Article Figures & Data
Figures
- Figure 1.
Electronic form used by care team RN to document discharge follow-up communication.
- Figure 2.
LACE Index Scoring Tool.
- Figure 3.
Fitted lines of the segmented regression analysis of interrupted time series for the monthly 30-day readmission rates, October 2015-June 2017. Open circles represent the observed 30-day readmission rates. The solid line represents the fitted 30-day readmission rate before implementation of the transitional care management service. The dashed line represents the fitted 30-day readmission rate after implementations of the transitional care management service.
Tables
- Table 1.
Necessary Requirements to Bill for Transitional Care Services Using 99495 and 99496
Step 1 Interactive Contact with the Patient or Caregiver ■ Within 2 business days following discharge from an inpatient setting to an outpatient setting. ■ Contact may be way of a telephone call, email or face-to-face visit. ■ Can be accomplished by the provider or competent clinical staff. ■ Attempts to make contact should continue after the first 2 business days if initial contact is unsuccessful. ■ If two or more separate contact attempts are made unsuccessfully and documented in the medical record one may bill for the TCM service if all other elements are met. Step 2 Non-Face-to-Face Services Provided by Physicians or APPs ■ Acquire and review discharge information (e.g., discharge summary or continuity of care documents). ■ Review need for or follow-up on pending diagnostic tests and treatments. ■ Communicate with other health care professionals who will assume or reassume care of the patient's system-specific problems. ■ Provide education to the patient, 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. Non-Face-to-Face Services Provided by Clinical Staff Under the Direction of a Physician or APP ■ Communication with agencies and community services the patient uses. ■ Provide education to the patient, family, guardian, and/or caretaker to support self-management, independent living, and activities of daily living. ■ Evaluate and support treatment regimen adherence and medication management. ■ Identify available community and health resources. ■ Assist the patient and/or family in accessing needed care and services. Step 3 Face-to-Face Visit ■ A face-to face visit is a required element of TCM billing. ■ Services with moderate medical decision complexity with a face-to-face visit within 14 days of discharge use CPT code 99495. ■ Services with high medical decision complexity with a face-to-face visit within 7 days of discharge use CPT code 99496. ■ For eligible telehealth services, the use of a telecommunications system substitutes for an in-person encounter. APP, Advanced Practice Provider; CPT, Current Procedural Terminology; TCM, transitional care management.
- Table 2.
Segmented Regression Looking at Impact of New Service Line on 30-Day Readmission Rates
Variable Coefficient SE P Value Time −0.00407 0.00200 .057 Intervention 0.02323 0.01630 .17 Time after intervention 0.00369 0.00262 .18 SE, standard error
