Transitional Care Management (TCM) and Chronic Care Management (CCM) Overview and Billing Process. April 19, :00 PM

Transcription

1 Transitional Care Management (TCM) and Chronic Care Management (CCM) Overview and Billing Process April 19, :00 PM

2 2 Discussion Topics TCM Requirements TCM Services and C247 Process Medical Decision Making Level TCM Appointment, Billing and Concluding Services TCM Tasks to 29 th Day TCM Billing Process CCM Billing Process Client Portal Reimbursement Q and A

3 3 Medicare Requirements for TCM During the 30 days beginning on the date the beneficiary is discharged from the hospital inpatient setting, the following three components must be provided: An interactive contact; within 2 business days of discharge (contact may be via telephone, , or face-to-face) C247 contacts the patient/caregiver upon admission Certain non-face-to-face services; (e.g., obtain and review discharge information; review need for follow-up pending diagnostic tests and treatments; provide education to beneficiary, family, guardian, and/or caregiver; establish referral for needed community resources) And, a face-to-face visit with TCM Provider; (CPT code face-to-face visit within 14 days of discharge (based on moderate complexity level of medical decision making); CPT code face-to-face visit within 7 days of discharge (based on high complexity level of medical decision making)

4 4 Requirements for TCM Services Services are required during the beneficiary s transition to the community setting following inpatient discharges; Health care professional accepts care of the beneficiary post-discharge from the facility setting without a gap; Health care professional takes responsibility for the beneficiary's care; and Beneficiary has a medical and/or psychosocial problems that require moderate or high complexity medical decision making 30-day TCM period begins on the date the beneficiary is discharged from the inpatient hospital setting and continues for the next 29 days.

5 5 TCM Services Settings Discharged from Inpatient hospital setting: Inpatient Acute Care Hospital; Inpatient Psychiatric Hospital; Long Term Care Hospital; Skilled Nursing Facility; Inpatient Rehabilitation Facility; Hospital outpatient observation or partial hospitalization; and Partial hospitalization at a Community Mental Health Center. Returned to community setting His or her home; His or her domiciliary; A rest home; or Assisted living

6 6 Sample Letter Provided at Admission

7 7 Care 24/7 TCM Service Process Contractual Agreement to offer TCM services and facilitate TCM appointments with Capella Healthcare employed and/or managed primary care providers Services are required during the beneficiary s transition to the community settings following covered discharges; Identify patient s PCP for assignment; (C247 utilizes a live ADT feed to gain this information) If patient has not identified an PCP on admission, the patient will be assessed by C247 staff to determine an existing PCP or referral to a participating PCP (TCM Provider); (the process used to assign patients to a Capella TCM providers Provider accepts care of the beneficiary post-discharge from the facility setting in order eliminate service gaps; Provider (and C247) provides TCM services and care to the beneficiary post-discharge for 29 days (30 days including the day of discharge) Medical Decision Making Level;

8 8 Medical Decision Making Level Patient s medical decision making level determines the 7-day or 14-day patient appointment; Moderate complexity level of medical decision making CPT Code is a face-to-face visit within 14 days of discharge; High complexity level of medical decision making - CPT code is a face-to-face visit within 7 days of discharge;

9 9 Elements for Each Level of Decision Making The table below shows the elements for each level of medical decision making. Note that to qualify for a given type of medical decision making, two of the three elements must be either met or exceeded. Elements for Each Level of Medical Decision Making Type of Decision Making Number of Possible Diagnoses and/or Management Options Amount and/or Complexity of Data to Be Reviewed Risk of Significant Complications, Morbidity, and/or Mortality Straightforward Minimal Minimal or None Minimal Low Complexity Limited Limited Low Moderate Complexity Multiple Moderate Moderate High Complexity Extensive Extensive High

10 10 Book TCM appointment C247 TCM Specialist will contact the Patient s PCP (Primary Care Practice/Front Office Staff/Scheduler) to book the TCM/CCM Initiation appointment ( CCM Initiation visit type is NOT a billing code) Recommended visit type for office staff to recognize and book: TCM 7 (face-to-face visit within 7 days of discharge for high complexity level of medical decision making) TCM 14 (face-to-face visit within 14 days for moderate complexity level of medical decision making)

11 11 TCM Appointment and Billing When the TCM visit is completed ( TCM 7 or TCM 14): The 30-day period for the TCM service begins on the day of discharge and continues for the next 29 days. The date of service you report should be the date of the required faceto-face visit. You may submit the claim once the face-to-face visit is furnished and need not hold the claim until the end of the service period (CMS, March 17, 2016)

12 12 Conclude TCM Services TCM Services continue 29-days following discharge from the last TCM service setting the patient has been in (30 day service) Generate 29 th day report FYI: Reasonable and necessary evaluation and management (E/M) services (other than the required face-to-face visit) to manage the beneficiary s clinical issues should be reported separately;

13 TCM Service Implementation Utilizing Care 24/7 Platform Software Care 24/7 software is aligned to meet all CMS required components through step-by-step tasks during the 30 day TCM period 1. Pre-Discharge contact - TCM Explainer (letter) provided at admission. 2. Obtain discharge instructions (and updated medications list) 3. Verify complexity level* (beneficiary has medical and/or psychosocial problems that require moderate or high complexity level decision making) - Provides information that will indicate a TCM-7 or a TCM Contact patient and/or caregiver* (interactive contact within two (2) business days) 5. Book TCM appointment* (face-to-face visit within 7 days of discharge for high complexity level of medical decision making and within 14 days for moderate complexity level of medical decision making) C247 Staff will call Front Office Staff to book a visit type of TCM-7 or TCM Input discharge instructions into client EHR Portal Documents may be pushed to the TCM Providers bucket 7. Remind patient of appointment 8. Confirm visit has been completed with the TCM Provider (utilizing the EHR) and obtain encounter summary Billing to Medicare may be released once patient has completed TCM visit. 9. Review encounter summary following visit with TCM Provider* (non-face to face service) 10. (May contact patient for wellness check(s)) 11. Contact patient for TCM service discharge 12. Generate 29 th day report The TCM 29-Day Summary Report is placed in the Client Portal and beneficiary s EHR. *Asterisk indicates CMS required components included in TCM 13

14 14 TCM Billing Process (Weekly) On a weekly basis (every Wednesday for transactions completed the prior week, Sat-Fri) 1. Send Billing Report: compile Excel list of completed TCM transactions 2. Batch Reports: generate PDF reports for all completed TCM transactions 3. Save #1-#2 on client portal ( for access by facility s billing staff and management 4. Notify facility billing staff and management via when new documents have been posted in client portal 5. Upload TCM 29 th -day report (PDF) for each completed TCM patient into their Athena EHR (under clinical documents no provider review necessary)* 6. Send Invoice Report: Care 24/7 billing staff will formal invoice to Capella Corporate *only applicable for patients with existing Athena EHR records with Capella

15 15 CCM Billing What date of service should be used on the physician claim and when should the claim be submitted? Payment/PhysicianFeeSched/Downloads/Payment_for_CCM_Services_FAQ.pdf The service period for CPT is one calendar month, and CMS expects the billing practitioner to continue furnishing services during a given month as applicable after the 20 minute time threshold to bill the service is met (see #3 above). However practitioners may bill the PFS at the conclusion of the service period or after completion of at least 20 minutes of qualifying services for the service period. When the 20 minute threshold to bill is met, the practitioner may choose that date as the date of service, and need not hold the claim until the end of the month. Providers may bill Medicare at the conclusion of the service period or after completion of at least 20 minutes of qualifying CCM services during the calendar month. The date of service is the date that the minimum of 20 minutes has been met.

16 16 CCM Billing 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? 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.

17 17 CCM Billing Process (Monthly) On a weekly basis* 1. Send Billing Report: compile Excel list of billable CCM patients (who have completed 20min and passed Quality Assurance) 2. Batch Reports: generate PDF reports for all completed CCM patients 3. Save #1-#2 on client portal ( for access by facility s billing staff and management 4. Notify facility billing staff and management via when new documents have been posted on client portal 5. Upload CCM summary report (PDF) for each completed CCM patient into their Athena EHR (under clinical documents no provider review necessary) On a monthly basis (end of month) 1. Send Invoice Report: Care 24/7 billing staff will formal invoice to Capella Corporate report will compile weekly lists of eligible CCM eligible patients into a monthly invoice 2. Batch reports: generate end-of-month summary PDF reports for completed CCM patient and load on client portal clients can pull this report as they wish to view any additional services provided after the initial 20min as been met for each patient *Some facilities have requested monthly, rather than weekly reports of billable CCM patients

18 Client Portal 1. The purpose of the client portal is to allow clients (e.g., practice managers, billing managers) to view end-of-month CCM and TCM summary reports and monthly invoices 2. This secure portal is similar to an FTP site; users will only see files relevant to their facility 3. Users will receive a registration link via , where you will be asked to establish your own password; the link expires 24-hrs from receipt. 4. A security question and answer will be set, unique to each facility 5. For future reference, please bookmark this URL: 6. Care 24/7 will also import these same reports into the client s EHR, per client guidance 18

19 Client Portal 1. Users can edit their profiles and security question 2. To download files, check box to left of Zip file folder and select the down arrow 3. You will see the zip file folder open with each of the patients CCM summary reports (PDF) Care 24/7 staff will also post an Excel file listing all billable patients, grouped by provider and listing ICD10 codes for their chronic conditions 4. Users can upload files here. They cannot edit the sub-folders 19

20 Client Portal Light Version 1. Per request, we can create a light version view, so that all files are displayed Patient names masked 2. However, with light view, users are unable to upload files---only download Patient names masked 20

21 21 Medicare Payment for Care Coordination Services National Payment Amounts 2016 CMS reimburses physicians and other non-physician professionals for post-discharge transitional care management (TCM services) under two CPT codes. Service initiated January 1, $ (face-to-face visit within 14 days of discharge) = $ (face-to-face visit within 7 days of discharge) CMS recognizes care management as one of the critical components of primary care that contributes to better health and care for individuals, as well as reduced spending. Beginning January 1, 2015 Medicare pays separately under the Physician Fee Schedule (PFS) under American Medical Association Current Procedural Terminology (CPT) code 99490, for non-face-to-face care coordination services furnished to Medicare beneficiaries with multiple chronic conditions $40.82 (chronic care management service 20 min) Source: Physician Fee Schedule Search:

22 Q and A 22