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Transitional Care Could Have Separate Payment in 2013

August 23, 2012:

Regina Magnani, RHIT, Clinical/Technical Editor

Both physicians and facilities may be eligible for a new payment in 2013 to cover the cost of transitional care.

As a part of a strategy to encourage the provision of primary care and care coordination services, the Centers for Medicare and Medicaid Services (CMS) proposes creating a HCPCS G code for care management involving transitioning a patient from care furnished by a treating physician during a hospital stay (inpatient, outpatient observation services, or outpatient partial hospitalization), skilled nursing facility stay (SNF), or community mental health center (CMHC) partial hospitalization program to care furnished by the patient’s physician or qualified nonphysician practitioner (NPP) in the community. Details of this proposal are in the CY 2013 Medicare physician fee schedule (MPFS) proposed rule.

The proposed HCPCS Level II G code would address the non-face-to-face work involved in hospital or SNF discharge care coordination. The code specifically describes post-discharge transitional care management services the community physician or NPP furnishes within 30 calendar days following the date of discharge from an inpatient acute care hospital, psychiatric hospital, long-term care hospital (LTCH), SNF, and inpatient rehabilitation facility (IRF); discharge from hospital outpatient observation or partial hospitalization services; or discharge from a partial hospitalization program at a CMHC, to the community-based care. Such services include non-face-to-face care management services provided by clinical staff members or office-based case managers under the supervision of the community physician or NPP.

Transitional care management services include:

  1. Assuming responsibility for the patient’s care without a gap.
  2. Establishing or adjusting a plan of care to reflect required and indicated elements to correlate with the services furnished during the stay at the specified facility and to reflect the result of communication with the patient.
  3. Communication with the patient and/or caregiver, including education of the patient and/or caregiver within two business days of discharge based on a review of the discharge summary and other available information such as diagnostic test results. Communication may be direct contact, telephone, or electronic.

While OPPS does not pay for physician or NPP professional services, certain elements of the transitional care coordination services could be provided to a hospital outpatient as ancillary or supportive services in conjunction with a primary diagnostic or therapeutic service, such as a clinic visit, that would be payable under OPPS. Transitional care management services may be considered ancillary and supportive to a primary service provided to an OPPS service. CMS proposes assigning this HCPCS Level II G code, an OPPS status indicator of N (Items and services packaged into APC rates) signifying that its payment is packaged. (See the 2013 OPPS proposed rule.)


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