Coordination of Care: How to
Implement in Practice
Melissa Gaines MD
Assistant Professor
October 4, 2013
Purpose
Care Transitions
Care Transitions
Care Transitions
• Barriers to Safe Transitions
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
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
Case Challenges
• No discharge summary
• Potential missed intervention with battery
change in BiVAICD
• Medication change
• CHF patient with syncope
• Insurance change
Care Coordination Codes
• Transitional Care Management (TCM) Codes
– 99495
– 99496
TCM Codes
• Once in a 30 day period after discharge
– Acute hospital
– Rehabilitation hospital
– Long term acute care hospital
– SNF/NF
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
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
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
TCM Codes
TCM Codes
• Documentation
– Must document initial contact occurred
– 2 separate attempts in a timely manner if
unsuccessful
– MDM only component required
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
Team Based Care
• KU Adult Medicine Providers
Debbie APRN
Lisa RN
Dr. Gaines
Day 1
Front Office
Day 2
Nursing
Call arrives for
hospital follow-up
appointment
Pull discharge
med
reconciliation
Confirm date
discharge & record
appointment
scheduled within 7
days with PCP or
APRN
Patient
phoned next
morning to
review
meds, order
labs, answer
questions
Send list of
pts to
nurse at
end of day
Day 3-7
Provider
Patient arrives for
appointment with
appropriate pre-visit
planning &
documentation
available
EMR
codes
99495
99496
EMR
updated
See
screen
shots
Day 1
Provider
Receive Discharge
documents
Forward
documents
to RN
Day 2
Day 3-7
Nursing
Nursing
Appointment
scheduled within
7 days with PCP or
APRN
Patient arrives for
appointment with
appropriate pre-visit
planning &
documentation
available
Patient
phoned
review
meds, order
labs, answer
questions
EMR
updated
Pull discharge
med
reconciliation
Provider
Bill
99495
99496
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)
EMR Documentation
EMR Documentation
Contact
M
TCM Code Results
• January 1-July 30
– 49 TCM visits
– Payment for 42 visits
Insurance and TCM
– Paid
•
•
•
•
•
Aetna
Coventry
Medicare
Humana
Advantra
– Unpaid
• BCBS
– Requesting notes and explanation of code
Insurance and TCM
Charge
Average
Reimbursement
Highest
Reimbursement
99495 (14 day)
$270
$140
$218.60
99496 (7 day)
$385
$205
$327.25
Conclusion
• Care transitions are valued with higher
reimbursement
• Proper documentation of initial contact is
essential
• Visit must be within 7-14 days after discharge
References
• http://www.acponline.org/running_practice/p
ayment_coding/coding/tcm_codes.htm
• http://www.aafp.org/dam/AAFP/documents/
practice_management/payment/TCMFAQ.pdf
Questions?