Establishing a System to Monitor Patients

July 21, 2017

Written by Kristen Schuster, Practice Facilitator

The utilization report contains information about how your patients are using the system and how much they are costing the system. Now that the data are available, how do you start the process of establishing a transition of care workflow with hospitals? This post will give some quick tips for workflow and care coordination for patients transitioning from the hospital. Please refer to the 5/24/2017 blog post for more information on how to access this report through your practice portal.

Getting Started

Establish which hospitals your patients utilize
Designate a member of your staff as primary contact for the hospital

Having a designee and phone/fax line for the hospital will make it easier for the discharge nurses to call
Train your designee to schedule the patient while the discharge nurse is on the phone

How will data be shared?

Fax
Secure email
Information exchange

How are you going to track these patients?

Registry reports for transition of care codes
Excel spreadsheet
Other EHR reports

Educate billing staff to bill for the Transition of Care codes

What can you get paid for?

CPT 99495

Communication with the patient within 2 business days

Phone call

Moderate complexity for medical decision making
Face-to-face visit within 14 calendar days of discharge
$111.35 Medicare Part B

CPT 99496

Communication with the patient within 2 business days
High complexity for medical decision making
Face-to-face visit within 7 calendar days of discharge
$161.12 Medicare Part B

Remember readmissions and emergency room visits are part of the utilization portion of the incentive payment.

Also please refer to CPC+ Connect to network with other CPC+ practices utilizing the same EHR for ideas and best practices. We are in the process of setting up regional pages for both Montana and Hawaii in the CPC+ Connect Portal. We will let you know when that has been completed. This will make it easier to identify practices utilizing the same technology. On the Plus Side is a weekly newsletter, emailed to all subscribers that lists upcoming educational events, CPC+ tasks and links to CMS resources. As always, complete CPC+ information from CMS can be found on the CPC+ Connect Portal. We encourage you to access the portal and check out all available CMS CPC+ resources.

If you have any questions, or run into issues with any of the CPC+ objectives and would like help please use the “Leave a Reply” section below, or email Kristen Schuster directly with your questions or comments.

Other Resource Links
Catch up on the national learning webinars with Mountain-Pacific Quality Health’s quick FAQ sheet.
Recorded CMS Feedback Report Webinar
CMS Change Package
See all CPC+ Blog Posts

Subscribe to the HTS CPC+ Blog
Subscribe