Shared savings and transition care management after inpatient discharges

Anthem Blue Cross and Blue Shield is actively seeking to promote CMS’s transition care management (TCM) program for its Medicare members.

The goal is to ensure comprehensive physician follow-up and management of patients within seven and/or 14 days of discharge from hospital, skilled nursing facility (SNF), inpatient rehabilitation hospital (IRF), or long-term acute care hospitals (LTAC). And thus, to minimize clinical relapses, that often result in acute hospital readmissions, within 30-days of discharge.

CPT^® codes for these visits are:

• 99496 (post-discharge comprehensive follow-up within seven days): pays between $250 to $350, depending on region, and;
• 99495 (post-discharge follow-up within 14 days): pays between $190 to $260, depending on region. 

The primary intent for these visits is close post-discharge patient follow up with comprehensive physician/provider management of ongoing chronic comorbidities. So, visits should include:

• Review of the discharge information
• Medication reconciliation
• Treatment of acute exacerbations and/or fluctuations in the physician office as appropriate
• Active management of and attention to chronic renal, lung, cardiac, skeletal, social, caregiver, etc. conditions, and providers should:
  • Review the need for pending diagnostics, and/or follow up of said diagnostics.
  • Interact with other healthcare professionals who may assume care of any system-specific problems.
  • Educate the patient, family, and caregiver.
  • Establish referrals, arrange needed community resources, address/assist/advise the member/family with relevant caregiver needs.
  • Help schedule required community providers and services follow-up.
  • Comprehensively and holistically manage common chronic/acute medical conditions seen after hospital discharge, such as (but not limited to): Heart failure, COPD, DM, AFIB, DVT, cellulitis, pneumonia, dehydration, AMS, encephalopathy, AKI, polypharmacy/medication reconciliation, and even custodial/social needs impacting/resulting in admission(s).

CMS encourages TCM for Medicare members. CMS has detailed fact sheets explaining the program, and billing, see resources below:

• https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/transitional-care-management-services-fact-sheet-icn908628.pdf
• https://edit.cms.gov/files/document/billing-faqs-transitional-care-management-2016.pdf 

Appendix

CPT 99496 coding requirements:

1. Attestation that the initial communication between patient/practitioner began within two business days of discharge:
   1. Geared to patients with conditions requiring medium or high-level decision-making
   2. Direct contact: telephone/electronic
2. Face-to-face visit within seven days of DC. Cannot be virtual
3. Clinician-patient visit can be done by physician, PA, or nurse practitioner, or other practitioners as authorized by state law
4. Includes DC from hospitals, SNFs, IRFs, and LTACs
5. Includes time spent coordinating patient services for specific medical care or psychosocial needs and guiding them through activities of daily living
   
   CPT 99495 coding requirements:
6. Attestation that the initial communication between patient/practitioner began within two business days of DC:
   1. Geared to patients with conditions requiring at least moderate complexity decision-making
   2. Direct contact: telephone/electronic
7. Face-to-face visit within 14 days of discharge. Cannot be virtual
8. Clinician-patient visit can be done by physician, PA, or nurse practitioner, or other practitioners as authorized by state law
9. Includes DC from hospitals, SNFs, IRFs, and LTACs
10. Includes time spent coordinating patient services for specific medical care or psychosocial needs and guiding them through activities of daily living