A Deep Dive into TCM Services
Let’s look now at what Transitional Care Management (TCM) services are and the importance of documentation.
Transitional Care Management (TCM) is a specific range of medical services that focuses on coordinating the care of adult patients during the transition from an inpatient (IP) healthcare setting to the patient’s community setting, such as the home. While most of the patients receiving TCM services come from an IP setting, it is also possible for patients to require TCM as a result of discharge from a skilled nursing facility (SNF) or even an outpatient (OP) setting. When patients are planning for an elective IP or surgical procedure at least 24 hours in advance, the patient’s physician may refer them for TCM. In consequence, TCM services are often provided in the community setting immediately following the patient’s discharge from an IP or SNF setting .
Regardless of where the patient receives these services, the objective of at least some of the TCM services is to prevent readmission to an IP or SNF setting, through follow-up care, education, coordination of care and other needs. The Preventive Services Task Force (USPSTF) recommends this service for all adults who have been treated in the IP or SNF setting and recommend follow-up visit(s) within 14 days of discharge for patients with chronic and/or acute conditions requiring care planning or coordination. The management plan should center on addressing "issues of poor medication management, loss of follow-up care, loss of home care services, psychosocial factors, and other problems that may lead to emergency department use or hospital admissions".
Essential Components of TCM Documentation
The key elements of TCM documentation include: initial contact, documentation of the patient record, follow-up notes, and record maintenance. We will address each of these in turn.
In HCC medical review, initial contact involves conducting a chart audit to ensure all requisite documents are present in the medical record and that they conform to the TJC, Medicare and other regulatory documentation standards.
Pursuant to the Medicare site visit, the medical record must contain documentation for diagnostic procedures, and there should be an indication that a physician or other qualified health care professional has reviewed or signed diagnostic tests and reports.
Documentation requirements of diagnostic test results include components pertaining to the test’s type and results, billing elements, supplier information, order information, signature of an individual who interprets or prepares the test results, payment instrument identifier as applicable, and date of service.
With respect to medical record documentation in the physician’s office, Medicare requires a note of current medications that includes:
• Medication name
• Dosage
• Route
• Frequency
• Reason for prescribing each medication
The documentation must also include evidence of:
• Antecedent elements of care (communication with the patient, referrals, prior treatments)
• Reason for the encounter (chief complaint, symptoms, diagnosis or assessment)
• ICD-10-CM code(s) linked to orders and results
• All tests, labs and other services provided
• Ordered tests, enforced ordered follow-up
• Active plan to address each diagnosis, status of/made progress towards that plan of care
• Current medications
CMS recommends that records be retained for ten years, consistent with the Medicare Claims Review Protocol.
Documentation of the patient record must include a record of:
• Elements of history, e.g., past medical history, physical status, etc.
• Physical examination findings
• Clinical impression
• Plan of care and modifications over time
• Evidence of orders been carried out or actions have been taken to ensure that orders have been carried out
Follow-up notes should indicate that the physician reviewed the test results, and that additional evaluations were recommended and/or interpreted.
The commercial payor medical review site visits do not currently address this area, although additional scrutiny may be implemented in future audits.
Who Requires TCM Documentation
The healthcare professionals obligated to maintain TCM documentation depend on the individual state and discipline. However, the most common practitioners who must complete TCM documents are physicians, physician assistants, and nurse practitioners. This is because these professionals are either performing TCM services or supervising the services of an in-house or external TCM provider.
In addition to the areas outlined above, the following practitioners also tend to be responsible for TCM documentation requirements:
Radiologists
Podiatrists
Physical therapists
Speech pathologists
Occupational therapists
In situations where multiple professionals supervise the service, the one coordinating and ensuring completion of the TCM documents is ultimately responsible. This requirement has been in place since at least 2015.
Pitfalls in TCM Documentation
There are several mistakes that practitioners can make when it comes to documenting their patient encounters.
Falling Short on the Subjective
The subjectives will be the most important part of the notes. Practitioners need to dig deep with their patients, ask probing questions, note everything that is bothering them. Sometimes those things will lead to the root problem.
Putting all the Subjectives at the end of the Treatment Plan
Do not do this, the subjectives should be upfront in the Treatment Plan. The Treatment Plan is ultimately to help you find the underlying cause and fix it. If there is no plan, then the practitioner will be hitting the ‘points’ without any rhyme or reason, so there will be a disconnect between the treatment, the patient, and the plan.
Not Noting Device Treatments and Speed of Devices
If you use devices, it’s essential to specify them, including the probes and the speed. Not documenting these can result in many unnecessary issues. For example, you may end up in an audit because you, for instance, didn’t note the speed or amount of stimulation. You may not think that the speed or amount of stimulation itself matters, but if you are auditing the claims, your software will categorize the codes in a way that is different than the actual procedures done. So, if you submit on code was intended for 50 milliamps and your notes do not state that, yet you used 30 milliamps, the auditor will adjust the code accordingly and demand repayment. On top of this, your accountant could audit the files and raise a red flag over it, resulting in further headaches.
Not giving enough detail on the First Visit to Indicate the Underlying Cause
On the first visit, you should try to figure out the underlying issue. You should spend time learning about where the main problem is, and why that is the main problem. You want to figure out what its the reason, what they were doing before, or other reasons. This information is important to determine the best treatment plan for them and to demonstrate what was wrong with them.
Problems with Treatment Plans
A Treatment Plan is not a list of treatments; it is a plan of action to address the underlying issue that you’ve discovered on the first visit. Today’s treatment plans are actually proof after the fact that show you did a good job and how you now know how long it will take, what it will cost, and that it has to be done along.
Not Checking Up on Patients
If your TCM documentation includes clear, specific plans to monitor the status of your patients, and if the patient does not seem to be improving, it is important to check up on them. You need to follow upon the problems that haven’t improved. For example, if a patient claims the problem is still there, ask them to describe what the problem is now. Where is it? When does it hurt? What is the quality?
Giving an impossible Treatment Plan
When it comes to treatments, it is important to do your best each visit and do what makes the most sense to you. Over time, the problems will all resolve thanks to your expert TCM practice. Do not worry—if you plan it out, your patients will get better.
Tips for Successful TCM Documentation
Managing TCM documentation can pose noteworthy challenges. The use of auditing software provides a user-friendly approach to batch-screening for issues across an entire TCM record. A TCM doc reviewer doesn’t have to manually perform those issues, and can focus on identifying patterns in issues that are likely to contribute to coding denial. The right education for staff is also crucial. This needs to include training on the rules and regulations, as well as standardizing guideline documentation. TCM staff need to be aware of what they need to avoid, both in respect to quality and compliance. While the specifics of these issues vary from provider to provider, one overview good practice includes disguising the identifying information for inaccurate or non-compliant TCM documentation. This prevents subjective assessment within the review process, and identifies the patterns from the individual reviewer. It’s effective for providers to measure the frequency of each coding denial type – this might be based on a certain number of TCM documentation assessments, or on a quarterly basis . The latter option, such as a TCM review every quarter, can provide useful insights into how TCM documentation generally trends, and helps to identify the specific focuses of a staff member’s future coding training. Take, for instance, the staff member who traditionally submits TCM documentation with low quality control rating in respect to ADLs. An audit with close attention to ADLs can help to improve that particular reviewer or coder’s performance. Other quality control issues that can be measured include: When it comes to documentation, clinical staff and office personnel need to be aware of the rules and regulations, and standardizing guideline compliance. It is equally important to ensure that everyone knows what not to do. Clinical staff need to be educated in avoidance of non-compliant TCM documentation, and when to ask about the elements of coding. Staff should not code residents’ records based solely on the current encounter, but instead review the full record and compare the coding with the actual resident condition. TCM clinical staff understand that proper TCM documentation doesn’t only benefit the billing provider by ensuring optimal reimbursement for CMT service, it also serves in the documentation the quality of care given to residents.
Regulatory Aspects of TCM Documentation
In addition to payer regulations, practitioners should be aware of state and federal regulations governing documentation. Knowledge is power. It is vital to a practitioner’s success to be aware of these regulations and know how to address them. Failing to comply with regulations can leave a practitioner without recourse if he or she is targeted by a government audit.
Practitioners must also be aware of state requirements in addition to federal requirements when it comes to documentation. Under Code Section 1861(r)(1) of the Social Security Act, a TCM service is covered when it is "furnished as an integral part of a physician’s or practitioner’s service (as defined in [Section 1861(gg)(1) of the Act]) for the condition for which payment may be made under [the Medicaid Act]." In determining whether or not the encounter was furnished as an integral part of a physician or practitioner service, the State Medicaid Program or the State Medicaid agency must consider whether the encounter occurred in the course of the provision of a service included in the State’s plan ("state plan") for Medicaid under Title XIX of the Social Security Act.
State Medicaid Agencies maintain guidelines that provide specificity as to which visits will be considered ancillary encounters. These agency rules were recently updated and all practitioners at the practice or clinic, who have an active TCM code on their National Provider Identifier (NPI). Be on the lookout for these updates, as some may no longer be endemic to your practice and you may need to revisit patient counters from the past if you are no longer on the list for providing certain of these services.
Regulations for Frederal Medicaid Programs implementing TCM and services paid under timely filing 42 CFR 447.59(a) state that "Providers may be subject to recoupment of prior payments for TEFRA covered and certain other services… if the office visit was as follows: (1) Furnished during the current stay in a hospital which paid the provider ‘per day’ or ‘per visit’; (2) Preceded by 3 or more covered TEFRA office visits in the prior 3 months; (3) Paid at a too high reimbursement rate pursuant to a State plan methodology or payment rate for office visits that does not distinguish between TCM and regular physician services; or, (4) are for physician’s visits which follow an inpatient stay and are subsequent to the first outpatient visit. The regulations also state that providers may bill non-time based CPT codes in association with TCM services as long as such groupings of CPT codes are consistent with the frequency of routine care provided to the recipient. The same rule applies to State Medicaid programs that are implementing physician office visit case rates.
Upcoming Trends in TCM Documentation
As we look toward the near future, the documentation requirements for TCM will continue to expand and grow. More and more payers are creating demand for these types of services and there are advancements in technology that help to streamline and ease the burden of maintaining appropriate documentation. Whereas quality improvement monitoring has generally been a manual process in the past, technology is expected to play a big role in monitoring program integrity. As providers begin to experience audits and monitoring programs by TRICARE or private payers, technology will translate into automation of prospective reviews for TCM documentation. The future of documentation processes for TCM may include innovations such as predictive input for diagnosis and medical decision-making , templated plans of care, or suggesting medical decision-making in consultation with an embedded or built-in clinical decision support tool. It may also be FQHC specific templates or historical search suggestion based on previous encounters or visits, allowing for pre-population based on historical data, or improving EHR functionality for TCM programs. Technology will inevitably change the future landscape of documentation processes for TCM. How these changes play out and are implemented, as well as how payers respond in terms of their coverage and reimbursement policies, will be factors impacting the future state of TCM documentation.