Thomas Weida, M.D. Professor, Family and Community Medicine Penn State College of Medicine Transitional Care Management Complex Chronic Care Management

Nothing to Disclose 4/5/2014© 2014, Thomas J. Weida, M.D.2

Objectives Implement proper use of Transitional Care Management Codes in the office Prepare practice for upcoming Complex Care Coordination Codes and Advanced Directive Codes

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 4/5/2014© 2014, Thomas J. Weida, M.D.4

Who may provide TCM service Physicians (any specialty) Non-physician practitioners (NPP) –Physician assistants –Nurse practitioners –Clinical nurse specialists –Certified nurse-midwives 4/5/2014© 2014, Thomas J. Weida, M.D.5

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 4/5/2014© 2014, Thomas J. Weida, M.D.6

Returning To: Home Domiciliary Rest Home Assisted Living 4/5/2014© 2014, Thomas J. Weida, M.D.7

99495: Moderate Complexity Communication (direct contact, telephone, electronic) with response with patient and/or caregiver within 2 business days of discharge MODERATEMedical decision making of at least MODERATE complexity during the service period 14Face-to-face visit within 14 calendar days of discharge Ongoing care management (Non-face-to-face services) for 30 days post discharge 4/5/2014© 2014, Thomas J. Weida, M.D.8

99496: High Complexity Communication (direct contact, telephone, electronic) with response with patient and/or caregiver within 2 business days of discharge HIGHMedical decision making of HIGH complexity during the service period 7Face-to-face visit within 7 calendar days of discharge Ongoing care management (Non-face-to-face services) for 30 days post discharge 4/5/2014© 2014, Thomas J. Weida, M.D.9

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 Voic not adequate Attempts to communicate should continue after the first 2 attempts within the required 2 business days until they are successful 4/5/2014© 2014, Thomas J. Weida, M.D.10 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 4/5/2014© 2014, Thomas J. Weida, M.D.11 DOCUMENT

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 4/5/2014© 2014, Thomas J. Weida, M.D.12 DOCUMENT

Medical Decision Making 2 of 3 Elements meet or exceed level 4/5/2014© 2014, Thomas J. Weida, M.D.13 Decision Making# of Possible Diagnoses and/or Management Options Amount and/or Complexity of Data Risk of Significant Complications, Morbidity and/or Mortality ModerateMultipleModerate HighExtensive High

Medication Reconciliation and Management Furnished no later than the date of the Face-to-Face Visit 4/5/2014© 2014, Thomas J. Weida, M.D.14 DOCUMENT

Initial Transitional Care Contact Note Need to send to clinician 4/5/2014© 2014, Thomas J. Weida, M.D.15

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: _ per Connected patient education. _ Other: _ Follow-up visit: _ days _ weeks _ months Other plans: _

Clinician note Documentation must include timing of initial contact, date of face-to face visit, complexity of medical decision making 4/5/2014© 2014, Thomas J. Weida, M.D.19

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 4/5/2014© 2014, Thomas J. Weida, M.D.20

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, ) –Prolonged without direct pt contact (99358, 99359) –Anticoag management (99363, 99364) –Medical team conferences ( ) –Education and training ( , 99071, 99078) –Telephone ( , ) –End-stage renal disease ( ) –Online medical evaluation (98969, 99444) –Preparation of special reports (99080) –Analysis of data (99090, 99091) –Complex chronic care coordination ( ) –Medication therapy management ( ) 4/5/2014© 2014, Thomas J. Weida, M.D.23

TCM – RVU’s for – Work RVU: 2.11 Non Facility RVU: 4.58, Payment $ F acility total RVU: 3.11, Payment $ – Work RVU: 3.05 Non Facility RVU: 6.47, Payment $ Facility total RVU: 4.50, Payment $ For comparison – Work RVU: 1.50 Non Facility RVU: 3.01, Payment $ Facility total RVU: 2.21, Payment $79.17 Codes billed 30 days after discharge 4/5/2014© 2014, Thomas J. Weida, M.D.24

References ce_management/payment/TCM30day.pdfhttp:// ce_management/payment/TCM30day.pdf ce_management/payment/TCMFAQ.pdfhttp:// ce_management/payment/TCMFAQ.pdf Education/Medicare-Learning-Network- MLN/MLNProducts/Downloads/Transitional- Care-Management-Services-Fact-Sheet- ICN pdfhttp:// Education/Medicare-Learning-Network- MLN/MLNProducts/Downloads/Transitional- Care-Management-Services-Fact-Sheet- ICN pdf

Coming Attractions Complex Chronic Care Coordination now Chronic Care Management Services (CCMS) –99490 –Medicare won’t pay until 2015 –Medicare did not adopt or Advanced Care Planning – –Not yet published in Final Rule 4/5/2014© 2014, Thomas J. Weida, M.D.26

Chronic Care Management Services (CCMS) Staff Time for CCCCCode Less than 20 minutesNot reported separately At least 20 minutes minutes minutes99487 and minutes or more99487 and x 2 and for each additional 30 minutes Reported once per calendar month

CMS CCMS Definition “Furnishing care management to beneficiaries with multiple chronic conditions requires multidisciplinary care modalities that involve: regular physician development and/or revision of care plans; subsequent reports of patient status; review of laboratory and other studies; communication with other health professionals not employed in the same practice who are involved in the patient’s care; integration of new information into the care plan; and/or adjustment of medical therapy.”

99490 Multiple (2 or more) chronic conditions expected to last at least 12 months or until the death of the patient Significant risk of death, acute exacerbation/decompensation or functional decline Establishment or substantial revision of a comprehensive care plan 20 minutes or more of clinical staff time directed by a physician or other qualified health care professional per calendar month Cannot double count staff time (2 staff meeting) Face-to-face visit not required

CCMS Office Requirements 24/7 access/contact for acute chronic care needs Continuity of care with a designated care team member with whom the patient can schedule successive routine appointments Timely follow-up access and management after ER or discharge EHR with timely access to clinical information Standardized method to ID patients requiring CCM Receives CCCC in a timely manner once identified Standardized form and format for documentation Educate patient & caregivers; coordinate care

CCMS Plan of Care Problem list Expected outcome and progrnosis Measurable treatment goals Symptom management Planned interventions Medication management and reconciliation Community/social services ordered Communication with outside entities Written or electronic copy for patient

Typical Care Management Communicate with patient, caregiver, professionals, home health agencies, community services Collect health outcomes data and registry documentation Self-management, independent living, and ADL support Assessment and support for treatment and med manage Identify available community and health resources Facilitating access to care and services Ongoing review of patient status, labs and studies Development, communication, and maintenance of a comprehensive care plan based on a physical, mental, cognitive, psychosocial, functional and environmental assessment

99490 Billing Can only bill once a month Cannot be billed with CPT , or CPT Cannot be billed by multiple clinicians in same month Patient must sign written agreement to have services provided, can withdraw at any time Payment $42.60

Advanced Care Planning –Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified healthcare professional; first 30 minutes, face-to-face with the patient, family member(s) and/or surrogate –each additional 30 minutes

Advanced Care Planning An advance directive is a document appointing an agent and/or recording the wishes of a patient pertaining to his/her medical treatment at a future time should he/she lack decisional capacity at that time. Examples of wri1tten advance directives include, but are not limited to, Health Care Proxy, Durable Power of Attorney for Health Care, Living Will and Medical Orders for Life-Sustaining Treatment (MOLST). When using these codes, no active management of the problem(s) is undertaken during the time period reported. Can be reported with another E&M code on the same day