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How to utilize care coordination to boost practice income


Doctors now can bill Medicare for transitional and chronic care managment, but not everyone will benefit.

With the proliferation of  accountable care organizations and other alternative payment models, the trend toward value-based reimbursement is already well underway. Primary care physicians who weather this storm of payment reform successfully will be those who prioritize care coordination to keep patients healthy. Unfortunately, this often requires three of the most limited commodities in today’s practices: time, operational resources and money.

The good news is that in 2013, the Centers for Medicare & Medicaid Services (CMS) began paying for transitional care management (TCM). TCM includes services rendered for certain patients during their transition from an inpatient hospital setting to a community setting, such as their home. In 2015, CMS continued to recognize the importance of care coordination by starting to pay for chronic care management (CCM). CCM includes non-face-to-face services provided to Medicare beneficiaries who have two or more significant chronic conditions.   

But many physicians feel that the financial payoff isn’t worth the extra effort required to fulfill documentation and other requirements.

About 68% of Medicare beneficiaries meet the criteria for CCM services, according to 2010 data from the Centers for Disease Control and Prevention (CDC). With an average 2016 Medicare payment of $40.82, it’s easy to see how payment for CCM could be significant. Consider an average panel of 2,000 patients, 40% of whom have Medicare coverage. If 68% of these 800 Medicare patients meet the CCM criteria-and a physician performs CCM services once a month for 10 months per patient-he or she has the potential to earn approximately $222,000 annually.

TCM reimbursement may be more difficult to predict, but it could be lucrative as well. Consider a physician who provides TCM services for an average of five patients per week. Even when performing moderate-level medical decision making, this translates to approximately $43,000 annually.

“What I tell physicians every day is, ‘You’re doing the work. Why not get paid for it? Why let money walk out the door?’” says Barbie Hays, CPC, CPMA, a coding expert with the American Academy of Family Physicians (AAFP). 

Stephen Canon, MD, cofounder of Phyzit, Inc.-an application that helps physicians establish transitional care management workflows and enables CCM vendors to track completion of the TCM service period-says TCM is a win for everyone. 

“Physicians get more money to do the right thing. Patients get closer follow-up. And then payers end up paying less money because patients don’t get readmitted as often,” he says.  

Unfortunately, not every physician sees the value in these codes. Kim Huey, CPC, CHC, an independent coding and reimbursement consultant, says “The [CCM] codes are designed for patients who need somebody who can oversee their care. Some physicians don’t want to do this for $40 a month.”

Other experts agree that not every physician is willing to put in the time and effort to report the codes. 

“Primary care physicians are paid so little compared to more procedural-based physicians. But when [CMS] created these codes, they did put in a lot of hoops to jump through,” says Margo Williams, senior associate of the Department of Medical Practice at the American College of Physicians. 


Williams specializes in financial and personnel management, practice improvement and implementation of regulatory programs such as HIPAA, PQRS and ICD-10. She says some practices don’t report CCM codes because they’re often complicated to set up, they require additional staff to support, and it’s difficult for patients to understand what they are getting for the additional copay.

The real scoop on TCM and CCM

Interestingly, CCM is reported more often than TCM, according to CMS. In 2015, physicians or other qualified practitioners reported CPT code 99495 (lower-level TCM) approximately 350,000 times. They reported CPT code 99496 (higher-level TCM) approximately 300,000 times. CPT code 99490 (CCM) was billed approximately 887,000 times.

Canon suspects that CCM codes are billed more frequently because they’re newer. CCM also doesn’t require integration or interfacing with a hospital. 

“I foresee CCM driving TCM utilization in the coming years,” he says. “TCM will continue to be important, though, since we know that following the steps of TCM actually lowers readmissions, and we can surmise that patient care is improved through this influence.”

Tarik Hasan, MD, an internist in Tampa, Florida, says he bills both TCM and CCM with the help of a full-time nurse practitioner, though he acknowledges the operational burdens associated with these codes. 

“The requirements are so stringent that some people prefer not to bill rather than make a mistake and then be penalized for not meeting all of the criteria. If physicians aren’t sure, they just don’t bill it,” Hasan says.

About 90% of Hasan’s patients have Medicare coverage. Of these, 40% receive CCM services regularly, making it a worthwhile venture that yields additional reimbursement and better clinical outcomes. 

TCM is less lucrative, though he bills for it primarily because he also works as a physician adviser and chief of medical staff at Tampa Community Hospital. Serving in both of these positions affords him unique insight into the day-to-day operations at the hospital, including admissions, discharges and readmissions.

Gregory Steinmetz, MD, a family physician at Associates in Primary Care Medicine, Inc. in Warwick, Rhode Island, says he hopes to bill for CCM but hasn’t yet established an effective workflow for doing so. “We just don’t have a good system in place for keeping track of who we’ve been talking to and how much time we’ve been spending,” he says. “I’m also not sure that we’re meeting the requirements very often.” About 20% of his patients have Medicare coverage.

Steinmetz does, however, have a process in place for providing and billing TCM. “We were already routinely contacting patients at the time of discharge from the hospital and encouraging them to come in and have a follow-up visit in a timely manner to coordinate care,” he says. “We just needed to change some of our documentation and be aware of some of the time line requirements.”

Associates in Primary Care employs a full-time medical assistant whose sole responsibility is to track patients following discharge from hospitals. To do so, she has access to the state’s health information exchange-CurrentCare-which she checks daily. She also calls hospitals to obtain status updates on each patient.

Steinmetz says some facilities automatically fax discharge summaries to a patient’s primary care physician. Upon a patient’s discharge, the medical assistant contacts the patient via phone, performs medication reconciliation and schedules the post-discharge appointment. 


“You do need to have someone who can help with this. I don’t think most doctors have the time to do this,” says Steinmetz.


Strategies for success

If physicians want to bill TCM and CCM, they must think strategically. Consider these tips.

First, contact local hospitals. In the Tampa area, Hasan says, case managers from various facilities met regularly to develop policies and procedures to facilitate communication. Can the practice contact local hospitals to see what similar initiatives may already be underway? How can practices get involved?

Eventually, Hasan suspects, smaller practices and solo practitioners may try to band together to share case management resources for TCM and CCM on a per diem basis. 

Finally, physicians should hire a certified coder  for their practices. Steinmetz says his office flags TCM-type visits as hospital follow-ups. Then a coder validates each visit to ensure that all TCM requirements are met before billing. The coder is also allowed to switch an evaluation and management code to TCM when all the requirements have been met.

“The reimbursement is significantly higher,” he says, “so it’s definitely worth the effort.” 

Overcome reporting barriers for TCM

Consider the following Transitional Care Management (TCM) requirements as well as various experts’ advice to meet them.

Primary care physicians often don’t know when their patients are hospitalized and/or discharged.

“Many of our members who aren’t hospital-owned may not be receiving a daily census report,” says Barbie Hays, CPC, CPMA, a coding expert with the American Academy of Family Physicians (AAFP).

Independent coding and reimbursement consultant Kim Huey, CPC, CHC, agrees. “With the advent of hospitalists, that doctor isn’t necessarily seeing his or her own patients in the hospital,” she says. Primary care physicians often aren’t notified of hospital admits and discharges within the two-day time frame for follow-up contact and sometimes not until the patient’s next office visit, she adds. 

To properly bill TCM, experts agree that primary care physicians must establish working relationships with hospitals in their area-specifically with hospitalists and physician advisers in those facilities. Ask  whether they can provide a daily census report based on patients listing you as their primary care physician. Ensure that hospitals are updating this information each time the patient is admitted. 


Tampa Community Hospital does this voluntarily. “We encourage hospitalists to do one-on-one communication with primary care physicians in the community. The case managers also try to send information at the moment of discharge so primary care physicians are aware,” says Tarik Hasan, MD, an internist in Tampa, Florida.

He says most hospitals want to provide this information to avoid readmissions within 30 days. “They fight very hard to ensure that the patient gets the post-hospital care he or she needs to avoid the Medicare penalization,” he adds.

“A lot of the EHRs in the inpatient setting can send an encrypted email to your practice notifying you of which of your patients have been in the hospital,” says Stephen Canon, MD, co-founder of Phyzit, Inc., a transitional care management solutions provider. 

TCM requires initial contact with the patient within two business days of discharge. 

Daily monitoring of hospital discharges is critical, says Huey. Documentation of this outreach is equally important. She suggests including documentation in the EHR’s patient message function stating, “Spoke with the patient and reviewed medications. Follow-up appointment is scheduled for [insert date]. We also need to see who made the call, their initials, and the date and time the call was made,” she adds.

TCM requires face-to-face visit within seven or 14 days of discharge, depending on the level of medical decision-making.

“Sometimes this is a challenge from a scheduling standpoint,” says Hays. “But if you want to bill it, then you need to make the changes to be successful.” Many practices automatically set aside time specifically for TCM visits or use sick visits for this purpose, she adds.

Gregory Steinmetz, MD, a Rhode Island-based family physician agrees, adding that his practice hired nurse practitioners so it could commit to being able to offer as many open slots as possible. 

Another challenge is that schedulers don’t often know what level of medical decision-making will be required, says Canon, adding that some practices choose to see patients within seven days for this reason. Canon urges providers to remember that the date of discharge is day one of the seven- and 14-day timeframe.

TCM is for 30 days of care.

According to a TCM FAQ dated March 17, 2016 (, providers can report TCM on the date of the face-to-face visit rather than wait until day 30 as CMS had required previously. 

However, TCM still requires 30 days of services. This means that if a patient dies prior to day 30 following discharge, providers must send a corrected claim, says Huey. However, physicians may be able to bill an office visit (e.g., 99214) if they did meet with the patient post-discharge. The specific code will depend on the documentation related to medical decision-making, she adds. 

If a patient is readmitted and subsequently discharge within the original 30 days-and a provider performs a second round of TCM services-he or she can’t rebill TCM until those 30 days have elapsed, says Huey.

“We typically flag the patient’s chart and hold that TCM charge for the 30 days to ensure that there is no readmission, or that additional follow-up visits included in the TCM charge are not billed separately,” says Heather Campbell, CPC, CPMA, of the AAPC. “Evaluation and management visits for unrelated problems can still be charged during the TCM period.”


Some EHR systems include ticklers or notifications to remind physicians to check for any readmissions or deaths, says Canon. “But it depends on your EHR. You do need to know when the service period ends. This is significant for future TCM episodes as well as CCM,” he adds.

The 30 days of TCM services also include an implicit requirement for follow-up contact and visits, when necessary, says Huey. “If you identify a problem, then you need to follow-up on a case by case basis. If you tell the patient that Meals on Wheels is available, then I think there is an inherent responsibility to follow up in a week or so to see whether the patient got the services,” she adds.

It also requires an assessment of psychosocial needs. “Part of it is identifying community resources to help with patients’ needs,” says Huey. “Let’s say a patient was in the hospital and had a lot of medication changes. Did you ask the patient whether they understand the medications, [and] have access to the pharmacy? What if there was a dietary change? Can someone help prepare meals?”

Reporting requirements for CCM

As with TCM, there are many requirements to meet:

Providers must obtain written patient consent for CCM services. 

“It’s hard to tell patients that you’re going to give them the same care you always have, but now you’re charging them an extra copayment for it. That’s a major mental hurdle to overcome especially for Medicare patients on limited incomes,” says Barbie Hays, CPC, CPMA, a coding expert with the American Academy of Family Physicians (AAFP).

She says providers must emphasize to patients that the extra reimbursement will allow the practice to provide even better care because it will be able to hire a nurse just to make sure that patients have their medications in order and receive the services they need.

“I think part of the challenge is in helping patients understand what it is that they’re getting that’s different from what they were getting before-and for which they’re going to owe a copayment. I think a lot of practices are uncomfortable with this or don’t have the systems in place to explain this adequately to patients,” says Williams.

Hasan says he makes it a point to speak personally with patients about CCM.

“Sometimes physicians don’t have the time to explain CCM, and they delegate it to a medical assistant. But patients want to hear it from the physician or head of the team directly,” he adds.

Providers must be able to share the care plan electronically with members outside of the immediate care team. 

This requires an EHR with a capability to create and send a care plan that other providers can accept, says Hays. Providers must ask their EHR vendor about this, she adds.

CCM requires a detailed care plan. 

“If you perform annual wellness visits-and document them appropriately-then you’re going to have your care plan,” says Huey. “However, beware of cloned documentation. Some of the care plans I’ve seen are not personalized to each patient.”

CCM is a time-based code that requires 20 minutes of CCM services per calendar month. 

The 20 minutes could include phone calls with the patient or caregiver as well as any type of coordination of care for a patient’s chronic conditions. Track and document this time carefully in the EHR, says Huey. 


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