Bridging the Gap in Care Management and Transitional Care Management

Paula Motes Part B Senior Provider Education Consultant Provider Outreach and Education

Agenda

• Chronic Illness Overview • Chronic Care Management (CCM) • Transitional Care Management (TCM)

2 Pre-Test

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3 Disclaimer

The information provided in this presentation was current as of August 23, 2019. Any changes or new information superseding the information in this presentation is provided in articles with publication dates after August 23, 2019 posted on our website at: https://www.palmettogba.com/

CPT® only copyright © 2019 American Medical Association. All rights reserved. The Code on Dental Procedures and Nomenclature is published in Current Dental Terminology (CDT), copyright © 2019 American Dental Association (ADA). All rights reserved.

4 Chronic Illness

• Half of adults in the U.S. suffer from a • 25% of Americans have two or more chronic conditions • Two-thirds of Medicare beneficiaries have two or more chronic conditions • 84% of care spending in U.S. is on people with chronic conditions • 99% of Medicare spending is on patients with chronic conditions • High percentage of deaths are from chronic conditions

5 What is Chronic Care Management?

• Chronic Care Management (CCM) services by a physician or nonphysician practitioner (physician assistant, nurse practitioner, clinical nurse specialist and/or certified nurse midwife) and their clinical staff, per calendar month, for patients with multiple (two or more) chronic conditions expected to last at least 12 months or until death, and that place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline.

6 Why CCM?

• CCM contributes to better health outcomes and higher patient satisfaction • Improves quality and reduces gaps in care • Provides care coordination • Provides person-centered care

7 Eligible Practitioners

• Physicians • Physician Assistants • Nurse Practitioners • Clinical Nurse Specialists • Certified Nurse Midwives

8 Other Eligible Healthcare Entities

• Federally Qualified Health Centers (FQHC) • Rural Health Centers (RHC) • Hospital Outpatient Departments

9 Supervision

• General • Performed under the direction of the billing practitioner • Physical presence of billing practitioner not required

10 Patient Eligibility

• Must have two or more chronic conditions • Expected to last at least 12 months or until death • Place them at significant risk of death, acute exacerbation, or functional decline • Must have no other diagnostic limitations

11 Examples of Chronic Conditions

• Alzheimer’s Disease and related dementia • Arthritis • Asthma • Atrial Fibrillation • Autism • Cancer • Cardiovascular Disease • COPD • Depression • •

12 CCM Service Elements

• Initiating Visit • Patient Consent • Structured Recording of Patient Information Using Certified EHR Technology • 24/7 Access and Continuity of Care • Comprehensive Care Management • Comprehensive Care Plan • Management of Care Transitions • Care Coordination • Home- and Community-Based • Enhanced Communication Opportunities

13 Initiating Visit

• New patients or patients not seen within one year • Performed by billing practitioner • Face-to-face encounter • Separately billed (not part of CCM code)

G0506 allowed for instances of extensive assessment and CCM planning in excess of the norm.

14 Patient Consent

• Obtain prior to furnishing CCM services • Verbal or written • Inform patient • Availability of CCM services • Applicable cost-sharing • Right to stop services at any time • Only one practitioner can provide this service • Document in medical record

15 Structured Recording of Patient Information

• Must use certified Electronic Health Record (EHR) • https://www.cms.gov/Regulations-and- Guidance/Legislation/EHRIncentivePrograms/ • Record • Patient demographics • Problems • Medications • Allergies • Care Plan • Care coordination • Clinical care provided

16 24/7 Access and Continuity of Care

• Access 24 hours per day, seven days per week • Access to qualified health care professionals • Provide patient/caregiver with means to make contact • Designated team member for the patient • Enhanced opportunities for communication

17 Comprehensive Care Management

• Systematic assessment of patient needs • Approach to ensure preventive care • Medication reconciliation/review • Oversight of patient self-management • Coordination of care

18 Comprehensive Care Plan

• Problem list • Expected outcome and prognosis • Measurable Treatment goals • Symptom management • Planned interventions and responsible parties • Medication management • Community/social services ordered • Description of coordination of outside services • Schedule for review/revision of care plan • Any other applicable information

19 Comprehensive Care Plan

Management of Care Transitions • Among health care providers • From setting to setting • Referrals • Follow-up

Care Coordination • Home- and community-based • Psychosocial needs • Functional needs

20 Levels of Care – CCM

CPT 99490 — Chronic care management services • At least 20 minutes of clinical staff time, per calendar month • Directed by physician/qualified health care professional • Comprehensive care plan action

CPT 99491 — Chronic care management services • At least 30 minutes of clinical staff time, per calendar month • Directed by physician/qualified health care professional • Comprehensive care plan action

21 Levels of Care — Complex CCM

CPT 99487 — Complex chronic care management • 60 minutes, per calendar month • Directed by physician/qualified health care professional • Moderate or high complexity medical decision making • Establishment or substantial revision of comprehensive care plan

CPT 99489 — Chronic care management • Each additional 30 minutes, per calendar month • Only report in conjunction with 99487 • Do not report for complex CCM services less than 30 minutes additional time

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CCM Billing Guidelines

• Bill once per calendar month • Can only be billed by one practitioner per calendar month • Time counted toward the reporting of a CCM code cannot be counted towards any other billed code • Date of service can be the date that the requirements to bill for the service have been met for that month, or any date after that but on or before the last day of the month

23 Concurrent Billing Restrictions

• Do not bill both complex CCM and non-complex CCM for a given patient during the same month • Do not bill CCM during the same service period as home health care supervision or hospice care supervision • Do not bill concurrently with certain End-Stage Renal Disease services • Do not bill during the 30-day TCM service period • Complex CCM and prolonged E/M services cannot be billed in the same calendar month by the same practitioner • Other services excluded by CMS reporting rules or additional CMS guidance

24

FQHC & RHC CCM Billing

• Report with HCPC code G0511, revenue code 052x • May be billed or alone or with other payable services • Can only bill one care management service for an individual • Payment is average of the national non-facility PFS payment rate for CPT codes 99490, 99487, 99491 and 99484 (2019 rate is $67.03) • Coinsurance and deductibles apply to all care management services in RHCs • Coinsurance applies to all care management services in FQHCs

25 Hospital Outpatient Department CCM

• POS-practitioners who furnish CCM in the hospital outpatient setting, including provider-based locations, must report the appropriate place of service for the hospital outpatient setting • Payment for CCM furnished and billed by a practitioner in a facility setting will trigger PFS payment at the facility rate • CPT 99490 cannot be billed to the PFS for patients who reside in a facility that receives payment from Medicare for care of that beneficiary

26 Transitional Care Management Services (TCM)

• Services during the beneficiary’s transition to the community setting following discharge from certain health care facility settings • Health care professionals take responsibility for the beneficiary’s post-discharge care • No gap in care during this transition • Moderate or high complexity medical decision making • TCM period is 30 days

27 TCM: Eligible Practitioners

• Physicians (any specialty) • Nonphysician practitioners (NPPs) • Physician assistants (PAs) • Nurse practitioners (NPs) • Clinical nurse specialists (CNSs) • Certified nurse midwives (CNMs)

28 Approved TCM Settings – Discharge From

• Inpatient Acute Care Hospital • Inpatient Psychiatric Hospital • Long-Term Care Hospital • Skilled Nursing Facility • Inpatient Rehabilitation Facility • Hospital outpatient observation or partial hospitalization • Partial hospitalization at a Community Mental Health Center

29 Approved TCM Settings – Discharge To

• Home • Domiciliary • Rest home • Assisted living facility

30 Supervision

• Direct supervision • Required face-to-face visit • General supervision • Non-face-to-face services • Subject to State law, scope of practice and incident to regulations

31 TCM Components

Interactive Contact • Must occur within two business days following the beneficiary’s discharge • With the beneficiary or their caregiver • Via telephone, email, or face-to-face • Address patient status and needs • Document attempts at contact in the medical record

32 TCM Components

Non-Face-to-Face Services Physicians or NPPs • May include the following: • Obtain and review discharge information • Review need for/follow-up on diagnostic tests and treatments • Coordinate with other health care professionals who will provide care for system specific problems • Provide education to beneficiary/caregivers • Handle referrals • Arrange for needed community resources • Assist in scheduling follow-up care/services

33 TCM Components

Non-Face-to-Face Services Clinical Staff • Under the direction of Physician or NPP, may include the following: • Communicate with agencies and community services • Provide education in support of self-management, independent living and activities of daily living • Assess and support treatment • Assess and support medication management • Identify available community/health resources • Assist in accessing needed care and services

34 TCM Components

Face-to-Face Visit • Must furnish one face-to-face visit • Must be furnished within the allowable timeframe • May be furnished via telehealth (if all telehealth requirements are met) • Not reported separately

35 TCM Services

CPT Code 99495 — Transitional care management with the following required elements • Contact within 2 business days of discharge • Medical decision making of at least moderate complexity • Face-to-face visit within 14 calendar days

CPT Code 99495 — Transitional care management with the following required elements • Contact within 2 business days of discharge • Medical decision making of high complexity • Face-to-face visit within 7 calendar days

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Minimum Documentation Requirements for TCM

• Beneficiary discharge date • Interactive contact date • Face-to-face visit date • Medical complexity decision making

37 TCM Billing

• Report services once per beneficiary during the TCM period • May be reported by only one health care professional • May be billed by the same practitioner that discharged the beneficiary from the hospital and billed discharge services • Required TCM face-to-face cannot take place on the same day the practitioner reported discharge day management services • Bill reasonable and necessary E/M services separately (except required TCM face-to-face)

38 TCM Billing

• Cannot bill TCM within a post-operative global period (same practitioner) • Date of service reported on claim should be the date of service of the face-to-face visit • May submit claim once the face-to-face visit is furnished • Place of service (POS) reported on the claim should correspond to the place of service of the TCM face-to-face visit

39 TCM Billing

• There is both a facility and non-facility MPFS payment for TCM. Report TCM services with the POS of the face-to-face visit • If the beneficiary dies prior to the 30th day, practitioners should not report TCM services but may report appropriate E/M codes

40 TCM Concurrent Billing Restrictions

When billing CPT codes 99495 or 99496, do not bill the following services during the TCM service period: • Can Plan Oversight Services • Home health or hospice supervision (G0181/G0182) • End-Stage Renal Disease services (90951–90970) • Chronic Care Management Services • Prolonged E/M Services (99358–99359) • Other services excluded by CMS reporting rules or additional CMS guidance

41 References

• CMS Chronic Care Management Webpage: https://www.cms.gov/Outreach- and-Education/Outreach/NPC/National-Provider-Calls-and-Events-Items/2015-02-18-Chronic- Care-Management-new.html

• Chronic Care Management Booklet: https://www.cms.gov/Outreach-and- Education/Medicare-Learning-Network- MLN/MLNProducts/Downloads/ChronicCareManagement.pdf • Chronic Conditions Information: https://www.cms.gov/Research-Statistics-Data- and-Systems/Statistics-Trends-and-Reports/Chronic-Conditions/ • Transitional Care Management Services Booklet: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNProducts/Downloads/Transitional-Care-Management-Services-Fact-Sheet- ICN908628.pdf • Physician Fee Schedule: https://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/PhysicianFeeSched/index.html

42 Questions?

43 Post-Test

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44 Have a Great Day!

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