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Coordination of Care: How to Implement in Practice
Melissa Gaines MDAssistant Professor
October 4, 2013
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Purpose
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Care Transitions
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Care Transitions
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Care Transitions
• Barriers to Safe Transitions
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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
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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
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Case Challenges
• No discharge summary• Potential missed intervention with battery
change in BiVAICD• Medication change• CHF patient with syncope• Insurance change
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Care Coordination Codes
• Transitional Care Management (TCM) Codes– 99495– 99496
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TCM Codes
• Once in a 30 day period after discharge– Acute hospital– Rehabilitation hospital– Long term acute care hospital– SNF/NF
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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
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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
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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
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TCM Codes
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TCM Codes
• Documentation– Must document initial contact occurred– 2 separate attempts in a timely manner if
unsuccessful– MDM only component required
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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
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Team Based Care
• KU Adult Medicine Providers
Debbie APRN Lisa RN Dr. Gaines
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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
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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
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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)
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EMR Documentation
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EMR Documentation
Contact
Meds
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TCM Code Results
• January 1-July 30– 49 TCM visits– Payment for 42 visits
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Insurance and TCM
– Paid• Aetna • Coventry • Medicare• Humana• Advantra
– Unpaid• BCBS
– Requesting notes and explanation of code
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Insurance and TCM
Charge Average Reimbursement
Highest Reimbursement
99495 (14 day) $270 $140 $218.60
99496 (7 day) $385 $205 $327.25
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Conclusion
• Care transitions are valued with higher reimbursement
• Proper documentation of initial contact is essential
• Visit must be within 7-14 days after discharge
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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
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Questions?