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
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