The ins and outs of new transitional care codes

The government wants to reduce the rehospitalization rate among Medicare patients, and that could mean a bottom line boost for many primary care practices.

Since the start of this year, Medicare has, for the first time, begun paying doctors and their staffs for 30 days of transitional care management (TCM)-the time spent following up with patients after their discharge from an inpatient hospital setting or nursing or skilled nursing facility, and coordinating care as the patient makes the transition back to a community setting, which is defined as a home, domiciliary, rest home, or assisted-living facility.

The expectation is that encouraging immediate post-discharge follow-up will reduce the number and severity of mistakes that lead to patient rehospitalization.

New CPT codes

TCM is covered under two new Current Procedural Terminology (CPT) codes, 99495 and 99496, that have been included in the 2013 Physician Fee Schedule.  The required elements for using CPT code 99495:

• communication (direct contact, telephone, or electronic) with the patient and/or caregiver within 2 business days of discharge,

• medical decision-making of moderate complexity during the service period, and

• a face-to face visit within 14 calendar days of discharge.

The required elements for using CPT code 99496:

• communication (direct contact, telephone, or electronic) with the patient and/or caregiver within 2 business days of discharge,

• medical decision-making of high complexity during the service period, and

• a face-to-face visit within 7 days of discharge.

Both codes permit the face-to-face visit to take place in the patient’s residence or somewhere other than the doctor’s office.

The Centers for Medicare and Medicaid Services (CMS) values code 99495 at 4.82 total relative value units (RVUs), or approximately $163, and code 99496 at 6.79 RVUs, or about $231. CMS estimates that about 7% of the funds earmarked for the two codes for 2013 will go to family practices, and 4% will go to internal medicine practices.

Medicare requires services performed under the codes to be billed 30 days after the patient’s discharge. Rules for private payers may differ.

Long-term savings expected

Although paying for TCM will mean additional outlays from Medicare over the short term, both CMS and medical groups expect that it will produce savings over the long term, says Shari Erickson, MPH, director of regulatory and insurer affairs for the American College of Physicians (ACP).

“The intent of these codes is to check in with the patient[s] or their caregiver[s] and make sure they are clear on their care plan and their medications and prevent emergency department visits and hospital readmissions, with the idea being that over time, the system will see savings from these codes, and we can document those savings,” Erickson explains.

A 2007 Medicare Payment Commission Advisory study found that 18% of Medicare patients discharged from the hospital were readmitted within 30 days of discharge, at a cost of $15 billion.

More payments for previously uncompensated time may be coming. The 2013 CPT codes also include three new codes covering complex chronic care coordination (CCCC) services. CMS did not include the codes in its 2013 fee schedule, however, so Medicare will not yet reimburse for them. (See below: “On the horizon: Distinct reimbursement for complex chronic care coordination services?”)

Paying for non-face-to-face communication

Of particular significance to primary care practices as related to the TCM codes is that they pay for time spent in non-face-to-face communications by physicians and qualified members of their staffs. Types of covered services for staff members (under the physician’s direction):

• communication (including telephone or e-mail) with the patient and/or caregiver within 2 business days of discharge,

• communication with home health agencies and other community services the patient uses,

• patient and/or family or caregiver education to support patient self-management and independence,

• assessment and support for treatment regimen adherence and medication management,

• identification of available community and health resources, and

• facilitation of access to care and services needed by the patient and/or his or her family.

Non-face-to-face services provided by either the physician or a qualified staff member covered under the codes:

• obtaining and reviewing discharge information;

• reviewing the need for, or following up on, the patient’s discharge information;

• reviewing the need for, or following up on, pending diagnostic tests and treatments;

• communicating with other healthcare professionals who will assume or re-assume care for the patient;

• educating the patient, his or her family, guardian, and/or caregiver;

• establishing or reestablishing referrals and arranging needed community resources; and

• help with scheduling any required follow-up with community providers and services.

Debra Seyfried, MBA, CMPE, coding and compliance strategist for the American Academy of Family Physicians (AAFP) says that some of the services included in the TCM codes also are covered under the existing code 99214, the evaluation and management code for a post-discharge, follow-up visit with an established patient. The older code, however, is worth 4.82 RVUs, or between $103 and $130. Moreover, she says, the face-to-face visit in the newer codes is not “exam-intensive.”

“It’s more of, ‘Do you [the patient] understand your disease state? How can I help you better manage this disease to keep you from going back into the hospitals?’ ” she says.

The rules for the TCM codes permit only one billing per patient in a 30-day patient, which can be submitted by any doctor treating the patient except if the doctor has provided a 10- or 90-day global service discharge. In practice, however, Seyfried says the primary care physician (PCP) is the most likely to submit the bill.

“The surgical practices I’ve been associated with have been more than happy to turn over transitional care responsibilities,” she adds. “They don’t want to manage all the patient’s medications and their diabetes and all those other things. They just want to do their procedure and be done with the patient.”

According to Erickson, CMS’ initial draft of the codes did not require a face-to-face visit. “We actually pushed back on that, because the evidence shows that a face-to-face visit, when incorporated with all the non-face-to-face work, is actually more effective at preventing readmissions,” she says.

Early follow-up is crucial

Jeffrey Kagan, MD, an internal medicine practitioner in Newington, Connecticut, and a member of the Medical Economics editorial board, thinks the 2-day, post-discharge contact requirement in the codes is crucial.

“You take the busy physician, who’s glad he’s gotten the patient out of the hospital and doesn’t want to think about him again until he shows up in the office. Now we’re contacting [patients] to find out how they’re doing. It’s great public relations. The patients love it, and it gives them the chance to ask, ‘Was I supposed to take the blue pill I had been taking, since now they’ve given me this pink pill?’ That’s the type of thing that will help keep them out of the hospital.”

At the end of January, Kagan’s practice billed Medicare using CPT code 99496, for which it received payment of $245. (See “New TCM codes: Case histories” for more information.)

Tracking patient discharges

For most primary care practices, the biggest challenge the TCM codes will pose is knowing when a patient is discharged from the hospital.

“Everything hinges on the date of discharge,” says the AAFP’s Seyfried. “That’s when the clock starts ticking on the [follow-up] 2-business day communication and 7- or 14-day face-to face-visits, and the 30-day billing rule.”

The AAFP has developed a worksheet to aid physicians and their staffs in tracking the status of newly discharged patients. It is available on the organization’s Web site at www.aafp.org/online/etc/medialib/aafp_org/documents/prac_mgt/codingresources/tcmworksheet.Par.0001.File.dat/TCM30day.pdf.

Kagan says his practice has started opening transitional care notes in his practice’s electronic health record (EHR) system following the initial communication with the patient or caregiver within 2 business days.

“We leave that note unfinished, to continue and document when we see the patient for the face-to-face,” he explains. “The medical assistants know to look at the last note and see whether there is an open TCM note to be continued.” Kagan’s practice partner developed the EHR template for entering the note. 

The growing use of hospitalists in many areas adds another wrinkle to discharge communications, says Maxine Lewis, CMM, CPC, CPC-I, CCS-P, president of Medical Coding Reimbursement Management in Cincinnati, Ohio.

“Somewhere, there’s got to be communication between the hospitalist and the PCP when the patient is discharged,” she says. “Sometimes the hospitalist doesn’t even know who the PCP is. And is it even the hospitalist’s responsibility to notify the PCP? I don’t know how that’s going to be resolved.”

Seyfried says she has fielded calls from PCPs asking how they will know when their patients are discharged.

“It’s really just a matter of establishing good relationships with your hospital, and having some way you can access that [discharge] information,” she says. “The other part is having good relationships with your specialty providers and with your patients so your patients will tell the specialists that you are their PCP.”

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New TCM codes: case histories

Whether the care you are providing is defined as transitional care management (TCM) or complex chronic care coordination (CCCC) affects the reimbursement you’ll receive under Current Procedural Terminology, as illustrated in these case histories from Jeffrey Kagan, MD, an internal medicine physician in Newington, Connecticut, and a Medical Economics editorial board member.

Case history 1: TCM

Patient: A 67-year-old male who usually lives at home with his family.

History: Alcoholism is in remission after several episodes of pancreatitis resulting in insulin-dependent diabetes mellitus, cirrhosis with ascites and hepatic encephalopathy, ischemic bowel resulting in a surgical resection and Ileostomy, chronic kidney disease stage 6 on hemodialyis, atrial fibrillation, and chronic hypotension. The patient is hospitalized frequently due to his multiple comorbidities.

The patient spent 4 days in the hospital in December. Our office saw him for a follow-up visit within a week of discharge; it was an extended visit of an established patient (CPT 99214). Our office received $111.65, the 2012 rate for Medicare participation in Connecticut. The 2013 rate would be $114.62.

The patient was hospitalized again in January for 5 days. The physician placed a brief telephone call to his house within 2 business days of the hospital discharge and had a discussion with one of his family caregivers concerning the plan of care, including diet, medication, blood glucose, and medical follow-up appointments.

The doctor saw the patient in the office for a face-to-face visit 6 days after he was discharged from the hospital. The medical decision-making level was deemed high complexity due to his several comorbidities. CPT code 99496 was used. Reimbursement was $245.

Case history 2: CCCC

Patient: An 82-year-old-female with a past history of easily controlled hypertension.

History: December 18, the patient blacked out while at home and fell down stairs, landing at the bottom step face down. She woke up after a brief period of unconsciousness. She declined to go to the hospital and instead had a friend drive her to my office.

She had two black eyes and extensive facial swelling. After a brief examination, I insisted she go to the emergency department (ED) for a computed tomography scan and further evaluation.

The ED physician subsequently called to say that her injuries were limited to the facial contusions. A routine chest x-ray performed because of the syncope, however, revealed a 3-cm right upper lobe mass not present on her last chest x-ray a year earlier. She was admitted to the hospital for observation and underwent a needle biopsy of the lung mass.

I saw the patient again, for follow-up in my office, December 28 and advised her that the lung mass was malignant. Further testing was scheduled, along with a referral to a thoracic surgeon. The patient returned to my office January 7 with a new cough and was treated for bronchitis. I ordered a chest x-ray to exclude pneumonia or a delayed pneumothorax from the recent needle biopsy.

January 8, I received a call from the pulmonary function lab that the patient missed her appointment for spirometry. A call to the patient confirmed this fact, and one of our clinical staff members spoke with the pulmonary function lab and again with the patient to get her spirometry test rescheduled.

At this point, I began tracking time under the CCCC TCM code. These calls took 15 minutes. I also called the surgeon to update him on the patient’s acute bronchitis and the need to delay things a bit. This call lasted 3 minutes.

I called the patient January 9 to tell her that the chest x-ray was negative except for the previously documented lung cancer. We spoke for 5 minutes.

The patient called to speak with me January 10 to say her cough was no better. We spoke for 5 minutes. The same day, one of her daughters came to the office to discuss her mother’s case. We discussed the respiratory symptoms, whether her illness could be influenza, and the possible treatments of the cancer. I spent 10 minutes with the daughter.

I called the patient January 14 to inform her that her positron emission tomography scan showed no spread of the cancer and that delaying surgery due to her bronchitis would not adversely affect her ultimate outcome. Once again, her spirometry test was rescheduled. We also discussed her visit with the surgeon. I spoke to her for 15 minutes.

Total CCCC management time: 53 minutes.

Billing outcome: Medicare informed us that for 2013 it considers CCCC services as being bundled with other billings.

On the horizon: Distinct reimbursement for complex chronic care coordination?

In addition to two codes covering transitional care management, the 2013 Current Procedural Terminology (CPT) list includes three new codes-CPT 99487, 99488, and 99489-for complex chronic care coordination (CCCC) services. The Centers for Medicare and Medicaid Services considers the included services to be bundled services and thus will not pay for them separately, but it is studying them for possible separate implementation in the future.

The CPT listing defines CCCC services as “patient-centered management and support services provided by physicians, other qualified health professionals, and clinical staff” that “address the coordination of care by multiple disciplines and community service agencies. The reporting individual provides or oversees the management and/or coordination of services, as needed, for all medical conditions, psychosocial needs, and activities of daily living.”

Specific applications of the codes:

• 99487: Complex chronic care coordination services; first hour of clinical staff time directed by a physician or other qualified healthcare professional with no face-to-face visit, per calendar month.

• 99488: Complex chronic care coordination services; first hour of clinical staff time directed by a physician or other qualified healthcare professional with one face-to-face visit, per calendar month.

• 99489: Complex chronic care coordination services; each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month.

Care coordination activities performed by clinical staff members may include:

• communicating with the patient, family members, other caregivers, or guardian regarding aspects of care,

• communicating with home health agencies and other community services the patient might use,

• collecting health outcomes data and registry documentation,

• Patient and/or family/caretaker education to support self management, independent living, and activities of daily living;

• assessment and support for treatment regimen adherence and medication management,

• identifying available community and health resources,

• facilitating access to care and services needed by the patient and/or family, and

• developing and maintaining a comprehensive care plan.