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

Nothing to Disclose 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 re- hospitalized 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, , 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, , 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, , 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: 7/28/2015© 2015, Thomas J. Weida, M.D.12 1.Inpatient Acute Care Hospital 2.Emergency Room 3.Inpatient Rehab Facility 4.Hospital Outpatient Observation 5.Skilled Nursing Facility

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: 7/28/2015© 2015, Thomas J. Weida, M.D.14 1.Home 2.Domiciliary 3.Rest Home 4.Partial Hospitalization 5.Assisted Living

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 7/28/2015© 2015, Thomas J. Weida, M.D.16 1.True 2.False

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 7/28/2015© 2015, Thomas J. Weida, M.D.17

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

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 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 Voic 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 7/28/2015© 2015, Thomas J. Weida, M.D.21 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 7/28/2015© 2015, Thomas J. Weida, M.D.22 DOCUMENT

Medical Decision Making 2 of 3 Elements meet or exceed level 7/28/2015© 2015, Thomas J. Weida, M.D.23 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 7/28/2015© 2015, Thomas J. Weida, M.D.24 DOCUMENT

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

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

Transitional care team  Transitional care coordinator: Kim McMillian  Nurse: Amy Yourbrought  Social Services: Robert McKinney  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  Comprehensive medical management.  Early access: within 48 hours a phone call to check on patient, confirm appointment and assess need for transportation.  Medication reconciliation.  Address cost and affordability of medication.  Psychological and behavioral support.

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

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

Aim of TCM  Patient wellbeing, health promotion and maintenance.  Comprehensive patient care as a part of patient centered medical home.  Providing community resources.  Reduction of ER utilization.  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, ) –Prolonged without direct patient contact (99358, 99359) –Anticoagulation 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 ( ) 7/28/2015© 2015, Thomas J. Weida, M.D.39

TCM – RVU’s for – Work RVU: 2.11 Non Facility RVU: 4.63, Payment $ F acility total RVU: 3.13, Payment $ – Work RVU: 3.05 Non Facility RVU: 6.50, Payment $ Facility total RVU: 4.51, Payment $ For comparison – Work RVU: 1.50 Non Facility RVU: 3.03, Payment $ 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 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

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, , April 2011

And I can’t resist a few E&M codes

Office visit for a 70 year old female, established patient, with diabetes mellitus and hypertension, presenting with a 2 month history of increasing confusion, agitation and short term memory loss. 7/28/2015© 2015, Thomas J. Weida, M.D

Outpatient visit for a 77 year old male, established patient, with hypertension, presenting with a three month history of episodic sub-sternal chest pain on exertion. 7/28/2015© 2015, Thomas J. Weida, M.D

7/28/2015 © 2015, Thomas J. Weida, M.D or more chronic illnesses with severe exacerbation, progression or side effects of treatment Acute or chronic illnesses or injuries posing threat to life or function (MI, PE, Resp distress) Abrupt neuro status change (TIA, Sx, weakness, sensory loss) 4 HPI elements 10 ROS 1 of each PFSH Comprehensive (general multisystem or complete single organ) Decision Making History Physical 40 min

7/28/2015 © 2015, Thomas J. Weida, M.D chronic stable illnesses 2+ or more chronic stable illnesses 1+ chronic illness with exacerbation Undiagnosed new problem with uncertain diagnosis Acute illness with systemic symptoms Acute complicated injury 4 HPI elements 2-9 ROS 1 of 3 PFSH Detailed (affected area and related organ system) Decision Making History Physical 25 min

7/28/2015 © 2015, Thomas J. Weida, M.D or more self limited problems 1 stable chronic illness acute uncomplicated illness (cystitis, sprain) 1-3 HPI elements Pertinent ROS Expanded problem focused Decision Making History Physical 15 min