Transitions of care management

The following is a review of the requirements for using the new Transition of Care Management Codes (TCM) with a review of the process development, which SETMA has done to make it possible for SETMA providers to respond to this opportunity for enhanced reimbursement with clarity and accuracy.

Over the past 15 years, SETMA has developed the use of electronic, systems-wide solutions that often were not reimbursed. We have always believed that the day would come when we would be compensated for the quality of our work. The TCM codes, along with the Physician Quality Reporting System, Meaningful Use and Bridges to Excellence are the most recent example of why our hard work is now paying off, both for our patients and our practice.

Below, we review each of the requirements for billing for TCM and then we discuss SETMA’s information technology and organization structural development for performing each of the tasks required. The solutions are discussed under the heading of “Preparation.” It is, I think, remarkable that except in one instance, SETMA has built functionalities that answer every element of the complex TCM Codes. That one issue is follow-up calls within two days for patients discharged from the hospital on Friday. We are already devising a solution for that need.

In order to bill for a TCM Service, the following must occur: 1. The provider must have contact with the patient within two days of the patient leaving the hospital.

Preparation — In August 2010, SETMA began care coaching calls the day following a patient’s discharge from the hospital. We are now adding an MSW and an RN for home visits following hospitalization and for fragile patients who are at increased risk of hospitalization.

a. Communicating (via direct contact, telephone, electronic) with the beneficiary and/or caregiver, including education of patient and/or caregiver within two business days of discharge based on a review of the discharge summary and other information such as diagnostic test results, including each of the following tasks:

Preparation – In 2001, SETMA began completing hospital discharge summaries in our EMR making them instantly available in the clinic, in the Nursing Home and in all other venues where patients are treated. In 2005, SETMA reorganized the hospital care team such that now, 98.7% of the time the discharge summary is completed at the time the patient leaves the hospital. In June 2009, the Physician Consortium for Performance Improvement published a Transitions of Care Measurement Set. SETMA immediately deployed that quality measure set and has audited our hospital charts since as to our performance on these measures. At under Public Reporting, we publicly report by provider name these measures for 2009, 2010, 2011 and 2012. (See

Going forward this audit is published quarterly. In 2010, SETMA’s Care Coordination Department began making care coaching calls to all discharged patients the day after discharge. In September 2010, SETMA renamed the “discharge summary.” The new name is “Hospital Care Summary and Post Hospital Plan of Care and Treatment Plan.” This plan includes a reconciled medication list, an assessment for potential of readmission, and all follow-up information.

b. An assessment of the patient’s or caregiver’s understanding of the medication regimen as well as education to reconcile the medication regimen differences between the pre and post-hospital, CMHC, or SNF stay.

Preparation – the Hospital Care Summary is given to the patient or caregiver prior to the patient leaving the hospital. It contains a reconciled medication list. The reconciled medication list is explained to the patient or caregiver. Another medication reconciliation and explanation of medication is done with the patient at their care coaching call the day after discharge.

c. Education of the patient or caregiver regarding the on-going care plan and the potential complications that should be anticipated and how they should be addressed if they arise.

Preparation – The old “discharge summary” having been changed to the Hospital Care Summary and Post Hospital Plan of Care and Treatment Plan, includes:

1) The patient’s diagnoses; 2) Potential Complications; 3) An explanation of the patient’s risk of readmission; 4) The details of patient’s follow-up care with appointment times and places; 5) Any additional consultations, which are visits with providers who were not involved in the hospital care; 6) An order for the care coaching call including discussion of potential complications and what to do it any such occurs; 7) Etc.

d. Assessment of the need for and assistance in establishing or re-establishing necessary home and community based resources.

Preparation – A simplified solution to this is a referral template to the Care Coordination Department to obtain assistance in obtaining home health, physical therapy, provide in-home provider support, Meals on Wheels, medications, financial support, DME, education, etc. This referral includes the ability to request patient support from The SETMA Foundation.

e. Addressing the patient’s medical and psychosocial issues, and medication reconciliation and management.

Preparation — At the time of discharge from the hospital and at the post-hospital visit, the team assesses fall risk, pain, function, wellness and stress. The tools deployed for these functions allow providers and staff to uncover unspoken needs in the patient’s care.

2. In lieu of a call, in cases of patients who are very high risk of re-admission, a face-to-face visit in the home by an MSW or an RN would qualify for the contact within 48 hours.

Preparation – SETMA completes a “readmission risk assessment” at the time a patient is admitted to the hospital. This is given to the patient in a document entitled, “Hospital Care Plan.” This document tells the patient why they were admitted, what they can expect as far as treatment and length of stay, gives them a reconciled medication list and gives them the admission estimate of their risk of readmission. The risk assessment is repeated upon discharge and is reported to the patient or caregiver in the Hospital Care Summary and Post Hospital Plan of Care which they are given at discharge. The security and confidence the MSW and RN give to the patient that their healthcare needs are and will be met is significant. It begins breaking the link with the idea that the emergency department is their healthcare safety net.

3. Have medication reconciliation done prior to or at the time of the face-to-face visit.

Preparation – a medication reconciliation is done at admission, at discharge, at the time of the care coaching call the day after discharge and at the hospital follow-up visit which takes place in two days for patients at high risk of readmission and within five days for all others.

4. Have a follow-up visit, which is a 99214 (there will be very many of these) or a 99215 (there will be very few of these). This requirement is not specific to the face-to-face encounter but is designated as “Medical decision making of at least moderate complexity during the service period.” The entire coding system for TCM is “for the service period” – 30 days post discharge.

Preparation – SETMA’s ability to correctly assess the complexity of decision making based on published CMS guidelines allows us to assess the correct Evaluation and Management code in order to correctly determine if the Transition of Care Management codes are appropriately used.

5. Have a follow-up face-to-face with the provider (this must be done by a Nurse Practitioner or by a Physician) within seven days for a 99496 or within 14 days for a 99495.

Preparation – SETMA has launched functionality in the EMR to make these management codes available (see below). This functionality includes automation of the determination of whether the: a. Level of E&M is achieved, which is required for the TCM; b. Contact within two days post discharge was done; c. Patient is seen within seven or 14 days post discharge; d. Medication reconciliation has taken place; e. Plan of care and treatment plan has been given to the patient or caregiver.

Ongoing training will take place with SETMA’s providers to make certain that these codes are used properly. Ongoing auditing of provider compliance with CMS requirements will be done.

6. At the face-to-face, this would include: a. Assuming responsibility for the beneficiary’s care without a gap.

Preparation – The SETMA team is seamless between inpatient and ambulatory care. Four reconciliations for each admission are performed on the same medication list. The admission plan of care, the hospital care summary and post hospital plan of care and treatment plan, the care coaching call and the follow-up face-to-face visit are all competed in the same data base. While there is continuity of personalities helping with the patient’s care, the ultimate continuity of care is data driven by the EMR being used at ALL points of care.

b. Obtaining and reviewing the discharge summary.

Preparation – The discharge summary is instantly available in the ambulatory setting. A SETMA provider, performing a TCM face-to-face visit has the entire hospital documentation immediately available at the time of discharge.



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