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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.

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coordination of care how to implement in practice

Coordination of Care: How to Implement in Practice

Melissa Gaines MD

Assistant Professor

October 4, 2013

care transitions2
Care Transitions
  • Barriers to Safe Transitions
case example
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 example1
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
Case Challenges
  • No discharge summary
  • Potential missed intervention with battery change in BiVAICD
  • Medication change
  • CHF patient with syncope
  • Insurance change
care coordination codes
Care Coordination Codes
  • Transitional Care Management (TCM) Codes
    • 99495
    • 99496
tcm codes
TCM Codes
  • Once in a 30 day period after discharge
    • Acute hospital
    • Rehabilitation hospital
    • Long term acute care hospital
    • SNF/NF
tcm codes1
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 codes2
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 codes3
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
tcm codes5
TCM Codes
  • Documentation
    • Must document initial contact occurred
    • 2 separate attempts in a timely manner if unsuccessful
    • MDM only component required
tcm codes6
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
Team Based Care
  • KU Adult Medicine Providers

Dr. Gaines

Debbie APRN

Lisa RN

slide18

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

slide19

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

emr documentation
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)
tcm code results
TCM Code Results
  • January 1-July 30
    • 49 TCM visits
    • Payment for 42 visits
insurance and tcm
Insurance and TCM
  • Paid
    • Aetna
    • Coventry
    • Medicare
    • Humana
    • Advantra
  • Unpaid
    • BCBS
      • Requesting notes and explanation of code
conclusion
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
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