Transitional Care Management - Mistakes, CCM Interface, and the 2016 Fee Schedule Changes

Transcription

1 Transitional Care Management - Mistakes, CCM Interface, and the 2016 Fee Schedule Changes Stephen Canon, M.D. Program Director & Associate Professor UAMS Department of Urology Chief, Division of Pediatric Urology ACH Auxiliary-John F. Redman, M.D. Endowed Chair Arkansas Children's Hospital Chief Medical Officer, Phyzit, Inc. April 11, 2016 Speaker Disclosures Pediatric Urologist

2 Speaker Disclosures Phyzit, Inc. Outline Review the impact of hospital readmission and Transitional Care Management (TCM) Discuss the 5 Biggest Mistakes of Transitional Care Management Review the 2016 CMS TCM Fee Schedule Changes Discuss the interface between TCM and Chronic Care Management 2

3 Heading home after AAPC? TCM Pop Quiz 1. What percentage of Medicare patients are readmitted within 30 days of hospital discharge? a. <5% b. 5-10% c % d. 50% 3

4 TCM Pop Quiz 2. Hospital Readmissions cost Medicare how much annually? a. $24 million b. $240 million c. $2.4 billion d. $24 billion TCM Pop Quiz 3. Data exists demonstrating reduction in hospital readmissions with implementation of Transitional Care Management Program. True False 4

5 TCM Pop Quiz 4. For TCM, the initial communication must be completed within: a. 24 hours b. 2 business days c. 2 calendar days d calendar days TCM Pop Quiz 5. The face-to-face visit must take place within the following time period after hospital discharge: a. 2 Calendar days b. 2 Business days c. 7 Business days d. 14 Business days e. Either c or d 5

6 TCM Pop Quiz 6. Which of the following must always be accomplished to justify TCM billing? a. Medicine reconciliation b. Moderate to highly complex decision making c. Prevention of readmission for 30 days following discharge d. Both a and b e. All of the above TCM Pop Quiz 7. The date of service for TCM billing occurs on which date? a. Calendar day 7 after discharge b. Calendar day 14 after discharge c. On day of face-to-face for TCM within 7 to 14 calendar days d. Calendar day 29 after discharge e. Any day within 1 month after discharge 6

7 Hospital Readmissions For every 5 Medicare patients admitted to the hospital, how many will be readmitted within 30 days after discharge? Almost 1 of 5 patients are readmitted per month In 2011, 1.8 million 30 day Medicare readmissions cost $24 billion What conditions have the highest readmission rates (2011)? Congestive Heart Failure 134,500 Septicemia 92,900 Pneumonia 88,800 COPD 77,900 Cardiac dysrhythmias 69,400 June 10,

8 Readmissions - Payers Medicare 58.2% Medicaid 20.6 % Private 18.6% Regional Disparity in Readmissions 8

9 How can we keep patients healthy and out of the hospital? Enhanced Case Management In the 1990s, with the advent of managed care, organizations began case management to reduce preventable readmissions Fitzgerald JF, Smith DM, Martin DK, et al. A case manager intervention to reduce readmissions. Arch Intern Med. 1994;154:

10 Section 3025 ACA Added section 1886(q) to the Social Security Act establishing Hospital Readmission Reduction Program: Began October 2012 Hospitals penalized for high readmissions within 30 days of hospital discharge Focus on Transitional Care Management/ TCM Program for transitioning patients back to their home environment after hospitalization. Improvement of communication between hospital and PCP or specialist office required. Increased oversight in a non-face-to-face fashion required. Prompt reevaluation in person with a face-toface visit also inherent to the process. 10

11 Transitional Care Management The Centers for Medicare and Medicaid Services (CMS) added transitional care management (CPT Code 99495/99496) to the list of services that are reimbursable in January, CMS invested an estimated 1.34 Billion dollars per year through creation of TCM codes Awareness of TCM (2014) Have you heard of the following: CPT Transitional Care Management Services ( )? Are you interested in earning additional revenue through TCM? O Byrne, Bill. (2014, November 1). Help NJ-HITEC Conduct Research on Transitional Care Management [E-Newsletter]. Retrieved from 11

12 Does TCM make an impact on reducing readmissions? No clear definition of a successful care transition has been established. These outpatient and billable TCM visits are the focus of this review because other hospitalinitiated interventions. 12

13 Meta-analysis: Roper et al Systematic review of 3 databases between that report on readmissions in the US Of 969 studies identified - 77 met inclusion criteria but only 3 included all elements for TCM Three institutional improvement studies identified with no randomized trials performed Readmission reduction 8.87 % 1.8 % 19.9 % 13

14 White et al The Journal of Family Practice, patients following hospital discharge were included in the analysis: 685 (71.3%) were in Group (28.7%) were in Group 2 Primary outcome - hospital readmission rate White B, Carney PA, Flynn J, Marino M, Fields S. Reducing hospital readmissions through primary care practice transformation. J Fam Pract Feb;63(2): PubMed PMID: Group 1 Consisted of PCPs in a university-based practice group at 4 outpatient clinics Systematic approach for clinic and PCP notifications of admission and discharge Case managers phone calls ensuring appointments within 1 week after discharge Medical directors at the 4 clinics received detailed monthly summary reports 14

15 Group 2 Consisted of patients with assigned PCPs from 12 county/community health centers Considered usual care without interface between outpatient and inpatient teams Note: Discharge summaries sent either electronically via EMR or system-generated automated fax to both Groups 1 and 2 White et al Results: Readmissions Group 1 decreased from 27% to 7.1% (P=0.02) Readmissions in Group 2 were variable with a a nonsignificant trend (P=0.53) Figure 2 Significant difference in readmission rates for Group 1 and Group 2 patients (P=0.05) 15

16 White et al Figure 2 Limitations Small sample sizes Average length of stay for Group 2 (7.1 days) patients was longer by just over 1 day compared to Group 1 (5.8 days)? Sicker patients Pre-study Group 1 patient readmission rates began higher than the Group 2 patients Unknown to what degree Group 2 engaged the hospital setting and TCM since they were not purposefully interfaced. 16

17 Tools to make it home K hukewjq8pi39ijlahvhpiykhbpxc2aq_auibigb#imgrc=ai7dufr8dyjhim%3a 17

18 Transitional Care Management Services Requirements Jan Initial Communication within 2 business days 2. Face-to-face visit in 7 (high complexity) or 14 (mod complexity) calendar days 3. Date of Service (DOS) on 30 th calendar day with day 1 being the date of discharge Initial Communication You must make an interactive contact with the beneficiary and/or caregiver, as appropriate, within 2 business days following the beneficiary s discharge to the community setting. The contact may be via telephone, , or face-toface. For Medicare purposes, attempts to communicate should continue after the first two attempts in the required 2 business days until they are successful. 18

19 Medicine Reconciliation/ Complex Decision-Making Patient must have medicine reconciliation performed by the end of the face-to-face visit, and the visit must achieve moderate to high complexity decision making. TCM Timeline 19

20 Practitioners Eligible to Bill Medicare for TCM Physicians: PCPs Specialists Advanced Practitioner of Nursing Physician Assistants TCM Service Settings Inpatient Acute Care Hospital Inpatient Psychiatric Hospital Long Term Care Hospital Skilled Nursing Facility Inpatient Rehabilitation Facility Hospital outpatient observation or partial hospitalization Partial hospitalization at a Community Mental Health Center 20

21 Exclusions - TCM Postoperative global period Home health oversight G0181 Hospice care plan oversight G0182 Care plan oversight 99339, 99340, Prolonged services without contact Anti-coagulant management End stage renal disease Chronic care management Miscellaneous medical team conferences, education and training, telephone services, online medical evaluation, analysis of data, preparation of special reports, complex chronic care coordination services Additional TCM Notes Only one provider can bill for each TCM event TCM cannot be billed in FQHCs or THCs While FQHCs and RHCs are not paid separately by Medicare under the PFS, the face-to-face visit component of TCM services could qualify as a billable visit in an FQHC or RHC. 21

22 &ved=0ahukewiniodapoflahwe7sykhtncbqgq_auibigb#imgrc=wdqthnp5qbywbm%3a 5 Biggest Mistakes of TCM Scenarios 22

23 Case #1 Scenario Patient in the hospital for say a CHF episode. After the patient s diuretics were adjusted, his respiratory status normalizes. However, the hospital does not alert the PCP of the admission or discharge. The PCP is not aware of the admission/discharge until 1 week after discharge when the patient calls him with recurrent shortness of breath. Mistake #1 What is the problem with this scenario for billing TCM? Failure of integration of inpatient and outpatient settings/lack of discharge notifications 23

24 Case #2 Scenario A 52 year old man with hypertension and hypercholesterolemia is admitted for an acute myocardial infarction. He undergoes cardiac catheterization and stent placement and is discharged on Friday, 5/27/16 (before 5PM). By which day must the initial communication be performed by? a. Sunday b. Monday c. Tuesday d. Wednesday Mistake #2 What is the problem with this scenario for billing TCM? Failure to understand metrics and requirements of TCM 24

25 Case Scenario #3 A 22 y/o G1P0 woman is admitted on Thursday for delivery of a healthy baby girl by SVD. She is discharged on the next day (TCM day 1), and the initial communication is performed on Monday. She is seen by calendar day 12 and is doing well with her medicine reconciliation performed is billed for on Hospital Discharge day 30, and the TCM bill is rejected. Mistake #3 What is the problem with this scenario for billing TCM? Low complexity decision making Failure to correctly identify TCM candidates 25

26 Medical Decision-Making Scenario #4 An 80 year old woman with COPD and HTN is admitted for acute pneumonia for oxygen supplementation, respiratory monitoring, and intravenous antibiotics and is ready for discharge 3 days later on a Saturday. The initial communication occurs on schedule, and she reports that she is taking her antibiotic therapy and feels better as well during the call. 26

27 Scenario #4 She returns for the face-to-face visit two weeks from the Monday after discharge. TCM is billed after 30 days but is denied. Mistake #4 What is the problem with this scenario for billing TCM? Failure to schedule face-to-face within the correct time frame 27

28 Case Scenario #5 A 45 year old man with metastatic prostate cancer, hypertension, and COPD is admitted for vomiting and diarrhea secondary to gastroenteritis. After intravenous fluids, the patient has resolution of his vomiting and dehydration on hospital day 3. He is discharged on 1/1/15 with the initial communication and face-to-face visits occurring prior to the deadlines for these metrics, and the patient remains well for the following 30 days. TCM is billed with a date of service of 1/29/15 but is rejected. Mistake #5 What is the problem with this scenario for billing TCM? Billing wrong date of service before 1/1/16 Originally, the DOS was the 30 th day with the date of discharge being day 1 of TCM. After 1/1/16, the DOS is the date of the faceto-face visit prior to the 7 th or 14 th day of TCM. 28

29 5 Biggest Mistakes of TCM Failure of integration of inpatient and outpatient settings/lack of discharge notifications Failure to understand metrics and requirements of TCM Failure to correctly identify TCM candidates Failure to schedule face-to-face within the correct time frame Billing the wrong date of service (before 1/1/16) 2016 TCM Fee Schedule Changes Regarding TCM services, we are adopting the commenters suggestions that the required date of service reported on the claim be the date of the faceto-face visit, and to allow (but not require) submission of the claim when the face-to-face visit is completed, consistent with current policy governing the reporting of global surgery and other bundles of services under the PFS. We will revise the existing subregulatory guidance for TCM services accordingly. (80 FR 70921) 29

30 CMS 2016 TCM PFS Changes The DOS will reflect the date of the face-to-face visit: High Complexity within 7 business days Moderate Complexity within 14 business days CMS 2016 TCM PFS Changes The service period has not changed with only one billable TCM per service period, AND Only TCM or CCM are typically billed during the same calendar month. 30

31 Anticipated Effect of Mistake #5 Problems with billing occurring with: Other Admissions/TCM periods Chronic Care Management Awareness of completion of the TCM period is imperative in both scenarios. Chronic Care Management/CCM Begun January Non face-to-face services provided to Medicare beneficiaries who have two or more chronic conditions Comprehensive health care plan must be established, implemented and monitored for every patient 20 minutes of clinical staff time per month 31

32 Chronic Care Management/CCM ~ $40 per patient per month Potential market - 18 Billion Dollars per year TCM/CCM Interface Medicare and CPT specify that CCM and TCM cannot be billed during the same month. Does this mean that if the 30-day TCM service period ends during a given calendar month and 20 minutes of qualifying CCM services are subsequently provided on the remaining days of that calendar month, CPT code cannot be billed that month to the PFS? 32

33 TCM/CCM Interface CPT could be billed to the PFS during the same calendar month as TCM, if the TCM service period ends before the end of a given calendar month and at least 20 minutes of qualifying CCM services are subsequently provided during that month. However we expect that the majority of the time, CCM and TCM will not be billed during the same calendar month. Payment/PhysicianFeeSched/Downloads/Payment_for_CCM_Services_FAQ.pdf Top 10 ICD 10 Codes 10. W6133XA, or being pecked by chicken. 9. V0001XD, Pedestrian on foot injured in collision with rollerskater, subsequent encounter. 8. W5922XA: Struck by a turtle. 7. S30867A: Insect bite (nonvenomous) of anus, initial encounter 6. S1087XA: Other superficial bite of other specified part of neck, initial encounter. 33

34 Top 10 ICD 10 Codes 5. Y92250, or when a patient is injured in an art gallery 4. V91.07XA Burn due to water-skis on fire, initial encounter 3. V9542XA: Spacecraft crash injuring occupant, initial encounter 2. A281, or cat scratch disease (also known as cat scratch fever) 1. G4482, or a headache associated with sexual activity Conclusions Evidence exists for the benefit of TCM in reducing hospital readmissions although additional study is needed. Completion of the steps for TCM is challenging with additional automation and integration needed for maximal benefit. 34

35 Conclusions The 2016 TCM PFS allows for the date of service to occur on the date of the face-to-face visit. TCM and CCM typically cannot be billed for in the same calendar month unless 20 minutes clinical time after TCM service period conclusion. Future of TCM Improvement in awareness of hospital admission/discharge Workflow integration with electronic medical records and chronic care management 35

36 Questions 36