no later than the date of the face-to-face visit • 7 or 14 Day follow up office visit (based on medical complexity as determined by Physician or Advance Practice Provider) 1. Effective January 1, 2015 (42 CFR§ 410.26(b)(5) www.flhsa.org

  5. Transitional Care Management Requirements • 7 day visit for highly complex - extensive number of possible diagnoses and/or management of options, extensive complexity of medical data (e.g., tests) to be reviewed, and a high risk for significant complications, morbidity and/or mortality, as well as co-morbidities. • 14 day visit for moderately complex – multiple diagnoses and/or management of options, moderate complexity of medical data (e.g. tests) to be reviewed and moderate risk of complications, morbidity or mortality as well as co-morbidities. www.flhsa.org

  6. Who Can Provide Services • Intent is to engage the patient with the primary care practices. (can include other specialties) • FQHC and RHC can bill face-to-face • Advance Practice Providers (APP) • Certified Nurse-Midwife • Clinical Nurse Specialists • Nurse Practitioners • Physicians Assistants • Licensed Clinical Staff can perform services under the direction of the Physician or APP www.flhsa.org

  7. Physician/APP Services • Generally responsible for overseeing management and coordination of services for all medical conditions, psychosocial needs, and ADL supports. • CMS expects these services unless not medically indicated or needed: • Obtain/review discharge information • Review need for, or follow-up on, pending diagnostic tests and treatments • Interact with other providers involved in patient’s care • Educate patient, family, guardian, and/or caregiver • Arrange for needed community resources • Assist in scheduling any required follow-up with community providers and services www.flhsa.org

  8. Licensed Clinical Staff Services CMS expects services unless not medically needed or indicated • Communicate with home health agencies and other community services utilized by patient • Educate regarding self-management, independent living, and activities of daily living • Assess and support treatment regimen adherence and medication management • Identify available community and health resources www.flhsa.org

  9. Billing TCM Codes • When and who can you bill • No sooner than 30day following discharge • Only one provider can report TCM services and only once in 30 day period • Other specialties can bill, first to bill will be paid! • What must be documented in medical record? • Discharge Date • Date of Communication or two failed attempts within 2 days must be documented to fulfill 2 business day rule • Date of face-to-face visit • Visit that occurs within 2 business days can count as communication and visit • Documentation to support complexity of decision making only www.flhsa.org

  10. Billing TCM… • Re-admitted to Hospital: • If provider has completed TCM services, the provider can bill an E/M visit with a modifier and restart 30 day period after the second discharge • If provider has completed TCM services, report TCM including the time following the second discharge towards the 30 day period. • E/M visits during the TCM Period • E/M visits including visits for the same condition can be billed with the exception of Coumadin management. • When billing TCM, cannot bill: • Chronic Care Coordination Services (99487-99489) • Home Health and Hospice Supervision (G0181,G0182) • End Stage Renal Disease Services (90951-90970) • Coumadin patients may not bill an E&M code (99211) • Additional codes refer to CPT Guidelines www.flhsa.org

  11. Panel Discussion • How did you stratify the work? • What has worked well in your process? • What challenges/barriers did you find when you started TCM? Are they still a barrier? • What impact has it had on readmissions? www.flhsa.org

  12. Sources • Transitional Care Management Services Fact Sheethttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications-Items/ICN908628.html • Frequently Asked Questions about Billing Medicare for Transitional Care Management Services http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/FAQ-tcms.pdf • Frequently Asked Questions: Transitional Care Managementhttp://www.aafp.org/dam/AAFP/documents/practice_management/payment/TCMFAQ.pdf • Providing and Billing Medicare for Transitional Care Management Updated November 2014http://www.pyapc.com/resources/collateral/white-papers/TCM-whitepaper-PYA.pdf • Transitional Care Management Services: New Codes, New Requirementshttp://www.aafp.org/fpm/2013/0500/p12.html • “The Future of PC MD Payments” Harvard University, April 2014www.wehealny.org/services/ipa/files/Transitional%20Care%20Management%20and%20Coding_JGoodsonMD_CPPIPA_April%202014.pdf www.flhsa.org

  13. Finger Lakes Health Systems Agency The triangle represents our agency’s role as a fulcrum—the point on which a lever pivots—boosting the community’s health by leveraging the strengths of all stakeholders. The fulcrum is also a point of equilibrium, reflecting our ability to balance the needs of consumers, providers and payers on complex health matters. The inner triangle also evokes the Greek letter delta—used in medical and mathematical contexts to represent change—with a forward lean as we work with our community to achieve positive changes in health care. Give me a lever long enough and a fulcrum on which to place it, and I shall move the world. —Archimedes 1150 University Avenue • Rochester, New York • 14607-1647 585.461.3520 • www.FLHSA.org www.flhsa.org

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