Transition Care Management Update: Practical Applications for 2016

Transcription

1 60 th Annual Greenville Postgraduate Seminar: A Primary Care Update Transition Care Management Update: Practical Applications for 206 Nick Ulmer, MD CPC VP Clinical Services and Medical Director of Case Management, Spartanburg Regional Healthcare

2 Objectives State the importance of care coordination and understand how to begin this in the hospital setting Name components specific to the two different Transition Care Management (TCM) codes for 206 Understand processes needed to successfully implement these in your practices

3 Background As part of the ACA, the Hospital Readmissions Reduction Program (HRRP) was created as a way to reduce readmissions. TCM was developed by the CMS/AMA in 202 and rolled out in CPT 203 Encourages seamless patient care coordination from an inpatient hospital to the outpatient setting Since implementing TCM and other post-discharge initiatives, hospital readmission rates have decreased by 2%

4 Complex patients need care coordination Chronic disease burden affects multiple organ systems and debilitates Complicates surgical cases, both planned and unplanned Orthopedic procedures Healing and rehabilitation is difficult General surgical procedures, especially with general anesthesia Routine infections can become more difficult to treat Diabetes Vascular disease Transition Care Management codes are not limited to just multi-chronic disease patients

5 Lack of coordination leads to costly care Higher re-admission rates 90% are unplanned (AHRQ), usually related to poor care coordination and continuity <50% see a provider prior to the readmission Medication mismanagement is second leader associated with readmits When admitted, more costly care with prolonged LOS Preventable re-admissions could save $2B/ year In DRG payment world, less chance for profit Heart disease and Stroke lead the way, Diabetes #2

6 206 update: Transition Care Management One potential solution to prevent readmissions Hospital penalty of up to 3% of Medicare payments began in 205 TCM codes set to apply mostly to primary care practices to help cover the non face-to-face services they offer For TCM codes to be successfully used, we need partnerships: Hospital Hospital based physician and primary care physician working as team

7 How do we coordinate care? Begins in the hospital before discharge Out of hospital services aligned with the patient s needs Home health, rehab services, outpatient ancillary follow-up with dietitians/counseling, etc. Medication reconciliation and education of proper compliance and reasons for medication use Education of the disease(s) and how they caused the hospitalization and self-directed modifications that can be embraced to keep disease state in check Identification of barriers to self-care The Team is key to re-admission reduction and patient quality of life optimization Relay of the information to outside entities is key

8 Discharge encounter Inclusions for physician/npp on unit/floor that day The face-to-face examination Review of the hospital course, and discharge instructions Medication reconciliation Paperwork preparation/form fill-out Discharge summary dictation Time for completion of this is additive and must be documented

9 The discharge from hospital Discharge summary Must be completed timely Even observation services!! Must be succinct but complete Abbreviated as compared to the admit note Some musts Pertinent tests that were negative or positive Ac of 6.4 means something as does an ECHO of 22% EF Procedures re-stated with findings EGD with stricture, etc. Medication list with med changes from admit summarized If meds changed for sake of formulary, consider reverting to admit medication if class of drug or clinical effect not different Needed follow-up tests, office visits, or other appointments recheck potassium at ov in wk and get a f/u ECHO in 4wks

10 Discharge care billable codes Inpatient care services (<30 minutes of time involved) (>30 minutes of time involved) Observation (outpatient) care services 9927 observation discharge (no time) admit/discharge same day Nursing home admission is separately billable even if performed on the same day (0/2006)

11 TCM Service: 99495/99496 Provided to patients discharged from Inpatient or Observation status hospital care Skilled Nursing Facilities Partial Hospitalization programs NOT to be used Unless physician or NPP accepts the care of the patient postdischarge without a gap and accepts responsibility for patient s care By surgeons in post-hospital global surgical period (90d) By hospitalists who do a one-time f/u visit By RHC and FQHCs In hospital hospital or hospital SNF transfer Established or new patients qualify Place of service (office), 2 (pt home), 3 (assisted living)

12 TCM Service: 99495/99496 Time period is 30 days (date of discharge and for next 29 days) Additional E/M visits outside of the one required are billed separately, even if <30d (but not on the same day) Documentation needs: Date of discharge Date of dialogue to secure/confirm appointment Minimal content to address hospital course Disease status, medication compliance, f/u interim access Subsequent correspondence The E/M note associated with the f/u care (your exam, A/P) Medication reconciliation completed no later than initial office visit

13 update: Transition Care Management Communication (direct contact, telephone, electronic) with the patient/caregiver (includes home health agencies) within 2 business days by staff Discuss caretaker education, care management, ADLs Assess for support and treatment adherence Identify available community health resources Assist in access to care and other services as needed by family Non face-to-face services provided by physician, or other qualified healthcare provider Discharge summary review Lab f/u issues Contact other providers of care to coordinate healthcare delivery Educational outreach MDM of moderate complexity during the service period Face-to-face visit within 4 calendar days of discharge

14 update: Transition Care Management Communication (direct contact, telephone, electronic) with the patient/caregiver (includes home health agencies) within 2 business days by staff Discuss caretaker education, care management, ADLs Assess for support and treatment adherence Identify available community health resources Assist in access to care and other services as needed by family Non face-to-face services provided by physician, or other qualified healthcare provider Discharge summary review Lab f/u issues Contact other providers of care to coordinate healthcare delivery Educational outreach MDM of high complexity during the service period Face-to-face visit within 7 calendar days of discharge Same rules for billing as for 99495

15 The Third Key Component History Examination Medical Decision Making Diagnoses managed (number and type) Data reviewed to manage diagnoses of visit Risk associated with the management plan

16 What is it? it is not medical necessity it is the thought work what (we) went to school for our brain at work.put into words Cannot be found in an automated coding software Once all boxes checked, is the sole determinant of the charge for level of TCM visit

17 For MDM calculation on diagnosis Maximum point total is 4 If 4 is maximum, then the maximum MDM is being met ( High ) If 3 is achieved, then moderate If 2 is achieved, then low If is achieved, then straightforward/minimal

18 For MDM calculation on diagnosis Maximum point total is 4 If 4 is maximum, then the maximum MDM is being met ( High ) 99205/25 If 3 is achieved, then moderate 99204/24 If 2 is achieved, then low 99203/23 If is achieved, then straightforward/minimal 9920/202/22

19 For MDM calculation on diagnosis Maximum point total is 4 If 4 is maximum, then the maximum MDM is being met ( High ) 99205/25 If 3 is achieved, then moderate 99204/24 If 2 is achieved, then low 99203/23 If is achieved, then straightforward/minimal 9920/202/22 There is no medical decision making defined for the 992 nurse visit.

20 Number of Diagnoses or Treatment Options Types of Problems Number x points = subtotal Self limited, minor (max = 2) Est. problem, stable or improved Est. problem, medical adjustment needed New problem*, no workup planned New problem*, further work-up planned Total 2 3 4

21 Number of Diagnoses or Treatment Options Types of Problems Number x points = subtotal Self limited, minor (max = 2) Est. problem, stable or improved Est. problem, medical adjustment needed New problem*, no workup planned New problem*, further work-up planned Total 2 3 4

22 Number of Diagnoses or Treatment Options Types of Problems Number x points = subtotal Self limited, minor (max = 2) Est. problem, stable or improved Est. problem, medical adjustment needed New problem*, no workup planned New problem*, further work-up planned Total XXXXX

23 Number of Diagnoses or Treatment Options Types of Problems Number x points = subtotal Self limited, minor (max = 2) Est. problem, stable or improved Est. problem, medical adjustment needed New problem*, no workup planned New problem*, further work-up planned Total 3 or 4

24 TABULATION OF DECISION MAKING ELEMENTS A Diagnoses/Management Options Minimal (0-) Low (2) Moderate (3) X High (4) X B Amount/Complexity of Data Min./Low (0-) Low (2) Moderate (3) High (4) C Highest Risk (from any category in table) Minimal Low Moderate High Medical Decision Making Straightforward Low Moderate High (Choose the column with at least 2 elements. Otherwise, pick the middle column of the three columns with element) X X USC 200 Pediatric Update 99204/ /25

25 MDM for Diagnosis Lots of MDM credit Often get 9924 and 9925 for this Managing multiple chronic diseases or see new multi-system problems Recall it is 2 of 3 parts with 2 being equal Still have Data and Risk to assess

26 For MDM calculation on data Maximum point total is 4 If 4 is maximum, then the maximum MDM is being met ( High ) 99205/25 If 3 is achieved, then moderate 99204/24 If 2 is achieved, then low 99203/23 If is achieved, then straightforward/minimal 9920/202/22 There is no medical decision making defined for the 992 nurse visit.

27 Amount and Complexity of Data Reviewed Total Categories of Data Reviewed Points Order and/or review clinical lab tests (CPT 8xxxx series) Order and/or review tests from radiology section (nuclear med., Xray not echo/cath) (CPT 7xxxx series) Order and/or review tests from medicine section (EKG,EMG,echo,dopplers,cath,PFT,audiometry,etc.) (CPT 9xxxx series) Decision to obtain old records or decide to obtain history from other caregivers/family, or discuss tests with performing physician Review and summarize old records by updating chart or taking history from someone other than patient (nurse at NH, interpreter, children) Independent visualization of image, tracing, or specimen 2 2

28 Amount and Complexity of Data Reviewed Total XXXX Categories of Data Reviewed Points Order and/or review clinical lab tests (CPT 8xxxx series) Order and/or review tests from radiology section (nuclear med., Xray not echo/cath) (CPT 7xxxx series) Order and/or review tests from medicine section (EKG,EMG,echo,dopplers,cath,PFT,audiometry,etc.) (CPT 9xxxx series) Decision to obtain old records or decide to obtain history from other caregivers/family, or discuss tests with performing physician Review and summarize old records by updating chart or taking history from someone other than patient (nurse at NH, interpreter, children) Independent visualization of image, tracing, or specimen 2 2

29 Amount and Complexity of Data Reviewed Total 3 or 4 Categories of Data Reviewed Points Order and/or review clinical lab tests (CPT 8xxxx series) Order and/or review tests from radiology section (nuclear med., Xray not echo/cath) (CPT 7xxxx series) Order and/or review tests from medicine section (EKG,EMG,echo,dopplers,cath,PFT,audiometry,etc.) (CPT 9xxxx series) Decision to obtain old records or decide to obtain history from other caregivers/family, or discuss tests with performing physician Review and summarize old records by updating chart or taking history from someone other than patient (nurse at NH, interpreter, children) Independent visualization of image, tracing, or specimen 2 2

30 TABULATION OF DECISION MAKING ELEMENTS A Diagnoses/Management Options Minimal (0-) Low (2) Moderate (3) High (4) B Amount/Complexity of Data Min./Low (0-) Low (2) Moderate (3) High (4) C Highest Risk (from any category in table) Minimal Low Moderate High Medical Decision Making (Choose the column with at least 2 elements. Otherwise, pick the middle column of the three columns with element) Straightforward Low Moderate High USC 200 Pediatric Update

31 For MDM calculation on risk Highest box wins Moderate or High is our focus

32 RISK FACTORS SELECT HIGHEST IN CATEGORY LEVEL OF RISK PRESENTING PROBLEM PROCEDURES ORDERED MANAGEMENT OPTIONS CHOSEN Minimal One self-limited or minor prob. Labs, X-rays, EKG, EEG Rest, superficial dressings Low Many self-limited or minor chronic stable illness Acute, uncomplicated illness/injury Physiologic test w/o stress Imaging studies w/ contrast Superficial needle biopsy Skin biopsy Arterial blood draw OTC meds Minor surgery w/o risk factors Physical/Occupation Therapy IVF w/o additive Moderate One or more chronic illnesses with exacerbation, progression, or treatment of side effects 2 or more chronic stable illnesses New prob w/ uncertain prognosis Acute illness with systemic symptoms Acute complicated injury Stress test Endoscopies w/o risk factors CV imaging w/o risk factors Deep needle biopsy Centesis of body cavity Minor surgery w/ risk factors Elective major surgery w/o risk factors Prescription drug management IVF w/ additives Closed Rx of skeletal injury High or more chronic illness with SEVERE exacerbation, progression, or treatment side effects Acute/chronic illness that may pose threat to life or bodily f(x) Sudden neurologic change CV imaging studies with risk factors Cardiac EPS tests Endoscopy with risk factors Discography Elective major surgery with risk factors Emergency major surgery IV controlled drug Drug therapy requiring intensive monitoring DNR status

33 TABULATION OF DECISION MAKING ELEMENTS A Diagnoses/Management Options Minimal (0-) Low (2) Moderate (3) High (4) B Amount/Complexity of Data Min./Low (0-) Low (2) Moderate (3) High (4) C Highest Risk (from any category in table) Minimal Low Moderate High Medical Decision Making (Choose the column with at least 2 elements. Otherwise, pick the middle column of the three columns with element) Straightforward Low Moderate High USC 200 Pediatric Update

34 TABULATION OF DECISION MAKING ELEMENTS A Diagnoses/Management Options Minimal (0-) Low (2) Moderate (3) High (4) B Amount/Complexity of Data Min./Low (0-) Low (2) Moderate (3) High (4) C Highest Risk (from any category in table) Minimal Low Moderate High Medical Decision Making (Choose the column with at least 2 elements. Otherwise, pick the middle column of the three columns with element) Straightforward Low Moderate High USC 200 Pediatric Update

35 TABULATION OF DECISION MAKING ELEMENTS A Diagnoses/Management Options Minimal (0-) Low (2) Moderate (3) High (4) B Amount/Complexity of Data Min./Low (0-) Low (2) Moderate (3) High (4) C Highest Risk (from any category in table) Minimal Low Moderate High Medical Decision Making (Choose the column with at least 2 elements. Otherwise, pick the middle column of the three columns with element) Straightforward Low Moderate High USC 200 Pediatric Update

36 TABULATION OF DECISION MAKING ELEMENTS A Diagnoses/Management Options Minimal (0-) Low (2) Moderate (3) High (4) B Amount/Complexity of Data Min./Low (0-) Low (2) Moderate (3) High (4) C Highest Risk (from any category in table) Minimal Low Moderate High Medical Decision Making (Choose the column with at least 2 elements. Otherwise, pick the middle column of the three columns with element) Straightforward Low Moderate High USC 200 Pediatric Update

37 Moderate (Detailed) Medical Decision Making (MDM) IF you manage a prescription, AND There are three chronic, stable problems OR There are two chronic problems, in need of medical management OR There is one new problem, with no further work-up planned THEN, there is MODERATE MDM

38 High (Comprehensive) Medical Decision Making (MDM) More difficult to get as multiple medical issues need to be addressed new problem in need of further evaluation, or 2 problems out of control, or 3 problems with one out of control, or 4 stable problems evaluated and managed PLUS Data management ( 4 points ) OR Clinically unstable patient or medical illness out of control that could threaten the patient long term Send someone to ED for evaluation of abdominal pain Severe respiratory distress, acute kidney injury (2-3x Cr bump), suicidal gesture/threat, acute MS changes, TIA, severe progressive RA, seizure disorder exacerbation, sudden profound weakness

39 Connect with me. Nick Ulmer, MD CPC