Coordination of Care: How to Implement in Practice

1. Coordination of Care: How to Implement in Practice Melissa Gaines MD Assistant Professor October 4, 2013

2. Purpose

3. Care Transitions

4. Care Transitions

5. Care Transitions • Barriers to Safe Transitions

6. 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

7. 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

8. Case Challenges • No discharge summary • Potential missed intervention with battery change in BiVAICD • Medication change • CHF patient with syncope • Insurance change

9. Care Coordination Codes • Transitional Care Management (TCM) Codes • 99495 • 99496

10. TCM Codes • Once in a 30 day period after discharge • Acute hospital • Rehabilitation hospital • Long term acute care hospital • SNF/NF

11. 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

12. 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

13. TCM Codes • 99496 • Contact 2 business days • Face-to-face visit within 7 calendar days • Medication reconciliation at time face-to-face • MDM highcomplexity (level 5) • Medicare reimbursement • $218.26

14. TCM Codes

15. TCM Codes • Documentation • Must document initial contact occurred • 2 separate attempts in a timely manner if unsuccessful • MDM only component required

16. 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

17. Team Based Care • KU Adult Medicine Providers Dr. Gaines Debbie APRN Lisa RN

18. Day 1 Day 2 Day 3-7 Front Office Nursing Provider Call arrives for hospital follow-up appointment Pull discharge med reconciliation Patient arrives for appointment with appropriate pre-visit planning & documentation available Confirm date discharge & record appointment scheduled within 7 days with PCP or APRN Patient phoned next morning to review meds, order labs, answer questions EMR codes 99495 99496 EMR updated Send list of pts to nurse at end of day See screen shots

19. Day 1 Day 2 Day 3-7 Provider Nursing Nursing Receive Discharge documents Appointment scheduled within 7 days with PCP or APRN Patient arrives for appointment with appropriate pre-visit planning & documentation available Forward documents to RN Patient phoned review meds, order labs, answer questions Pull discharge med reconciliation Provider EMR updated Bill 99495 99496

20. 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)

21. EMR Documentation

22. EMR Documentation Contact Meds

23. TCM Code Results • January 1-July 30 • 49 TCM visits • Payment for 42 visits

24. Insurance and TCM • Paid • Aetna • Coventry • Medicare • Humana • Advantra • Unpaid • BCBS • Requesting notes and explanation of code

25. Insurance and TCM

26. Conclusion • Care transitions are valued with higher reimbursement • Proper documentation of initial contact is essential • Visit must be within 7-14 days after discharge

27. 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

28. Questions?