Presented by Lesa Schlatman, RN, BSN Care Coordinator Specialist at ICAHN

Iowa Transformation Consortium Project: Care Management

“Kickoff & Transitional Care Management Part II”

August 17, 2017

A PORTION OF THESE MATERIALS WERE PRODUCED PURSUANT TO THE Iowa Small Hospital Improvement Program (SHIP) Grant FY 17 IA Contract #5888SH01.

WEBINAR ETIQUETTEHospital Transformation Consortium

•All attendees are in “Listen Only” mode•Questions or comments?- Open “Questions” pane in

dashboard.- Type in comments or questions.- Comments & questions will be monitored and addressed!

•This webinar will be recorded and emailed to you to share with others on your team.

•Handouts are available for download in the Handouts pane and will posted on your Dashboard

WEBINAR RESOURCESHospital Transformation Consortium

As an IACET Authorized Provider, HomeTown Health, LLC offers CEUs for its programs that qualify under the ANSI/IACET Standard. HomeTown Health, LLC is authorized by IACET to offer 0.1 CEUs/1 credit hour for this program.

In order to obtain these units, you must: • Attend webinar/view recording in its entirety within 30 days• Pass online quiz with 80% or better.• Complete webinar evaluation.

Following this webinar, all attendees who have viewed the recording in its entirety will receive an email with a link to the quiz and evaluation.

Anyone that misses the webinar can view the recording online, posted on the program Dashboard, for CEUs.

CONTINUING EDUCATIONHospital Transformation Consortium

CONTINUING EDUCATIONHospital Transformation Consortium

HTHU provides over 300 courses online, over 100 Webinars a year, and various live training conference and workshops. Accredited Education from the International Association for Continuing Education & Training (IACET). (Who accepts the IACET CEU? Full list at www.iacet.org)

• American Association of Respiratory Therapy• American Board of Medical Microbiology• American Society for Clinical Laboratory Science• American Society for Quality• American Speech‐Language‐Hearing Association• Board of Certified Safety Professionals• The Child Care Development Associate National 

Credentialing Program• Clinician’s View (Occupational, Speech, and Physical 

Therapy)• Federal Emergency Management Agency• Georgia, Massachusetts and Ohio Board of Nursing• Georgia Professional Standards Commission• Human Resources Certification Institute (for their 

Professional in Human Resource Designation)• National Association of Rehabilitation Professionals in the 

Private Sector• National Association of Social Workers

• National Board for Certification in Occupational Therapy, Inc. (NBCOT)

• National Council for Therapeutic Recreation Certification

• National Registry of Emergency Medical Technology (EMT)

• National Registry of Microbiologists• National Society of Professional Engineers• Society for Human Resources Management• State of Georgia, FL and Iowa Board of Professional 

Engineers• The American Association of Integrative Medicine• The American College of Forensic Examiners 

Institute• The American Council on Pharmaceutical Education• The American Psychotherapy Association• The International College of The Behavioral Sciences• The National Board for the Accreditation of 

Occupational Therapy (NBCOT)

ACTION ITEM: GROUP PARTICIPATIONHospital Transformation Consortium

Are you on this webinar with a group?

If so, please enter:first/last names and email addresses of those in attendance with you in the

Questions Pane.

Welcome & Introductions Jennie Price, HomeTown Health, LLC

Transitional Care Management Part II Lesa Schlatman,ICAHN

Upcoming Events & Resources Jennie Price, HomeTown Health, LLC

AGENDAProject: Care Management

Program GoalsProject: Care Management

Two new models of payment, Chronic Care Management and Transitional Care Management, are based on collaborating to improve outcomes.

In this project, the ICAHN team will provide an overview on Transitional Care Management for hospital and physician billers. Then, training will focus on implementing a successful Chronic Care Management model.

CONSORTIUM PROJECT

Project Participants will gain access to:• Series of Collaborative Training Webinars: July 20, 2017 - Kickoff Webinars/Transitional Care

Management August 17, 2017 - TCM Part IIOctober 26, 2017 - Chronic Care Management Part INovember 16, 2017 - CCM Part IIDecember 21, 2017 - CCM Part IIIJanuary 18, 2018 - CCM Part IV/ Closing Webinar

• Live Workshop Meeting on September 19, 2017

• Supplemental Staff Support Courses & Resources, including a Rural CCM Certification program

CONSORTIUM PROJECT

Recap of TCM Part I: Lesa discussed… • the different ways TCM can work for you and your staff. • the many options/models available, and the benefits for 

each one• key components in TCM guidelines

Your suggested action items included: • Bring team together to discuss all options• Reach out to your partners to build teamwork• Identify what is working & not working• Adjust program to utilize what makes sense• Review current process for compliance

Poll QuestionProject: Care Management

Have you had a chance to meet together with your “team” to discuss options or opportunities for your hospital, or to review your current processes for compliance?

Trainer BiographyProject: Care Management

Lesa Schlatman, RN, BSN Care Coordinator Specialist at ICAHN

Lesa grew up in a small rural town, where she experienced the hardship of chronic illness first hand through the care of her beloved grandfather. Her passion to make a difference flourished from that point forward. She started 23 years ago as an RN, and has had a vast career in bedside nursing; Skilled Care settings; Managerial & Administrative positions; and regulatory/compliance oversight. She understands the importance of coordinated patient care, and strives to assist healthcare settings achieve this through her current position with ICAHN and IRCCO as the Care Coordination Specialist.

Disclosure of Proprietary InterestProject: Care Management

ICAHN does not have any proprietary interest in any product, instrument, device, service, or material discussed during this learning event.

The education offered by ICAHN in this program is compensated by the HRSA Small Hospital Improvement Program (SHIP) grant, Iowa FY17-18, Contract #5888SH01.

Presented by Lesa Schlatman, RN, BSNCare Coordinator Specialist at ICAHN

Project: Care Management:“Transitional Care Management Part II”

Learning Outcome Standard: Based upon Centers for Medicare and Medicaid (CMS) guidelines for Transitional Care Management Services Program.

Transitional Care Management Part IIPurpose of Today

Project: Care Management

Today’s webinar is designed to help your health care setting learn key elements associated with TCM coding & billing, and to learn what steps to implement in your process to meet compliance. We will outline common TCM mistakes & errors, and discuss what solutions and options you can use to avoid them. Finally, we will help you understand how Chronic Care Management patients fit into the overall TCM process.

Transitional Care Management Part IILearning Outcomes

Project: Care Management

By the end of this presentation, attendees should be able to:

• Identify what TCM codes are available to your healthcare setting

• Describe what different billing options are available for TCM services

• Recognize “Red flags” and how to avoid them

• Identify what elements are required to consider TCM completed

• Compare how the TCM process differs for a CCM patient

• Identify other audiences that need to know this information

• Identify actions items to take in response to this training

LET’S REVIEW WHAT WE LEARNED

• TCM PROGRAMS HAVE FLEXIBILITY:• DIFFERENT OPTIONS FOR WHO IMPLEMENTS EACH REQUIRED ELEMENT

• DIFFERENT OPTIONS FOR WHO IMPLEMENTS THE BILLING PROCESS

• BUILD YOUR PROGRAM BASED ON: • WHAT MEETS THE NEEDS OF THE HEALTHCARE SETTING

• WHAT WILL PROMOTE THE BEST  WORKFLOW

• WHAT PROCESS SUPPORTS COMPLIANCE AND SUCCESS

• TEAMWORK IS ESSENTIAL AND NECESSARY:• KEY CLINIC/ER/INPATIENT STAFF MEMBERS WORK TOGETHER TO PROVIDE CARE

• COMMUNICATION & COLLABORATION REDUCE ERRORS

• IMPROVES PATIENT OUTCOMES & OVERALL QUALITY OF LIFE  

TCM BILLINGWhat codes can be billed in your health 

care setting?

POLL QUESTION

Poll: Are you currently billing for TCM Services?Yes, No, I’m Not Sure

If you answer no, what are the hurdles you are experiencing that are preventing billing? 

(enter into the question pane)

TCM CODES & RATES

CODE

2 DAY CALL 

REQUIRED

FACE TO FACE VISIT

RHC/FQHC RATE

NONRHC/FQHC

FACILITY RATE

NON RHC/FQHC NON‐FACILITY 

RATERVU’S

99495

YESBY DAY 14

POST HOSP. D/C (MODERATE COMPLEXITY)

A.I.R. $112 $166 2.11

99496

YESBY DAY 7 POST 

HOSP. D/C (HIGH 

COMPLEXITY)A.I.R. $163 $234 3.05

• A.I.R. = All Inclusive Rate

• Facility/Non‐facility Rates = adjust based on demographic areas

• Complexity = # Dx, Amount Data to review, Complication risks

WHAT ABOUT OTHER CODES:

99490 = CCM SERVICES PAID AT APPROX. $42 PER SERVICE MONTH

NON FACE TO FACE ACTIVITIES OF CLINICAL STAFF COUNTED

CAN NOT BILL BOTH CCM AND TCM WHEN TIME COUNTED OVERLAPS

99497 = ADVANCED CARE PLANNING PAID AT A.I.R.

REQUIRES 30 MINUTES PROVIDER TIME

ADDRESS LIVING WILL, DNR, END OF LIFE DECISIONS

CAN BILL IN SAME MONTH AS TCM BUT TIME COUNTED HAS TO BE SEPERATE

TCM SERVICES CAN’T BE BILLEDDURING FOLLOWING SCENERIOS:

• Post‐operative global period 

• TCM 30 day service period can’t fall inside global period billed by the same Provider

• CCM services (99490, 99487, 99489)

• Can’t bill CCM & TCM in same month if CCM activity minutes counted fall inside the TCM 30 day service period

• Patient readmits to hospital within 30 days

• TCM services cannot be billed until 30 days after hospital discharge – readmit halts billing

• Start new 30 day TCM window with new discharge

• Bill face to face as E/M visit (if transpired)

• Patient death before 30 day service period closes

• Can’t bill even if 2 day call & face to face took place

• Service paid for 30 day period only – not less

• Bill face to face as E/M visit (if transpired)

WITHIN SAME MONTH AS CODES:• Home healthcare care plan oversight (G0181) 

• Hospice care plan oversight (G0182) 

• Care plan oversight services (99339, 99340, 99374‐99380) 

• Prolonged services without direct patient contact (99358, 99359) 

• Anticoagulant management (99363, 99364) 

• Medical team conferences (99366‐99368) 

• Education and training (98960‐98962, 99071, 99078) 

• Telephone services (98966‐98968, 99441‐99443) 

• End stage renal disease services (90951 – 90970) 

• Online medical evaluation services (98969, 99444) 

• Preparation of special reports (99080) 

• Analysis of data (99090, 99091) 

• Medication therapy management services (99605‐99607)

OPTIONS WHEN BILLING FOR TCM

WHAT MAKES SENSE?

Where are face to face services taking place?

Provider based/Non‐provider based?

Who already does billing?

How is the current workflow working?

What is the most cost effective option?

Are the available systems meeting needs?

WHERE ARE FACE TO FACE SERVICES TAKING PLACE?

• “Place of Service” = where face to face takes place• Billing required to correctly identify place of service on claims

• Altering the place of service is not optional

• This drives reimbursement rates (RHC vs. Facility/Non‐facility)

• Billing completed at place of service• Typically chosen due to convenience

• Workflow ‐ is it optimal?..is it efficient?

• Are there other options?

PROVIDER BASED vs. NON‐PROVIDER BASED

• Provider based Clinic:

• Hospital policy may depict billing process

• Centralized billing is typical 

• Staffing needs are reduced

• Total overhead is controlled

• Efficiency increased – potential errors reduced

• Non‐Provider based Clinic:

• Internal resources drive process

• If already doing billing – continue doing billing

• Lack of optimal systems may force outsourcing

LOOK AT THE BIGGER PICTURE WORKFLOW & COST EFFECTIVENESS

BUT WE ALREADY DO THE BILLING!

• DOES THAT STILL MAKE SENSE

• IS IT AGAINST OPTIMAL WORKFLOW

• DO YOU HAVE THE RIGHT RESOURCES & MANPOWER

• IS IT THE MOST EFFICIENT OPTION

• CHANGE IS SOMETIMES THE RIGHT STEP TOWARDS SUCCESS

Only bill for TCM once per 30 day TCM period 

Multiple Providers could bill for TCM ‐ Only 1 Provider will be paid (Who’s 1st)

Same Provider can bill for the hospital discharge and the TCM services

BUT – face to face and discharge cannot be on same date

Bill for TCM services separately from other services

Co‐pays & deductibles apply

Bill types & revenue codes same as typical E/M claim

‐CG modifier should be applied

Date of service will be the date of the face‐to‐face visit

Hold claim until 30 day service period finished

Patient readmission or death effect billing process

Diagnosis on claim should be reason for TCM services

KEY ITEMS TO CONSIDER

“Red flags”COMMON MISTAKES AND ERRORS 

2 DAY FOLLOW UP CALL: RED FLAG: Follow up call made on day 3 or later• Count business days (usual days clinic is open for business)• Pt. D/C on Fri. @ 3pm – Clinic open Sat. & closed Sun. – 1st business day

is Sat. – 2nd business day is Mon. – Call due by Monday @ 3pm

TCM 30 DAY SERVICE PERIOD: RED FLAG: Submitting claim with wrong date count (To many/few days)• 30 day window – Day 1 is D/C day & then next 29 days• Should always count out and not assume end date• Important to track for billing purposes

DETAILS ARE IMPORTANT

7 DAY VS. 14 DAY FACE TO FACE: RED FLAG: Visit code on claim does not match complexity charted• Level of patient condition & risk complexity determines time frame

• Sicker & more fragile the patient – the sooner should see them• 14 Day = Moderate Complexity:

• Multiple diagnosis for patient• Moderate amount data to be reviewed• Moderate risk for complications and/or decline in condition

• 7 Day = High Complexity: • Extensive diagnosis list for patient • Extensive amount data to be reviewed • High risk for complications and/or decline in condition

• Problem when Patient is Mod. Complex but billed for High Complex• Non RHC clinic would be getting paid higher rates falsely• RHC gets same A.I.R. for both visits

• Seems harmless right?• Audit = compliance issues/payment recoupment • Future A.I.R. effected by higher coding – inflates rate

DETAILS ARE IMPORTANT

7 DAY & 14 DAY FACE TO FACE DATE: RED FLAG: Face to face visit happened outside of required time frame• Face to face is to happen on or before required day

• Count all days from day of discharge (not just business days)• Day of discharge is Day 1

• This means on or before day 7 or day 14• Easy Fix = Some clinics do all visits before day 7

• Meets required time frame for both visit types• Avoids confusion and errors • Still need to code correctly – avoid up/down coding

If face to face visit is missed and 14 days are passed• Can’t bill for TCM• Bring patient in for E/M visit instead

Can’t do face to face on same day of discharge• Can do face to face on day 2 or later

DETAILS ARE IMPORTANT

RED FLAG: Always submitting same code for all TCM claims• Suggests over or under coding – compliance in question

RED FLAG: Provider and/or place of service frequently changes on claim for same patient (Bigger flag if also CCM patient)

• Suggest a lack of continuity of care & compliance becomes a concern • Typically see same PCP – CCM patient should always see same PCP

RED FLAG: Submitting claims frequently before 30 day service period closes & never submitting amended claims

• Readmission/death would prompt amendment to already submitted claim

• DOCUMENTATION & COMPLIANCE: • Does your charting support completion of all required elements?

• 2 day call - Medication reconciliation – face to face visit• Assessment of all needs & any plan of care changes• Oversight for entire 30 day service period

• Handoff of care back to PCP (if applicable)• Did you include patient education surrounding TCM services?

OTHER AREAS TO MONITOR

TCM SERVICES

COMPLETE THE REQUIRED ELEMENTS PRIOR TO BILLING

Interactive contact with patient/caregiver within 2 business days post discharge:o Via phone – email ‐ or face‐to‐face by qualified provider/clinical staff o Address patient status & needs, identify problems, review D/C instructions, provide educationo Make sure f/u appointment with provider scheduled & patient ready to attendo Document all unsuccessful attempts to contact patient in medical record

Must furnish one face‐to‐face visit within required timeframe: o CPT Code 99495 – 14 day D/T moderate medical decision complexityo CPT Code 99496 – 7 day D/T high medical decision complexityo Telehealth is option, but has to be an eligible site/system  

KNOW WHAT IS REQUIRED

Must furnish medication reconciliation with patient on or before required face‐to‐face:o Do over phone or in person with home visito Identify errors & confusion surrounding orders (Med available – did they pick up at pharmacy –

taking medications correctly?)

At a minimum must document this information in the patient’s medical record:o Date the beneficiary was discharged o Date of interactive contact with the patient and/or caregiver

o Any attempts to contact patient both successful & unsuccessfulo Date furnished the face‐to‐face visito The complexity of medical decision making (moderate or high)o Suggest to include more details for each item above:

o Any discussions – identified problems – interventions or order changes – communication with Provider about patient’s condition

KNOW WHAT IS REQUIRED

OTHER REQUIREMENTS Must furnish non‐face‐to‐face services to patient UNLESS determined not medically indicated/needed

o Provider may: Obtain & review D/C information, continuity of care document Review need for/follow‐up on pending diagnostic tests and treatments Interact with other Providers who will (re)assume care of patient D/T system specific problems Provide education to the beneficiary, family, guardian, and/or caregiver Establish or re‐establish referrals and arrange for needed community resources Assist in scheduling required follow‐up with community providers and services

o Clinical Staff may (under Provider direction/supervision: Communicate with agencies and community services the patient 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 Assist the beneficiary and/or family in accessing needed care and services

TRANSITIONAL CARE MANAGEMENT FOR THE

CCM PATIENT

IS THERE A DIFFERENCE?

REQUIREMENTS FOR CCM ENROLLED PATIENTS DURING TCM

TRANSITIONS IN CARE:

• MUST PROVIDE “CONTINUTIY OF CARE DOCUMENT”

• ASSIGNED TO CARE COORDINATOR:

• WILL NEED TO COMMUNICATE WITH CARE TEAM

• REQUEST CURRENT PLAN OF CARE UPDATE

• WILL REQUEST COPIES OF DISCHARGE PLANS & RELATED HOSPITAL PAPERWORK

• FOLLOW UP IS EXPECTED TO BE MORE IMMEDIATE WHEN POSSIBLE

CONTINUITY OF CARE:

• SEE SAME ASSIGNED PCP WHEN POSSIBLE

• ASSIGNED CARE COORDINATOR EXPECTED TO FOLLOW CARE & PERFORM COMMUNICATION/FOLLOW UP

• ASSIGNED PCP/CARE COORDINATOR RESPONSIBLE FOR ALL PARAMETERS OF CARE PATIENT REQUIRES

TCM SERVICESTCM ONLY PATIENT vs. CCM/TCM PATIENT

SERVICEELEMENT

TCM ONLY PATIENT

CCM/TCMPATIENT

2 DAY CALL – PERFORMED BY HOSPITALOR CLINIC STAFF ASSIGNED CARE COORDINATOR

FACE TO FACE VISIT – PERFORMEDBY HOSPITAL OR CLINIC PROVIDER ASSIGNED PCP IS PRIORITY

MED. RECONCILIATION –WHEN? FLEXIBLE – COMPLETE ON OR BEFORE FACE TO FACE

PRIORITY TO COMPLETE ASAP –WAITING TILL FACE TO FACE DOES NOT 

FOLLOW CCM STANDARDS

MED RECONCILIATION –WHO? HOSPITALOR CLINIC STAFF/PROVIDER ASSIGNED CARE COORDINATOR/PCP IS PRIORITY

DOCUMENTATION PER TCM REQUIREMENTS MEET TCM & CCM REQUIREMENTS

BILLING BILL FOR TCM WHEN 30 DAY SERVICE PERIOD ENDS

BILL FOR TCM WHEN 30 DAY SERVICE PERIOD ENDS

BILL FOR CCM IF: 20 MIN. OF NON‐FACE TO FACE ACTIVITY ACCUMULATED 

OUTSIDE TCM 30 DAY SERVICE PERIOD

PATIENT TRUST/RAPPORT TYPICALLY ABSENT ESTABLISHED

FAMILIARITY WITH PATIENT HISTORY LIMITED KNOWLEDGE EXSTENSIVE KNOWLEDGE

POTENTIAL FOR ERRORS HIGH LOW/LIMITED

TCM & CCMWE CAN MAKE A DIFFERENCE

LABELS CAN BE DISMISSIVE

YOU SEE A BOAT….I SEE AN OPPORTUNITY FOR ADVENTURE

YOU SEE NONCOMPLIANCEI SEE AN OPPORTUNITY TO MAKE A DIFFERENCE

ACTION ITEMS

• Review current coding/billing processes to identify compliance/non‐compliance

• Identify what codes are available for your setting• Sample completed TCM services to identify if all required elements present 

• Adjust current program to accommodate CCM patient needs if necessary

• Review current process to identify “Red Flags” & implement solutions if necessary

COLLABORATION

Who else should you share this information with?

Administration, Providers, Partners, Entire Team, anyone 

you choose! 

REFERENCES & RESOURCES

Centers for Medicare & Medicaid:https://www.cms.gov/

https://www.cms.gov/Outreach‐and‐Education/Medicare‐Learning‐Network‐MLN/MLNProducts/downloads/Transitional‐Care‐Management‐Services‐Fact‐Sheet‐ICN908628.pdf

American Medical Association:https://www.ama‐assn.org/

https://www.ama‐assn.org/practice‐management/icd‐10

PYA:http://pyapc.com/resources/collateral/white‐papers/TCM‐whitepaper‐PYA.pdf

Transitional Care Management Part IILearning Outcomes

Project: Care Management

Now that we you have completed the presentation, you should be able to:• Identify what TCM codes are available to your healthcare setting

• Describe what different billing options are available for TCM services

• Recognize “Red flags” and how to avoid them

• Identify what elements are required to consider TCM completed

• Compare how the TCM process differs for a CCM patient

• Identify other audiences that need to know this information

• Identify actions items to take in response to this training

QUESTIONS?

If you have questions about this education, please contact:

Lesa Schlatman RN,BSNCare Coordination Specialist

ICAHNEmail: lschlatman@icahn.org

Phone: 1-815-875-2999

Or you can contact hthtech@hometownhealthonline.com

UPCOMING EVENTS & RESOURCESHospital Transformation Consortium

CALENDAR OF EVENTS

View the Program Dashboard at:www.hthu.net/iahtcPassword: transform

Click on Project Link:Password: ccm

CONSORTIUM TRAININGConsortium Project

Work Shop DaySeptember 19th, 2017

10am – 4:00pmCourtyard, Ankeny, IA

Some of the things you told us you wanted: • Gaining Provider support  and getting nurses excited• Building "the discharge" • Coding information• CMS guidelines • Follow up with non compliant patients. • Scripting for conversations with patients on the CCM 

program• To assist with transition toward population Health model

LIVE WORK SHOP DAY

Under the grant, each hospital can choose to send:

1 attendee with one hotel roomOR

2 attendees (no hotel room covered)*Extra attendees can come at a $125 registration cost*

REGISTER NOW!

NEXT STEPS FOR WORK SHOP:Consortium Project Work Shop Day

September 19th, 2017 10am – 4:00pm

Courtyard by Marriott, Ankeny, IA

October 26, 2017 - Chronic Care Management Part I

Understanding Chronic Care Management: Compliance & Requirements Identify what CCM components are available to your healthcare setting How to Start: Identify where to begin the process for setting up your CCM program Comparing what models are available when constructing your CCM care team What job duties should I expect my Care Coordinator to do?

CONSORTIUM PROJECT

TELL US HOW WE DID!

A survey will launch after this webinar closes: please take a moment to give us your feedback on the training, speaker, content, webinar format, and anything

else you can share!

If there’s something we can help your hospital with, please let us know!

Questions?

Questions about these resources or Upcoming Events?

Contact: Jennie Price, SHIP Program Manager

jennie.price@hometownhealthonline.com