Transitional care management

Transitional care management (TCM) services, which help patients transition from inpatient care to the community setting, are critical for preventing readmissions and keeping patients on a smooth track to recovery. The services, denoted by CPT codes 99495 and 99496, also are lucrative for practices, paying up to approximately $248 for 30 days of service.

However, there’s one big challenge: Independent physicians aren’t usually notified when patients are admitted to and discharged from the hospital. This makes it difficult to meet TCM billing requirements that specify physicians must contact patients within two business days of discharge and conduct a follow-up visit within seven or 14 days post-discharge, depending on the patient’s medical complexity, says Samuel Leroy Church, M.D., CPC, family medicine physician in Hiawassee, Georgia, and an American Academy of Family Physicians adviser for theAmerican Medical Association’s Current Procedural Terminology editorial panel.

The good news is that information between hospitals and physicians can flow more freely thanks to a new CMS Condition of Participation (CoP). CoPs are the health and safety standards that health care organizations must meet to participate in Medicare and Medicaid programs. The new CoP, which goes into effect May 1, 2021, requires hospitals (i.e., acute care hospitals, cancer hospitals, children’s hospitals, rehabilitation hospitals, long-term care hospitals and transplant programs) to send real-time e-notifications of any admissions, discharges or transfers (ADT) to applicable post-acute care providers with established care relationships who need that information for treatment, care coordination or quality-improvement activities.

E-notifications must include, at a minimum, the patient’s name, treating practitioner’s name and sending institution’s name. CMS created this requirement as part of the Interoperability and Patient Access Final Rule (85 FR 25510) to significantly accelerate information sharing between hospitals and other providers across the care continuum.

“If hospitals routinely send us their information, it does eliminate a lot of steps and busywork on our part,” says Gregory Steinmetz, M.D., a family medicine physician in Warwick, Rhode Island. “It will be better for patient care, and primary care practices will have more incentives and support to provide TCM services.”

“If practices don’t already perform and bill TCM, they may want to consider it in light of these new changes,” says Peter S. Tippett, M.D., Ph.D., founder and CEO of careMESH, a technology platform that improves the quality and reach of ADT data from hospitals to physician practices. “If they already do, they may want to revisit the efficiency of their existing service line and explore ways to partner with local hospitals trying to satisfy the new CoP requirement.”

Experts provide these tips to create a successful TCM offering:

Determine how the practice will receive ADT data

The new CMS CoP is a big step forward because it means independent practices may start to receive this data automatically. However, in order for this process to occur seamlessly, patients will need to identify their primary care physician at the time of hospital registration, says Kim Huey, CPC, CCS-P, independent coding and reimbursement consultant in Alabaster, Alabama. “This is a challenge because patients don’t seem to attach themselves to a primary care physician. Instead, they go to urgent care,” she says. “Care has become very fragmented.”

To address this challenge, physicians need to focus on building relationships with their patients, Huey says. Patients need to view their primary care as a one-stop shop for the majority of their health care needs. They also need to understand the importance of identifying their primary care physician when they are admitted to the hospital or seek care outside of the practice, she adds.

Another option for accessing ADT data is through a health information exchange (HIE). One drawback? Someone from the practice must log onto the HIE portal to manually review the ADT data. In addition, practices must frequently update their patient panel to ensure the HIE has the accurate list of patients to attribute to the practice, Tippett says.

Another challenge with HIEs is that they are regional. If a practice belongs to one HIE and a patient is admitted to a hospital that is part of a different HIE, the practice won’t have access to ADT data.

HIEs aren’t necessarily a timely source of information either, says Cheryl Mongillo, MBA, administrative director at a family medicine practice in Wilmington, Delaware. Some hospitals don’t push their data to the HIE until physicians sign the discharge summary, she says. “It could take a week for this to happen, which means it’s beyond the window for billing TCM,” she adds.

Finally, ADT data exchange through HIEs only works if patients actually consent to participate in the HIE itself.

Practices that belong to an Accountable Care Organization (ACO) may have more luck receiving timely ADT feeds. “What we pay to belong to our ACO has been worth it simply because it enables us to bill TCM,” Mongillo says. Her practice’s ACO sends ADT feeds for attributed patients as defined by their shared-savings contracts with Medicare, Medicaid and commercial payers. Then a medical assistant logs on to the ACO portal to check live data feeds and contact patients as necessary.

However, there are pitfalls even when receiving ADT feeds from an ACO. For example, when patients are discharged to a skilled nursing facility or inpatient rehabilitation facility, the ACO doesn’t have access to the facility name, making it difficult to track discharges from those settings, Mongillo says.

“Are there other patients who fall through the cracks? Absolutely because they may not be attributed to us, or we may not have a shared-savings contract with their insurer,” she says. However, there are other workarounds. For example, when patients come in for preoperative clearance, staff insert a flag in the EHR for the date of the surgery so they can follow up with the patient.

Mongillo also strives to build relationships with local hospitals so they provide ADT information via phone. “All hospitals have discharge planners,” she says. “I tell them, ‘Let us work with you to prevent readmissions. We can help schedule that follow-up visit to help the patient stay out of the hospital.’”

Provide TCM via telehealth or home visits, when warranted

If patients are unable to travel post-discharge, or if they are uncomfortable coming into the office during the pandemic, telehealth or home visits may be options. Giving patients the choice is paramount in terms of obtaining buy-in for TCM service, Mongillo says. “The more patients feel like they’re involved, the more willing they are to comply,” she adds.

Although Medicare covers TCM rendered via telehealth, commercial payer coverage may vary, says Huey, adding it’s best to contact each payer to determine its policy. Note that Medicare and most other payers will also require modifier -95.

Identify other patient care needs and revenue opportunities

Chronic care management (CCM) is a big one. While TCM focuses on the 30 days post-discharge, CCM focuses on the patient’s health indefinitely, Church says. “It’s all part of an ongoing movement to centralize care in the primary care setting,” he adds.

Note that effective January 1, 2020, with the calendar year 2020 Physician Fee Schedule Final Rule, CMS relaxed its restrictions on concurrent use of TCM and CCM as long as the work is distinct, meaning both services address two different diagnoses. Previously, practices couldn’t bill TCM and CCM during the same 30-day period.

“This was an important step in reducing administrative worries for practices trying to run an ongoing CCM program aimed at long-term reduction of hospitalization and emergency room visits,” Church says. “You don’t necessarily need to abandon the CCM work in order to provide the TCM. That has been a big help.”

For example, a patient admitted to the hospital due to pneumonia can receive TCM upon discharge as well as CCM related to their diabetes and ulcers.

An annual wellness visit or advanced care planning are other billable services from which patients could also benefit at the time of TCM, Huey says.

Physicians also can separately bill an office visit at the time of TCM as long as documentation supports each code, Huey says. For example, a patient receiving TCM post-discharge after a hip replacement develops a sore throat and needs to be seen. Practices can bill the TCM and an E/M code during the same 30 days, Mongillo says. “Many practices haven’t done this,” she adds. “This means they’ve been missing opportunities for revenue as well as closing care gaps.”

Ensure thorough documentation of
TCM services

Physicians may be tempted to document TCM sparsely (“The patient is recovering well. I reconciled their medications and referred them for physical therapy,” for example). However, if the patient is readmitted or dies within 30 days, practices are obligated to change the visit from TCM to an office visit and resubmit a corrected claim, Huey says. That’s because TCM is technically for 30 days of service, she adds.

Huey recommends physicians document the TCM visit as they would any other office visit, just in case the visit does need to be rebilled. What diagnoses, if any, did the physician take into consideration when developing an ongoing treatment plan? This may include diagnoses in addition to the condition for which the patient was hospitalized. What is the assessment and plan?

“Even though all of those details may not be necessary to get the TCM paid, it’s going to show the complexity — everything you need to consider when treating the patient,” Huey says. This translates to more accurate E/M codes, particularly in 2021 when codes will be driven by medical decision-making or time.

If physicians aren’t already billing for TCM, they should strongly consider it as the industry moves toward a value-based care model, Church says. “TCM is not just about payment for providers or saving money for the system,” he adds. “It’s about patient care. Patient care is better. Quality of life is better. Patient engagement is better. Ultimately, care outcomes are better.”