Tag Archives: transitional care management

Improving Transitional Care Management to Reduce Hospital Readmissions

Hospital readmissions have become a critical issue in healthcare, significantly impacting patient outcomes and increasing healthcare costs. In response, Transitional Care Management (TCM) programs have emerged as a vital strategy to ensure that patients experience smooth transitions from hospital to home or other care settings, thereby reducing the risk of readmissions. This blog explores the importance of TCM programs in preventing hospital readmissions, improving patient outcomes, and creating a more cost-effective healthcare system.

The Challenge of Hospital Readmissions

Hospital readmissions occur when a patient who has been discharged from a hospital is readmitted within a short period, usually within 30 days. According to the Centers for Medicare & Medicaid Services (CMS), nearly 20% of Medicare patients are readmitted within 30 days of discharge, costing the healthcare system approximately $26 billion annually, with $17 billion of that amount deemed preventable.

Readmissions are often caused by a lack of adequate follow-up care, poor coordination between healthcare providers, and insufficient patient education. These gaps in care are particularly problematic for patients with chronic conditions, who are at higher risk of complications post-discharge. As a result, healthcare systems are looking for ways to close these gaps and enhance post-discharge care.

The Role of Transitional Care Management in Reducing Readmissions

Transitional Care Management (TCM) is designed to fill the gaps in care following a patient’s discharge from the hospital. The primary goal of TCM is to ensure that patients receive timely follow-up care, which helps to prevent complications, reduce the likelihood of readmission, and improve overall outcomes. TCM services typically include:

Post-discharge Communication: TCM programs emphasize timely follow-up with patients after discharge. Within two business days, a healthcare provider should reach out to the patient to assess their condition, answer questions, and provide further instructions.
Face-to-face Visits: Within 7-14 days, patients are scheduled for a follow-up visit to evaluate their recovery progress, review medications, and address any new or existing health concerns. This visit is critical to identifying potential issues early, preventing complications, and ensuring patients adhere to their post-discharge care plan.
Care Coordination: TCM programs aim to improve communication and coordination between different healthcare providers involved in the patient’s care, including primary care physicians, specialists, home health services, and pharmacists. This coordination ensures that all providers are on the same page, preventing fragmented care that can lead to readmissions.
Patient and Caregiver Education: Educating patients and caregivers about the patient’s condition, medications, follow-up care, and warning signs of potential complications is vital to successful recovery. TCM services offer ongoing education to empower patients to manage their health post-discharge effectively.
Medication Management: Adverse drug events are a common cause of readmissions. TCM programs focus on reviewing patients’ medications during follow-up visits, addressing potential drug interactions, ensuring adherence to prescriptions, and adjusting medication plans as needed.

The Impact of Transitional Care on Patient Outcomes

Studies show that TCM programs significantly reduce the likelihood of hospital readmissions. Research published in the Journal of General Internal Medicine found that Medicare patients enrolled in TCM programs experienced a 13% reduction in readmissions compared to patients who did not receive these services. Another study published in Health Affairs reported a 20% decrease in 30-day readmissions for patients receiving high-quality transitional care.

Beyond reducing readmissions, TCM programs also contribute to better patient outcomes by:

Improving continuity of care: With better coordination between providers and regular follow-up, patients are more likely to receive the care they need in a timely manner.
Enhancing patient satisfaction: TCM services provide personalized attention and clear communication, which improve the patient experience and lead to higher satisfaction rates.
Reducing healthcare costs: Fewer readmissions result in lower healthcare costs, benefiting both the healthcare system and patients.

Key Strategies for Effective Transitional Care Management

To maximize the effectiveness of TCM programs and reduce readmissions, healthcare providers should focus on the following strategies:

Early Discharge Planning: Successful TCM begins before discharge. Providers should assess a patient’s needs for post-discharge care during the hospital stay, creating a plan that includes follow-up visits, medication management, and referrals to other services such as home health care.
Use of Digital Health Platforms: Digital health platforms, such as HealthViewX, can streamline care coordination by connecting various providers, tracking patient progress, and sending automatic reminders for follow-up appointments and medication adherence.
Patient-centered Care: TCM should be tailored to the unique needs of each patient. Personalized care plans that take into account the patient’s medical history, social determinants of health, and family support can improve outcomes and prevent readmissions.
Focus on High-Risk Patients: Patients with chronic conditions, recent surgeries, or social risk factors are more likely to be readmitted. Identifying and prioritizing these patients for TCM services can yield the greatest impact in reducing readmissions.
Data-driven Approaches: Providers can use data analytics to identify patterns in readmissions, enabling them to refine their TCM programs and address common issues that lead to hospital readmissions.

Conclusion

Transitional Care Management is a proven approach to improving patient outcomes and reducing hospital readmissions. TCM programs can significantly lower the risk of preventable readmissions by providing timely follow-up care, coordinating between healthcare providers, and ensuring patients and caregivers are well-informed. As the healthcare industry continues to focus on value-based care, TCM will remain essential in reducing costs, improving patient satisfaction, and enhancing the quality of care.

To fully realize the benefits of TCM, healthcare organizations must embrace innovative solutions, such as digital health platforms, to streamline care coordination and ensure that all patients receive the support they need during the critical post-discharge period.

Sources:

Centers for Medicare & Medicaid Services (CMS)
Journal of General Internal Medicine
Health Affairs

How HealthViewX is Revolutionizing Transitional Care Management for US Providers

Transitional Care Management (TCM) is a critical component in ensuring seamless post-discharge care for patients transitioning from hospital to home or other care settings. With increasing pressure on healthcare providers to reduce hospital readmission rates, the need for efficient, patient-centered TCM services has never been greater. HealthViewX, a cutting-edge care orchestration platform, is at the forefront of revolutionizing TCM by streamlining processes, enhancing communication, and ultimately reducing avoidable readmissions. This blog explores how HealthViewX is transforming TCM for US providers, backed by market data and insights on its impact on patient outcomes.

The Growing Importance of Transitional Care Management

The Centers for Medicare & Medicaid Services (CMS) introduced reimbursement for TCM services in 2013 to incentivize providers to offer comprehensive post-discharge care. These services, typically provided during the first 30 days following discharge, focus on preventing complications and ensuring patients adhere to their care plans. Effective TCM programs can significantly reduce the risk of readmissions, which cost the US healthcare system billions of dollars annually.

According to a study published by the National Institutes of Health (NIH), nearly 20% of Medicare patients are readmitted to the hospital within 30 days of discharge, costing the system $26 billion annually. Of this amount, $17 billion is considered avoidable through better post-discharge care coordination. This underlines the urgency of implementing efficient TCM programs and leveraging digital platforms to enhance these services.

The Role of HealthViewX in TCM

HealthViewX is designed to address the unique challenges of managing care transitions by providing a digital platform that streamlines communication, automates workflows, and ensures that no patient falls through the cracks. Here are some key ways HealthViewX is revolutionizing TCM for US providers:

1. Seamless Care Coordination

A major barrier to effective TCM is the lack of communication between hospitals, primary care providers, specialists, and other care team members. HealthViewX bridges this gap by offering a centralized platform where providers can share information, track patient progress, and collaborate seamlessly. The platform enables real-time updates on patient conditions, reducing the risk of errors or omissions that can lead to readmissions.

2. Automated Task Management

HealthViewX’s automation capabilities significantly reduce the administrative burden on care teams. The platform automates key TCM tasks, such as scheduling follow-up appointments, sending medication reminders, and tracking patient compliance with discharge instructions. This not only saves time but also ensures that critical steps in the care transition process are completed on time, reducing the likelihood of patient deterioration and readmission.

3. Patient Engagement and Education

One of the key drivers of successful TCM is patient engagement. HealthViewX offers tools that engage patients through automated reminders, educational materials, and personalized care plans. By ensuring that patients understand their post-discharge care instructions and adhere to their medication regimens, HealthViewX helps reduce the risk of complications that could result in hospital readmissions.

4. Data-Driven Insights

HealthViewX provides providers with access to comprehensive data analytics that allows them to track outcomes, identify high-risk patients, and measure the effectiveness of their TCM programs. By leveraging this data, providers can make informed decisions on how to optimize care transitions, focus resources on patients most at risk of readmission, and ultimately improve care quality.

Reducing Readmissions with HealthViewX: The Impact

HealthViewX’s platform has been shown to significantly reduce hospital readmission rates for providers implementing robust TCM programs. Studies show that effective TCM can reduce readmissions by up to 25%, which has a substantial financial impact on hospitals and healthcare systems. For example, hospitals that reduce their 30-day readmission rates can avoid CMS penalties, which are imposed under the Hospital Readmissions Reduction Program (HRRP).

Market data supports the value of reducing readmissions. A report by the American Hospital Association (AHA) found that hospital readmissions cost the healthcare system $41.3 billion annually. By leveraging HealthViewX’s digital tools, providers can make significant strides in cutting these costs while improving patient outcomes.

The Financial and Operational Benefits of TCM with HealthViewX

Implementing HealthViewX’s TCM solution offers not only clinical benefits but also financial and operational advantages for healthcare providers:

1. Reduced Penalties

CMS imposes penalties on hospitals with high readmission rates. By reducing readmissions through effective TCM, HealthViewX helps hospitals avoid these financial penalties. In 2023 alone, CMS penalized 2,273 hospitals, with a cumulative penalty of $320 million. Implementing a robust TCM program powered by HealthViewX can mitigate these risks.

2. Increased Reimbursements

Providers offering TCM services are eligible for Medicare reimbursements under specific CPT codes (99495 and 99496), which cover both non-face-to-face and face-to-face patient interactions post-discharge. By using HealthViewX to automate and document these interactions, providers can ensure they capture all billable services and maximize revenue.

3. Enhanced Care Team Efficiency

By automating administrative tasks and improving communication, HealthViewX allows care teams to operate more efficiently. This not only reduces the risk of burnout but also ensures that more time is spent on direct patient care rather than paperwork. In a survey conducted by the Medical Group Management Association (MGMA), 78% of respondents cited administrative burden as a significant challenge in managing transitions of care. HealthViewX alleviates this pressure through intelligent automation.

Conclusion

HealthViewX is transforming the landscape of Transitional Care Management for US providers. By streamlining communication, automating workflows, and engaging patients, the platform significantly reduces readmission rates, enhances patient outcomes, and offers financial benefits for healthcare providers. In a healthcare environment increasingly focused on value-based care, the adoption of digital platforms like HealthViewX is essential for success.

As hospital readmissions continue to be a costly problem for the US healthcare system, HealthViewX’s innovative approach to TCM provides a clear path forward for improving post-discharge care and reducing avoidable readmissions. Through seamless care coordination, automation, and data-driven insights, HealthViewX empowers providers to deliver better care while optimizing financial and operational performance.

2021 CPT Codes by the CMS for Medicare Extension Care Management Programs

Chronic Care Management:

The chronic care management program was virtually untouched by the 2021 Final Rule from CMS. There are three main CPT codes and two add-on CPT codes in 2021 that may be billed by primary care providers for CCM services.

Requirements for CCM:

Non-Complex CCM:

Two or more chronic conditions expected to last at least 12 months (or until the death of the patient)
Patient consent (verbal or signed)
Personalized care plan in a certified EHR and a copy provided to the patient
24/7 patient access to a member of the care team for urgent needs
Enhanced non-face-to-face communication between patient and care team
Management of care transitions
At least 20 minutes of clinical staff time per calendar month spent on non-face-to-face CCM services directed by a physician or other qualified healthcare professional
CCM services provided by a physician or other qualified healthcare professional are reported using CPT code 99491 and require at least 30 minutes of personal time spent in care management activities

Complex CCM:

Shares common required service elements with CCM but has different requirements for:

Amount of clinical staff service time provided (at least 60 minutes)
The complexity of medical decision-making involved (moderate to high complexity)

CPT Reimbursement Codes for CCM Service:

Non-complex CCM:

CPT Code 99490– This code requires that patients must have two or more chronic conditions, as well as documented consent to enroll in the program AND receive at least 20 minutes of CCM services from clinical staff within a given month. A personalized care plan, which shows an assessment of all patient factors and identifies gaps and barriers to be addressed, is also required. Reimbursement Rates – CPT Code 99490 – $42/patient/month.
CPT Code 99439 (formerly G2058) -This code allows providers to bill for each additional 20 minutes spent for Basic CCM services in a given month, up to 2 times. For example, if CCM services were provided for at least 40 minutes with a patient in a given month that was not Complex, 99490 ($42) and 99439 ($38) would be billed together for that month. Reimbursement Rates – CPT Code 99439 (formerly G2058) – $38/patient/month.

Complex CCM:

CPT code 99487– This code has a higher rate of reimbursement than the Basic CCM CPT code. To bill using this code requires moderate or high complexity in medical decision making AND acknowledgment by both patient & provider of an acute exacerbation (generally defined as a sudden worsening of a patient’s condition that necessitates additional time and resources). The patient must receive at least 60 minutes of services from clinical staff within a given month to bill for this code. Reimbursement Rates – CPT Code 99487 – $93/patient/month.
CPT code 99489 – The same as with the Basic Chronic Care Management code, the Complex Chronic Care Management code also has an add-on CPT code to cover time spent beyond 60 minutes. It allows for billing for each additional 30 minutes spent for Complex CCM services within a given month. Reimbursement Rates – CPT Code 99489 – $45/patient/month.

Transitional Care Management:

Transitional Care Management (TCM) services address the hand-off period between the inpatient and community settings. After a hospitalization or other inpatient facility stay (e.g., in a skilled nursing facility), the patient may be dealing with a medical crisis, new diagnosis, or change in medication therapy. Family physicians often manage their patients’ transitional care.

Requirements for TCM:

Contact the beneficiary or caregiver within two business days following a discharge. The contact may be via the telephone, email, or a face-to-face visit. Attempts to communicate should continue after the first two attempts in the required business days until successful.
Conduct a follow-up visit within 7 or 14 days of discharge, depending on the complexity of medical decision-making involved. The face-to-face visit is part of the TCM service and should not be reported separately.
Medicine reconciliation and management must be furnished no later than the date of the face-to-face visit.
Obtain and review discharge information.
Review the need for diagnostic tests/treatments and/or follow up on pending diagnostic tests/treatments.
Educate the beneficiary, family member, caregiver, and/or guardian.
Establish or reestablish referrals with community providers and services, if necessary.
Assist in scheduling follow-up visits with providers and services, if necessary.

CPT Reimbursement Codes for TCM Service:

CPT code 99495 – moderate medical complexity requiring a face-to-face visit within 14 days of discharge. Reimbursement rate – $175.76/patient/month.
CPT code 99496 – high medical complexity requiring a face-to-face visit within seven days of discharge. Reimbursement rate – $237.11/patient/month.

Allowed reported services alongside TCM services include,

Prolonged services without direct patient contact (99358-99359);
Home and outpatient international normalized ratio (INR) monitoring (93792-93793);
End-stage renal disease (ESRD) services for patients ages 20 years and older (90960-90962, 90966, or 90970);
Interpretation of physiological data (99091); and
Care plan oversight (G0181-G0182).

Remote Patient Monitoring:

RPM involves the collection and analysis of patient physiologic data that are used to develop and manage a treatment plan related to a chronic and/or acute health illness or condition.

Requirements for RPM:

To qualify for CMS reimbursements for utilizing the RPM services efficiently, the service providers and hospitals need to ensure the following:

Medicare part B patients are imposed 20% of copayment (renouncing the copayments regularly can trigger penalties under the Federal Civil Monetary Penalties Law and also the Anti-Kickback Statute)
Patients must take the remote monitoring services and are required to monitor for a minimum of 16 days to be applicable for a billing period.
The RPM services must be ordered by skilled physicians or other qualified healthcare experts.
Data must be wirelessly synced for proper evaluation, analysis, and treatment.

CPT Reimbursement Codes for RPM Service:

CPT code 99453 – It is a one-time practice expense reimbursing for the setup and patient education on RPM equipment. This code covers the initial setup of devices, training and education on the use of monitoring equipment, and any services needed to enroll the patient on-site. Reimbursement rate – $18.77/patient/month.
CPT code 99454 – This code covers the supply and provisioning of devices used for RPM programs, and the code is billable only once in a 30-day billing period. Reimbursement rate – $64.44/patient/month.
CPT code 99457 – This code covers the direct monthly expense for the remote monitoring of physiologic data as part of the patient’s treatment management services. To receive reimbursement, the physician, QHP or other clinical staff must provide RPM treatment management services for at least 20 minutes per month. Reimbursement rate – $51.61 (non-facility); $32.84 (facility) /patient/month.
CPT code 99458 – This code is an add-on code for CPT Code 99457 and cannot be billed as a standalone code. This code can be utilized for each additional 20 minutes of remote monitoring and treatment management services provided. Reimbursement rate – $42.22 (non-facility); $32.84 (facility) /patient/month.

Principal Care Management:

PCM codes are intended to cover services for patients with only one complex chronic condition that requires management by a specialist. Like other chronic care management (CCM) codes (chronic care management, transitional care management), the PCM codes are intended to reimburse physicians for the additional work they do to take care of high-risk, complex patients. This includes the extra time and work required for medication adjustments, creating a care plan, patient follow-up, and more.

Requirements for PCM:

One complex chronic condition lasting at least 3 months, which is the focus of the care plan,
The condition is of sufficient severity to place the patient at risk of hospitalization or has been the cause of recent hospitalization,
The condition requires development or revision of a disease-specific care plan,
The condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities

CPT Reimbursement Codes for PCM Service:

CPT Code G2064 – requires 30 minutes of provider (allergist, NP, PA) time each calendar month to care for the patient. This code can be billed monthly (in addition to appropriate E/M codes) and approximate reimbursement is $52/patient/month.
CPT Code G2065 – requires 30 minutes of clinical staff time directed by a provider each calendar month for patient care. Provider supervision does not require the provider to be onsite while clinical staff performs PCM services. This code can be billed monthly (in addition to appropriate E/M codes) and approximate reimbursement is $22/patient/month.

Annual Wellness Visit:

The Annual Wellness Visit (AWV) is a yearly appointment with your primary care provider (PCP) to create or update a personalized prevention plan. This plan may help prevent illness based on your current health and risk factors. Keep in mind that the AWV is not a head-to-toe physical.

Requirements for AWV:

For G0438 (initial visit),

Billable for the first AWV only.
- Patients are eligible after the first 12 months of Medicare coverage.
- For services within the first 12 months, conduct the Initial Preventive Physical Exam (IPPE), also referred to as the Welcome to Medicare Visit (G0402).
The patient must not have received an IPPE within the past 12 months.
Administer a Health Risk Assessment (HRA) that includes, at a minimum: demographic data, self-assessment of health status, psychosocial and behavioral risks, and activities of daily living (ADLs), instrumental ADLs including but not limited to shopping, housekeeping, managing own medications, and handling finances.
Establish the patient’s medical and family history.
Establish a list of current physicians and providers that are regularly involved in the medical care of the patient.
Obtain blood pressure, height, weight, body mass index or waist circumference, and other measurements, as deemed appropriate.
Assess a patient’s cognitive function.
Review risk factors for depression, including current or past experiences with depression or mood disorders.
Review patient’s functional ability and safety based on direct observation, or the use of appropriate screening questions.
Establish a written screening schedule for the individual, such as a checklist for the next 5 to 10 years based on appropriate recommendations.
Establish a list of risk factors and conditions for primary, secondary, or tertiary intervention.
Provide personalized health advice to the patient, as appropriate, including referrals to health education or preventive counseling services and programs.
At the patient’s discretion, furnish advance care planning services.

For G0439 (subsequent visit),

Billable for subsequent AWV.
The patient cannot have had a prior AWV in the past 12 months.
Update the HRA.
Update the patient’s medical and family history.
Update the current physicians and providers that are regularly involved in providing the medical care to the patient, as developed during the initial AWV.
Obtain blood pressure, weight (or waist circumference, if appropriate), and other measurements, as deemed appropriate.
Assess a patient’s cognitive function.
Update the written screening schedule checklist established in the initial AWV.
Update the list of risk factors and conditions for which primary, secondary, and tertiary interventions are recommended or underway.
Provide personalized health advice to the patient, as appropriate, including referrals to health education or preventive counseling services and programs.
At the patient’s discretion, the subsequent AWV may also include advance care planning services.

CPT Reimbursement Codes for AWV Service:

The four CPT codes used to report AWV services are,

G0402 Initial Preventive Physical Exam – This code is used for patients visiting within 12 months after enrolling in Medicare.
G0438 Initial Visit – This visit is eligible within 11 calendar months from the date of IPPE.
G0439 Subsequent Visit – This code is used for every subsequent visit. Patients are eligible for this benefit every year after their Initial AWV.
CPT 99497/99498 – Patients are eligible for an Advance Care Planning (ACP) at any time. But if performed during an AWV, the patient has no copay.

Behavioral Health Integration:

Integrating behavioral health care with primary care (“behavioral health integration” or “BHI”) is an effective strategy for improving outcomes for millions of Americans with behavioral health conditions. Medicare makes separate payments to physicians and non-physician practitioners for BHI services they furnish to beneficiaries over a calendar month service period.

Requirements for BHI:

Any mental or behavioral health condition being treated by the billing practitioner, including substance use disorders, that, in the clinical judgment of the billing practitioner, warrants BHI services.
The diagnosis or diagnoses could be either pre-existing or made by the billing practitioner and may be refined over time.

CPT Reimbursement Codes for BHI Service:

The CPT code used to report BHI services is,

CPT Code 99494 – Initial or subsequent psychiatric collaborative care management, each additional 30 minutes in a calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified healthcare professional.

References:

https://signallamphealth.com/2021-medicare-cms-chronic-care-management-ccm-cpt-code-updates/

https://www.cms.gov/newsroom/fact-sheets/final-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar-year-1

https://college.acaai.org/new-principal-care-management-cpt-codes/#:~:text=G2064%20requires%2030%20minutes%20of,is%20%2452%2Fpatient%2Fmonth

https://www.aafp.org/family-physician/practice-and-career/getting-paid/coding/transitional-care-management.htm

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/BehavioralHealthIntegration.pdf