BETHESDA, MD 10 April 2013—The Medicare program's efforts to improve the care of patients who make the transition from a hospital to a primary care setting include a way to pay for in-person and remote consultations.
Some of these services may, in theory, be performed by pharmacists.
The Centers for Medicare and Medicaid Services (CMS) 2013 final rule for care delivered in physicians' offices introduced two new Current Procedural Terminology (CPT) codes—99495 and 99496—that cover telephone and electronic communications with patients when the services are coupled with face-to-face clinic care and follow-up. The codes went into effect January 1.
The intent of the codes, according to CMS, is to provide incentives to improve postdischarge care coordination and ensure that patients are seen in a physician's office rather than be at risk for readmission.
Although the rule states that pharmacists may not use the codes to bill for their services, it appears that pharmacists can be part of the team that delivers the care specified by CMS.
"The way we are conducting our visits is, the pharmacist is a key person at that visit, but they are coupled with physicians," said Betsy Bryant Shilliday, associate professor at the University of North Carolina (UNC) School of Medicine and the UNC Eshelman School of Pharmacy in Chapel Hill.
Shilliday serves as assistant medical director of the UNC Internal Medicine Clinic, whose multidisciplinary team includes physicians, pharmacists, nurses, and social workers. She said the clinic has restructured its primary care visit procedures, in part, to be able to use the so-called TCM, or transitional care management, codes.
She said in late March that the medical practice has begun using the TCM codes but won't know for another month or two whether their Medicare carrier will accept or reject these claims.
About 14,000 patients receive care from the clinic. Shilliday said clinical pharmacist practitioner Jamie Cavanaugh, one of four pharmacists who work at the clinic, performs the patient care services that involve the TCM codes.
Reengineering the system. Shilliday said that before the TCM codes were created, the clinic had been working to decrease what she called a high 30-day hospital readmission rate for patients seen by the practice.
"We had already started this and were billing using the usual billing mechanisms," she said. "But once these codes were approved, we started to transition our model to match this, because the reimbursement rate with the TCM codes is actually better and aligns with our model."
Under the revamped process for postdischarge care, she said, the health care team reviews the discharge summary and discusses issues that need to be addressed during the upcoming visit, such as laboratory tests. This takes place before the patient arrives at the clinic.
On arrival at the clinic, she said, a nurse checks in the patients and assesses their vital signs.
The patient then spends about 30 minutes with Cavanaugh, who performs an in-depth medication reconciliation and other standardized procedures described in the Institute for Healthcare Improvement's "How-to Guide: Improving Transitions from the Hospital to the Clinical Office Practice to Reduce Avoidable Rehospitalizations."
"Then an attending physician comes in and provides the physical exam component; together, they develop a plan, and then Cavanaugh does the wrap-up" at the end of the visit, Shilliday said.
The wrap-up includes patient education and teach-back to assess whether the patient understood information conveyed during the visit.
Checking the boxes. To use TCM code 99495 in a claim to Medicare, a medical practice must have
- Communicated directly, electronically, or by telephone with the patient or caregiver during the first 2 business days after the patient's discharge from the hospital,
- Made a moderately or highly complex medical decision, and
- Conducted a face-to-face visit with the patient within the first 14 calendar days after discharge.
For TCM code 99496, the medical decision making must be of high complexity, and the face-to-face visit must occur within 7 days postdischarge.
CMS released a document (PDF) answering commonly asked questions about the TCM codes. To the question of whether only registered or licensed practical nurses may provide part of the TCM services, CMS responded that practitioners are "encouraged" to follow CPT guidance in reporting the services.
In addition, the communication states, practitioners must meet "incident to" requirements described in the agency's benefit policy manual.
"The way we're doing it seems to satisfy the wording in the March 12 bulletin," Shilliday said. "We're taking the pharmacist and the physician, bringing both of their strengths together, and providing the best care for patients."
She said the postdischarge phone call was something the clinic was already doing to ensure that the patient was aware of and able to keep their clinic appointment. The call also involves asking patients about problems with their medications or other issues related to the care transition.
"Now it's a required component, and it has to be documented in the medical record," she said.
According to CMS, because the codes address care during the first 30 days after hospital discharge, the first allowable date to bill for services specified under the codes was January 30, 2013.
Shilliday said this issue has been troublesome for the clinic because its electronic medical record system doesn't allow holding back the charges for the TCM visits. This means that the visits are recorded on paper and entered into the electronic system 30 days after the visit occurred, which disrupts the usual workflow.
She said an upcoming change to a new electronic medical record system may fix the problem.
What it means. At the practice level, Shilliday said, using the TCM codes promotes a structured approach that allows clinic staff members to clearly document in the medical record the services they provide to meet billing requirements.
She also said the use of the TCM codes provides "another great opportunity for pharmacists to be part of the medical home."
Daniel Buffington, practice director of Clinical Pharmacology Services Inc. of Tampa, Florida, said it's important for the pharmacists to use appropriate CPT codes to document and bill for professional services.
"The deeper practice meaning to me is the ability to be financially sustainable to provide the service you do," he said. "So by all means, yes, bill, even if you're not going to get paid each time you bill."
In essence, he said, each billing transaction, whether it involves CMS or other payers, provides a record of services that allows payers to take notice of the work pharmacists do—and that's more than just providing a profit on drug expenditures.
"We as a profession have to . . . become proficient with billing and developing a revenue stream out of our service side," Buffington said. "There's a tremendous amount of value in what we bring as a service. So . . . this discussion actually speaks . . . to the survivability of the pharmacists' role looking forward in health care," he said.