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CBR201704: Transitional Care

Management June 21, 2017

3:00 P.M. ET

mailto:[email protected]

CBR201704: Transitional Care

Management June 21, 2017

3:00 P.M. ET

CPT codes, descriptors, and other data only are copyright 2016 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

The CBR project has made every reasonable effort to

ensure the accuracy of the information and web links

provided in the CBR materials at the time of publication;

however, Medicare policy changes frequently, so the

information and links within the material may change

without further notice. It is the responsibility of the

provider to remain up-to-date with Medicare Program

requirements.

CBR materials are prepared as a service to the public and

are not intended to grant rights or impose obligations. The

information provided in the CBR material is only intended to

be a general summary. It does not supersede or alter the

coverage and documentation policies outlined in the Local

Coverage Determinations (LCDs) and Local Coverage

Articles (LCAs) for the A/B Medicare Administrative

Contractors (MAC) or DME Medicare Administrative

Contractors (DME MAC). Please refer any specific questions

you may have to the A/B or DME MAC for your region. We

encourage providers to review the specific statutes,

regulations, and other interpretive material for a full and

accurate statement of their contents.

Webinar Outline

1. Introduction

2. Coverage & Documentation Overview

3. Methods & Results

4. References & Resources

5. Q&A

6. Survey

CBR201704 5

Webinar Protocol

All attendee lines are muted

Submit questions via chat when prompted by speaker

Submit questions during the Q&A session at the end of webinar

Ask questions pertinent to webinar

Contact MAC for specific claims questions

CBR201704 6

Webinar Objective

Upon completion of this webinar, you should be able to:

Demonstrate a general understanding of CBR201704: Transitional Care Management (TCM)

Comprehend the analytical methods used to develop the report

Locate policy references and resources

CBR201704 7

Compuath-e Billing Report (CBR): ~I llllllllll Transitiona] Ca:re Manageme11t

lnb>oductiao

CBR.201 foru;es Oil !"""id= oi: T.ran.mfoaal CllrO Man.>,ga=t u~ Cumnt Procedmral Terminology (CPI"') co.res 9!14!15 an~ 119496. u1 ana~sis ='?J!ls clw MedicMe spending ,on TCM 5e!llic6 has increased m-er 200 peroent from WB ro 2016. '.fCM: is also, indoded. in ms, O,Gfr~ afbupro:w G

CBR Purpose & Focus

Percentage of services without corresponding discharge record

Percentage of services billed with CPT code 99496

Percentage of CPT code 99495 services billed after 14 days of discharge

Percentage of CPT code 99496 services billed after 7 days of discharge

6,000 providers

CBR201704 9

Webinar Materials

References and Resources

Webinar slides

MP4 of webinar

Webinar Ha ndout

Webinar Q&A Handout

CBR201704 10

Acronyms Code Description CERT Comprehensive Error Rate Testing CNM Certified Nurse Midwife CNS Certified Nurse Specialist CPT Current Procedural Terminology LCA Local Coverage Article LCD Local Coverage Determination NPP Non-Physician Practitioner OIG Office of Inspector General PA Physician Assistant

TCM Transitional Care Management

CPT codes and descriptions are copyright 2016 American Medical Association. All rights reserved. Applicable FARS/DFARS apply.

CBR201704 11

Coverage & Documentation

Overview


Topic Selection - OIG

Office of Inspector General (OIG):

OIG Work Plan 2017

Identifies TCM as potential problem area

Reviewing TCM payments to determine provider compliance with Medicare guidelines

Educate providers on proper billing of TCM services

CBR201704 13

2010 TCM Study

Maine Medical Partners Goals:

Follow-up telephone calls to patients within 24-72 hours post-discharge

Reduce inpatient readmission

Increase quality of care

CBR201704 14

2 0 .

a.

p

TCM Study Results

Maine Medical Partners Study Results

Copyright Maine Medical Partners

CBR201704 15

CMS

CMS introduced TCM Codes in 2013:

Two-thirds of hospital discharges eligible Reduce readmissions Increase quality of care Payments could increase to:

Family practices/internal medicine Gerontologists, Nurse practitioners/physician assistants

CBR201704 16

TCM Services

Requirements include:

Services required during beneficiarys transition from in-patient to community setting

Provider accepts responsibility for care of patient post-discharge with no gap

Patients condition requires moderate or high complexity decision-making

30-day TCM period begins on date of discharge and lasts for 29 days

CBR201704 17

Who Can Provide TCM

TCM can be performed by: Physician

Non-Physician Practitioners (NPPs) Clinical Nurse Specialist (CNS)

Certified Nurse Midwife (CNM)

Nurse Practitioner (NP)

Physician Assistant (PA)

CBR201704 18

TCM Components Performed During 30 Days

1. Interactive contact with patient or caregiver by provider or clinical staff within 2 days via: Telephone Email Face-to-face

2. Non-face-to-face Services to patient may be performed by provider or clinical staff

3. Face-to-face Visit within: 7 days of discharge - CPT 99496 14 days of discharge - CPT 99495

CBR201704 19

CPT Code 99495

CPT 99495 Requirements:

Provider communication with patient and/or caregiver within two business days of discharge

Medical decision making of moderate complexity

Face-to face visit within 14 calendar days of discharge

CBR201704 20

CPT Code 99496

CPT 99496 Requirements:

Provider communication with patient and/or caregiver within two business days of discharge

Medical decision making of high complexity

Face-to face visit within 7 calendar days of discharge

CBR201704 21

Medical Decision Making

Number of Diagnoses or Management

Options

Amount and/or Complexity of

Data to be Reviewed

Risk of Complications

and/or Morbidity or Mortality

Type of Decision Making

Minimal Minimal or none Minimal Straightforward

Limited Limited Low Low Complexity

Multiple Moderate Moderate Moderate Complexity

Extensive Extensive High High Complexity

Medicare Learning Network - ICN 006764 Evaluation and Management Services

CBR201704 22

Inpatient Settings

TCM covered after patient discharged 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

CBR201704 23

Community Settings

TCM covered when patient discharged to:

His or her home

His or her domiciliary

A rest home

Assisted living

CBR201704 24

Face-to-Face Visit

Inherent in the TCM codes: CPT 99495 visit within 14 days of discharge CPT 99496 visit within 7 days of discharge

Telehealth can substitute for face-to-face: Qualified provider can perform TCM services

via telecommunications Medicare pays for limited number of services

Medication Reconciliation: Must be provided by date of face-to-face visit

CBR201704 25

Non-Face-to-Face Services Performed by Physicians or NPPs

Obtain/review discharge records

Review need for or follow-up on diagnostic tests and treatments

Interact with health care professionals who will assume or reassume care of beneficiary

Provide education to beneficiary and/or caregiver

Arrange for needed community resources

Scheduling follow-up with community providers

CBR201704 26

Non-Face-to-Face Services Performed by Clinical Staff

Under Direction of Physician or NPP

Communicate with agencies and community services the beneficiary uses

Provide education to the beneficiary, family, guardian, and/or caretaker to support self-management, independent living, and activities of daily living

Assess and support treatment regimen adherence and medication management

Identify available community and health resources

CBR201704 27

Services that Cannot be Reported with TCM Codes

Care plan oversight services Prolonged services without direct patient contact Anticoagulant management Medical team conferences Education and training Telephone services End Stage Renal Disease (ESRD) services On-line medical evaluation Preparation of special reports Analysis of data Medication therapy management

CBR201704 28

Documentation

Date of discharge Date of interactive contact Date of face-to-face visit Place of service Medical decision making complexity

(moderate or high)

CBR201704 29

TCM Billing

Guidelines: One provider may bill for TCM

TCM service is billed once during 30 days

May bill evaluation and management (E/M)

Cannot bill TCM if service is within global period

Discharging physician may bill TCM, but must provide face-to-face visit on another date

CBR201704 30

Denial Reasons

Another provider billed for TCM

Face-to-face not done by 7th or 14th day

Hospital has not billed for services

Medical decision making complexity was not moderate or high

CBR201704 31

Readmission During TCM

If patient is readmitted to inpatient facility within 30-day TCM period:

Provider may bill for second TCM service after meeting criteria of first TCM

No billing from other provider for first 30 days

CBR201704 32

Methods & Results


Report Data

Medicare Part B Rendering Providers:

By National Provider Identifier (NPI)

6,000 Providers

Transitional Care Management CPT Codes

Extracted: April 6, 2017 from Integrated Data Repository (IDR)

Dates of Service: January 1, 2016 December 31, 2016

CBR201704 34

Table 1 Table 1: Transitional Care Management CPT Codes and Abbreviated Descriptions

January 1, 2016 December 31, 2016

CPT Code Description

99495

Communication (direct contact, telephone, electronic) with the patient and/or caregiver within two business days of discharge; Medical decision making of at least moderate complexity during the service period; Face-to-face visit within 14 calendar days of discharge

99496

Communication (direct contact, telephone, electronic) with the patient and/or caregiver within two business days of discharge; Medical decision making of at high complexity during the service period; Face-to-face visit within 7 calendar days of discharge

CBR201704 35

Table 2

Table 2: Summary of Your Utilization of CPT Codes 99495, 99496 January 1, 2016 December 31, 2016

CPT Code Allowed Charges

Allowed Services

Beneficiary Count

99495 $3,867 24 23

99496 $9,771 43 33

Total $13,638 67 53

CBR201704 36

Table 2 - Explained Table 2: Summary of Your Utilization of CPT Codes 99495, 99496


CPT Code Allowed Charges

Allowed Services

Beneficiary Count

99495 $3,867 24 23

99496 $9,771 43 33

Total $13,638 67 53

CBR201704 37

Selection of CBR Measures

Percentage of Services without Corresponding Discharge Record Each TCM service must be associated with a discharge

Percentage of Services Billed with code 99496 CPT code 99496 is the higher level TCM code that

requires medical decision making of high complexity

Percentage of CPT Code 99495 Services Billed After 14 days A face-to-face visit within 14 days is required

CPT Code 99496 Services Billed After 7 days A face-to-face visit within 7 days is required

CBR201704 38

Metrics and National Statistics

Services without Corresponding Discharge Record National Average: 24%

Services Billed with the Higher Code National Average: 48%

CPT Code 99495 Services Billed After 14 days National Average: 28%

CPT Code 99496 Services Billed After 7 National Average: 33%

CBR201704 39

Peer Groups

Peer Groups Used for comparison with the individual

providers

State Medicare providers in the providers state

billing TCM CPT Codes 99495 and 99496

National All Medicare providers in the nation billing

TCM CPT Codes 99495 and 99496

CBR201704 40

Comparison Outcomes

There are four possible outcomes:

1. Significantly Higher

2. Higher

3. Does Not Exceed

4. N/A

CBR201704 41

Percentage of Services Without Corresponding Discharge Record

Calculated as follows:

( ) x 100

CBR201704 42

Percentage of Services Without Corresponding Discharge Record - IDR

TCM begins on the day the beneficiary is discharged from an inpatient setting to a community setting and continues for 29 days.

Discharge dates were searched in Medicare Part A claims from the IDR:

Health Home Agency (HHA) Swing Bed / Non Swing Bed SNF Outpatient Hospice Inpatient Inpatient Full Encounter

CBR201704 43

Table 3 Table 3: Percentage of Services Without Corresponding Discharge Record


Services Without

Discharge

Total Number of Services

Your Percent

Your States Percent

Comparison with Your States

Percent

National Percent

Comparison with the National

Percent

13 67 19% 22% Does Not Exceed 24% Does Not Exceed

A chi-square test was used in this analysis, alpha = 0.05

CBR201704 44

Calculation of Percentage of Services Without Corresponding Discharge Record

Table 3: Percentage of Services Without Corresponding Discharge Record January 1, 2016 December 31, 2016

Services Without

Discharge


Your Percent

Your States Percent


Percent

National Percent


Percent

1 13 2 67 19% 22% Does Not Exceed 24% Does Not Exceed

( ) x 100

(13 / ) =

CBR201704 45

Percentage of Services Billed with CPT Code 99496


( ) x 100

CBR201704 46

Table 4 Table 4: Percentage of Services Billed CPT Code 99496


Services With CPT

99496


Your Percent

Your States Percent

Comparison with Your States Percent

National Percent

Comparison with the National Percent

43 67 64% 49% Significantly Higher 48% Significantly Higher

A chi-square test was used in this analysis, alpha = 0.05

CBR201704 47

Calculation of Percentage of Services Billed with CPT Code 99496

Table 4: Percentage of Services Billed With CPT Code 99496 January 1, 2016 December 31, 2016

Services With CPT

99496


Your Percent

Your States Percent


National Percent


1 43 2 67 64% 49% Significantly Higher 48% Significantly Higher

( ) x 100

(43/ ) =

CBR201704 48

Percentage of CPT Code 99495 Services Billed after 14 Days of Discharge Date


( ) x 100

CBR201704 49

Table 5

Table 5: Percent age of CPT Code 99495 Billed After 14 Days of Discharge Date January 1, 2016 December 31, 2016

Services Billed After

14 Days

Total Number of

CPT 99495 Services *

Your Percent

Your States Percent


Percent

National Percent


Percent

11 19 58% 26% Higher 28% Significantly Higher

A chi-square test was used in this analysis, alpha = 0.05.

CBR201704 50

Calculation of Percentage of CPT Code 99495

Billed After 14 days of Discharge Date

Table 5: Percentage of CPT Code 99495 Billed After 14 days of Discharge Date January 1, 2016 December 31, 2016


14 Days

Total Number of

CPT 99495 Services *

Your Percent

Your States Percent


Percent

National Percent


Percent

1 11 2 19 58% 26% Higher 28% Significantly Higher

( ) x 100

(11 / 19 ) =

CBR201704 51

Percentage of CPT Code 99496 Services Billed After 7 Days

of Discharge Date


( ) x 100

CBR201704 52

Table 6

Table 6: Percentage of CPT Code 99496 Billed After 7 days of Discharge Date January 1, 2016 December 31, 2016


7 Days

Total Number of

CPT

99496 Services *

Your Percent

Your States Percent


National Percent


23 35 66% 28% Significantly Higher 33% Significantly Higher

A chi-square test was used in this analysis, alpha = 0.05.

CBR201704 53

Calculation of Percent of CPT Code 99496

Billed After 7 days of Discharge Date

Table 6: Percent of CPT Code 99496 Billed After 7 days of Discharge Date January 1, 2016 December 31, 2016


7 Days

Total Number of

CPT

99496 Services *

Your Percent

Your States Percent


National Percent


1 23 2 35 66% 28% Significantly Higher 33% Significantly Higher

( ) x 100

(23/ ) =

CBR201704 54

Which Providers Received This Report?

Providers who are significantly higher than their peers on at least one measure

$3,500 in allowed charges

17 beneficiaries

CBR201704 55

Comparative Billing Reports Comparative B illing Reports (CBRs) a re educational too ls admin istered by the Centers for Medicare & Medicaid Servk: es (CMS). They are developed and disseminated under contract by eGloba lTech, a womanowned Federal services finn t>ased in Arlington, VA.

The CBRs are disseminated to tne prov ider community to provide insight into bill ing trends across reg ions and policy groups. AIB MACs nave Deen producing and disseminating limited numt>ers of CBRs to targeted providers for many years. CMS has now formalized and expanded the prog ram to a national level. The program also includes a CBR Support Help Desk that providers can contac t to ask questions regard ing the CBRs. Following the release of each CBR, eGT will hold an educational teleconference or webinar to educate providers on the substance of the CBR and to provide an opportunity fo r providers to ask questions

r lost Recent CBR

r 1AC Contact Information

Update Your Address

Feedback

CBR Website

http://www.cbrinfo.net

About Us CBR Releases Education Recommended Links FAQs CBR Support Contact Us

CBR201704 57

http:http://www.cbrinfo.net

CBR201704 Web Page

http://www.cbrinfo.net/cbr201704

Webinar Sample CBR Statistical Debriefing Recommended Links FAQs

CBR201704 58

http://www.cbrinfo.net/cbr201704

Provider Self-audit

Providers and suppliers have an obligationto ensure claims are submitted correctlyto Medicare

Self-audits allow providers and suppliers

to identify coverage and coding errors

Refer to the following CBR sections for assistance Documentation and Billing References

CBR201704 59

CBR Support Help Desk

MondayFriday: 9:00a.m. to 5:00p.m. ET

Toll Free 18007714430

Email: [email protected]

CBR201704 60

mailto:[email protected]

Contacting MACs

Providers should contact the Medicare Administrative Contractor (MAC) for assistance with:

Claim Information

Documentation Requirements

Billing and Coding

CBR201704 61

NPPES

National Plan & Provider Enumeration System

Source for mailing address used for the CBR

Correct your mailing information at https://nppes.cms.hhs.gov/NPPES

CBR201704 62

https://nppes.cms.hhs.gov/NPPES

Questions & Answers

We make every effort to address all questions submitted during our webinars. However, we cannot provide responses related to coding issues or to specific claims/scenarios. Since your Medicare Administrative Contractor (MAC) makes the determination to pay or deny a claim based on the CPT or HCPCS codes, medical documentation and description of the circumstances, and we do not have access to this documentation, we cannot respond to these types of questions. Please contact your MAC with questions that we do not address or if you identify any claims discrepancies while reviewing your CBR. The contact information for your MAC is located at http://go.cms.gov/IMap.

CBR201704 64

http://go.cms.gov/IMap

Stay Tuned for WebinarCBR201704 Transitional Care ManagementDisclaimer 1Disclaimer 2Webinar OutlineWebinar ProtocolWebinar ObjectiveSample CBRCBR Purpose & FocusWebinar MaterialsAcronymsCoverage & Documentation Overview Topic Selection - OIG 2010 TCM StudyTCM Study ResultsCMSTCM ServicesWho Can Provide TCM TCM Components Performed During 30 DaysCPT Code 99495CPT Code 99496Medical Decision MakingInpatient SettingsCommunity Settings Face-to-Face Visit Non-Face-to-Face Services Performed by Physicians or NPPsNon-Face-to-Face ServicesPerformed by Clinical Staff Under Direction of Physician or NPP Services that Cannot be Reported with TCM Codes Documentation TCM BillingDenial Reasons Readmission During TCMMethods & ResultsReport DataTable 1Table 2Table 2 - ExplainedSelection of CBR MeasuresMetrics and National StatisticsPeer GroupsComparison OutcomesPercentage of Services Without Corresponding Discharge RecordPercentage of Services Without Corresponding Discharge Record - IDRTable 3Calculation of Percentage of Services Without Corresponding Discharge Record Percentage of Services Billed with CPT Code 99496Table 4Calculation of Percentage of Services Billed with CPT Code 99496Percentage of CPT Code 99495 Services Billed after 14 Days of Discharge DateTable 5Calculation of Percentage of CPT Code 99495 Billed After 14 days of Discharge DatePercentage of CPT Code 99496 Services Billed After 7 Daysof Discharge DateTable 6Calculation of Percent of CPT Code 99496 Billed After 7 days of Discharge DateWhich Providers Received This Report?References & ResourcesCBR WebsiteCBR201704 Web PageProvider Self-auditCBR Support Help DeskContacting MACsNPPESQuestions & AnswersDisclaimer 3

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