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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
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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
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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
CPT codes, descriptors, and other data only are copyright 2016 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.
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
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2 0 .
a.
p
TCM Study Results
Maine Medical Partners Study Results
Copyright Maine Medical Partners
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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
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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)
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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
CPT codes, descriptors, and other data only are copyright 2016 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.
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
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 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
January 1, 2016 December 31, 2016
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
Total Number of Services
Your Percent
Your States Percent
Comparison with Your States
Percent
National Percent
Comparison with the National
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
Calculated as follows:
( ) x 100
CBR201704 46
Table 4 Table 4: Percentage of Services Billed CPT Code 99496
January 1, 2016 December 31, 2016
Services With CPT
99496
Total Number of Services
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
Total Number of Services
Your Percent
Your States Percent
Comparison with Your States Percent
National Percent
Comparison with the 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
Calculated as follows:
( ) 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
Comparison with Your States
Percent
National Percent
Comparison with the National
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
Services Billed After
14 Days
Total Number of
CPT 99495 Services *
Your Percent
Your States Percent
Comparison with Your States
Percent
National Percent
Comparison with the National
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
Calculated as follows:
( ) 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
Services Billed After
7 Days
Total Number of
CPT
99496 Services *
Your Percent
Your States Percent
Comparison with Your States Percent
National Percent
Comparison with the 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
Services Billed After
7 Days
Total Number of
CPT
99496 Services *
Your Percent
Your States Percent
Comparison with Your States Percent
National Percent
Comparison with the 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
References & Resources
CPT codes, descriptors, and other data only are copyright 2016 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply
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
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http://www.cbrinfo.net
About Us CBR Releases Education Recommended Links FAQs CBR Support Contact Us
CBR201704 57
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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.
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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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