{"id":2027,"date":"2017-07-21T07:00:26","date_gmt":"2017-07-21T13:00:26","guid":{"rendered":"https:\/\/dsiohn098w.mpqhf.org\/blog\/?p=2027"},"modified":"2017-08-08T08:21:55","modified_gmt":"2017-08-08T14:21:55","slug":"establishing-system-monitor-patients","status":"publish","type":"post","link":"https:\/\/dsiohn098w.mpqhf.org\/blog\/establishing-system-monitor-patients\/","title":{"rendered":"Establishing a System to Monitor Patients"},"content":{"rendered":"<p><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/dsiohn098w.mpqhf.org\/blog\/wp-content\/uploads\/2017\/07\/7.21.2017-Transitions-of-Care.png\" alt=\"\" width=\"1200\" height=\"300\" class=\"alignnone size-full wp-image-2028\" srcset=\"https:\/\/dsiohn098w.mpqhf.org\/blog\/wp-content\/uploads\/2017\/07\/7.21.2017-Transitions-of-Care.png 1200w, https:\/\/dsiohn098w.mpqhf.org\/blog\/wp-content\/uploads\/2017\/07\/7.21.2017-Transitions-of-Care-300x75.png 300w, https:\/\/dsiohn098w.mpqhf.org\/blog\/wp-content\/uploads\/2017\/07\/7.21.2017-Transitions-of-Care-768x192.png 768w, https:\/\/dsiohn098w.mpqhf.org\/blog\/wp-content\/uploads\/2017\/07\/7.21.2017-Transitions-of-Care-1024x256.png 1024w\" sizes=\"(max-width: 1200px) 100vw, 1200px\" \/><\/p>\n<h1>Establishing a System to Monitor Patients<\/h1>\n<h5>July 21, 2017<\/h5>\n<h6>Written by Kristen Schuster, Practice Facilitator<\/h6>\n<p>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 <a href=\"https:\/\/dsiohn098w.mpqhf.org\/blog\/regional-feedback-reports\/\" target=\"_blank\">5\/24\/2017 blog post<\/a> for more information on how to access this report through your practice portal.  <\/p>\n<p><strong>Getting Started <\/strong><\/p>\n<ul>\n<li>Establish which hospitals your patients utilize<\/li>\n<li>Designate a member of your staff as primary contact for the hospital<\/li>\n<ul>\n<li>Having a designee and phone\/fax line for the hospital will make it easier for the discharge nurses to call<\/li>\n<li>Train your designee to schedule the patient while the discharge nurse is on the phone<\/li>\n<\/ul>\n<li>How will data be shared? <\/li>\n<ul>\n<li>Fax<\/li>\n<li>Secure email<\/li>\n<li>Information exchange<\/li>\n<\/ul>\n<li>How are you going to track these patients?<\/li>\n<ul>\n<li>Registry reports for transition of care codes<\/li>\n<li>Excel spreadsheet<\/li>\n<li>Other EHR reports<\/li>\n<\/ul>\n<li>Educate billing staff to bill for the Transition of Care codes<\/li>\n<\/ul>\n<p><strong>What can you get paid for?<\/strong><\/p>\n<ul>\n<li>CPT 99495<\/li>\n<ul>\n<li>Communication with the patient within 2 business days<\/li>\n<ul>\n<li>Phone call <\/li>\n<\/ul>\n<li>Moderate complexity for medical decision making<\/li>\n<li>Face-to-face visit within 14 calendar days of discharge<\/li>\n<li>$111.35 Medicare Part B<\/li>\n<\/ul>\n<li>CPT 99496<\/li>\n<ul>\n<li>Communication with the patient within 2 business days<\/li>\n<li>High complexity for medical decision making<\/li>\n<li>Face-to-face visit within 7 calendar days of discharge<\/li>\n<li>$161.12 Medicare Part B <\/li>\n<\/ul>\n<\/ul>\n<p><strong>Remember readmissions and emergency room visits are part of the utilization portion of the incentive payment. <\/strong><\/p>\n<p>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.  <em>On the Plus Side<\/em> 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. <\/p>\n<p>If you have any questions, or run into issues with any of the CPC+ objectives and would like help please use the \u201cLeave a Reply\u201d section below, or email <a href=\"mailto:kschuster@mpqhf.org?subject=CPC+%20Assistance\" target=\"_blank\">Kristen Schuster<\/a> directly with your questions or comments.<\/p>\n<p><strong>Other Resource Links<\/strong><br \/>\nCatch up on the national learning webinars with Mountain-Pacific Quality Health\u2019s <a href=\"https:\/\/dsiohn098w.mpqhf.org\/blog\/wp-content\/uploads\/2017\/08\/FAQ-Sheet-2-7.13.17.pdf\" target=\"_blank\">quick FAQ sheet<\/a>.<br \/>\n<a href=\"https:\/\/www.youtube.com\/watch?v=V-BdMs7moEY&#038;feature=youtu.be\">Recorded CMS Feedback Report Webinar<\/a><br \/>\n<a href=\"https:\/\/dsiohn098w.mpqhf.org\/blog\/wp-content\/uploads\/2017\/03\/CPC-Change-Package.pdf\" target=\"_blank\">CMS Change Package<\/a><br \/>\n<a href=\"https:\/\/dsiohn098w.mpqhf.org\/blog\/comprehensive-primary-care-plus-cpc-blog\/\">See all CPC+ Blog Posts<\/a><\/p>\n<hr \/>\n<p>&nbsp;<\/p>\n<p><strong>Subscribe to the HTS CPC+ Blog<\/strong><br \/>\n<a href=\"http:\/\/eepurl.com\/cH6b4n\" class=\"su-button su-button-style-flat\" style=\"color:#ffffff;background-color:#385173;border-color:#2d415c;border-radius:5px\" target=\"_blank\" rel=\"noopener noreferrer\"><span style=\"color:#ffffff;padding:0px 30px;font-size:22px;line-height:44px;border-color:#74869d;border-radius:5px;text-shadow:0px 0px 0px #f4f4f4\"> Subscribe<\/span><\/a>\n<p>&nbsp;<\/p>\n<hr \/>\n<p><img loading=\"lazy\" decoding=\"async\" src=\"http:\/\/www.mpqhf.org\/corporate\/wp-content\/uploads\/2017\/02\/Untitled-3-300x95.png\" alt=\"\" width=\"300\" height=\"95\" class=\"alignnone size-medium wp-image-3035\" \/><\/p>\n<div id=\"boxzero\">\n<section id=\"boxone\">\n<p id=\"boxparagraph\"><strong>See a list of upcoming webinars<\/strong><\/p>\n<p><a href=\"http:\/\/www.mpqhf.org\/corporate\/health-and-technology-services\/webinars-and-events\/upcoming-webinars\/\"><span class=\"link-spanner\">See a list of upcoming webinars<\/span><\/a><\/p>\n<\/section>\n<section id=\"boxtwo\">\n<p id=\"boxparagraph\"><strong>Check out any webinars you missed<\/strong><\/p>\n<p><a href=\"http:\/\/www.mpqhf.org\/corporate\/health-and-technology-services\/webinars-and-events\/webinar-materials\/\"><span class=\"link-spanner\">Check out any webinars you missed<\/span><\/a><\/p>\n<\/section>\n<aside id=\"boxthree\">\n<p id=\"boxparagraph\"><strong>See our CPC+ resources<\/strong><\/p>\n<p><a href=\"http:\/\/www.mpqhf.org\/corporate\/health-and-technology-services\/resources\/cpc-resources\/\"><span class=\"link-spanner\">See our CPC+ resources<\/span><\/a><\/p>\n<\/aside>\n<\/div>\n<p>&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>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 [&hellip;]<\/p>\n","protected":false},"author":13,"featured_media":1738,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_genesis_hide_title":false,"_genesis_hide_breadcrumbs":false,"_genesis_hide_singular_image":false,"_genesis_hide_footer_widgets":false,"_genesis_custom_body_class":"","_genesis_custom_post_class":"","_genesis_layout":"","footnotes":""},"categories":[135],"tags":[],"class_list":{"0":"post-2027","1":"post","2":"type-post","3":"status-publish","4":"format-standard","5":"has-post-thumbnail","7":"category-cpc","8":"entry"},"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.5 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Establishing a System to Monitor Patients - Mountain Pacific Blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/dsiohn098w.mpqhf.org\/blog\/establishing-system-monitor-patients\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Establishing a System to Monitor Patients - Mountain Pacific Blog\" \/>\n<meta property=\"og:description\" content=\"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. 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