Transitional Care, Remote Physiologic Monitoring, Chronic Care and Principal Care Management

Transit ional Care Managem ent

Transitional Care Management (TCM) services play a crucial role in ensuring smooth and successful care transitions for patients moving from an inpatient hospital setting to their home or a community-based care facility. These services focus on coordinating and managing the patient's healthcare following a critical period after discharge. The aim of TCM is to reduce complications, improve outcomes, and enhance patient satisfaction Proper coordination and management of patients during the immediate post-discharge period may also reduce readmissions

KeyComponentsof TCM:

- Face-to-Face Visit

Following a patient's discharge from an inpatient hospital stay, a face-to-face visit is conducted within 7 or 14 days, depending on the complexity of the medical decision-making involved. During this visit, the physician evaluates the patient's medical condition, reviews the discharge summary, reconciles medications, and develops a comprehensive care plan.

- Communication and Care Coordination:

TCM services involve substantial communication and coordination between the physician, patient, and other healthcare providers This includes arranging necessary follow-up appointments, collaborating with specialists, and facilitating communication between the hospital and post-discharge care settings

- Medication Management

An important aspect of TCM is reconciling and managing medications during the transition This involves reviewing the patient's medication list, addressing discrepancies, providing education on medication usage, and addressing any potential adverse effects or interactions

- Comprehensive Care Plan

The physician, in collaboration with the patient and other members of the healthcare team, develops a comprehensive care plan tailored to the patient's specific needs and goals This plan includes instructions for follow-up care, self-management strategies, and coordination of additional services.

Billingand CodingConsiderationsfor TCM:

It is important to ensure accurate coding and documentation to support the services provided Here are some key considerations:

- Eligibility: TCM services are typically eligible for Medicare reimbursement Ensure that the patient meets the specific criteria set by Medicare or other payers for TCM services, including a face-to-face visit within the specified timeframes

- Documentation: Accurate and detailed documentation is essential to support the medical necessity of TCM services. Documentation must include the complexity of medical decision-making, the coordination efforts involved, medication reconciliation, and the development of a comprehensive care plan Reimbursement: TCM services are typically reimbursed separately from the Evaluation and Management (E/M) services provided during the face-to-face visit Ensure that the appropriate TCM codes are billed separately from any E/M codes to avoid duplication of services See CorroHealth TCM, CCM, RPM, PCM Table.

TRANSITIONAL, REMOTE, CHRONICCARE&PRINCIPAL CARE

- Reimbursement: TCM services are typically reimbursed separately from the Evaluation and Management (E/M) services provided during the face-to-face visit Ensure that the appropriate TCM codes are billed separately from any E/M codes to avoid duplication of services See CorroHealth TCM, CCM, RPM, PCM Table

- Reporting:

- Transitional Care Codes 99495 (TCM? within 14 calendar days of discharge) or 99496 (TCM? within 7 days of discharge) may be reported by the same practitioner during the 30-day TCM service period as Chronic Care Management codes 99487 (CCM? multiple? first 60 minutes of clinical staff time directed by a physician or other qualified healthcare professional), 99489 (CCM? multiple? first 30 minutes of clinical staff time directed by a physician or other qualified healthcare professional) or 99490 (CCM? multiple? first 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional)

- An RHCand FQHCmay bill TCM services and general care services for the same patient during the same service period if they are reported following the requirements for the code(s) billed.

- Shared or Incident-to-Billing: When performed in a clinic setting, some TCM services may be billed under the supervising physician or as incident-to-services. Understand the billing guidelines applicable to the practice and ensure compliance with the relevant regulations

- Consent: Obtain written consent from the patient for TCM services, explaining the scope and nature of the services, as well as any associated cost-sharing requirements.

Rem ot e Physiologic Monit oring:

Remote Physiologic (or Patient) Monitoring (RPM) services have emerged as a powerful tool in healthcare, enabling the continuous monitoring of patients?health status and providing timely interventions RPM is a collection and analysis of physiologic data transmitted from the patient electronically to the healthcare provider for assessment RPM allows real-time opportunities for assessment and the ability to view trends over periods of time.

TRANSITIONAL, REMOTE, CHRONICCARE&PRINCIPAL CARE

KeyComponentsof RPM:

- Remote Monitoring Devices:

RPM services rely on the use of remote monitoring devices that collect and transmit patient health data. These devices can include blood pressure monitors, glucose meters, pulse oximeters, weight scales, and wearable devices The data collected from these devices is securely transmitted to healthcare providers, allowing for continuous monitoring and assessment

- Data Transmission and Analysis:

RPM services involve the transmission of patient data from remote monitoring devices to healthcare providers or a designated monitoring center. Healthcare professionals review and analyze the data to identify trends, deviations, or any potential health concerns This allows for early intervention and proactive management of the patient's condition

- Care Coordination and Interventions: RPM services enable healthcare providers to coordinate care effectively and provide timely interventions. They can communicate with patients remotely, provide education on self-management, adjust treatment plans as needed, and address any concerns or questions raised by patients The goal is to optimize patient care and improve health outcomes

Consent: Obtain written consent from the patient for RPM services, explaining the scope and nature of the services, as well as any associated cost-sharing requirements

Billingand CodingConsiderationsfor RPM

- Eligibility: RPM services are typically eligible for reimbursement from Medicare and some private payers Ensure that the patient meets the specific eligibility criteria defined by the payer, which may include having chronic conditions that require ongoing monitoring and management.

- Time-Based Billing: RPM services are billed based on the total time spent on care management activities during a calendar month This includes the time spent by clinical staff, physicians, or other qualified healthcare professionals in monitoring, reviewing data, and providing interventions. See CorroHealth TCM, CCM, RPM, PCM Table for more information

- Documentation: Accurate documentation is crucial to support the medical necessity of RPM services Document the time spent on care management activities, including review and analysis of data, patient interactions, and interventions provided. Additionally, maintain records of the types of monitoring devices used and the patient's consent for remote monitoring

- Reporting services:

Most RPM services will be billed under service codes 99453/99454 and time-based codes 99457/99458

99453 (remote monitoring of physiologic parameter? .initial setup and patient education on use of equipment) may only be billed one time per patient

A provider may only bill 99454 (remote monitoring of physiologic parameters) one time per month regardless of how many devices are monitored. Reporting 99454 requires transmission and reading performed at least 16 days during the month