New Transitional Care Management Codes to Benefit Nurses

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By Debra Wood, RN, contributor 

November 20, 2012 - Recognizing the costs associated with hospital readmissions, the Centers for Medicare and Medicaid Services (CMS) has decided to reimburse physicians, nurse practitioners and other primary care professionals for “transitional care management” services, to more efficiently manage patients moving from one health care setting to another and prevent complications.

“The biggest impact on nursing is nurses who do care coordination as RNs for physicians and multispecialty offices,” said Eileen Shannon Carlson, RN, JD, associate director of government affairs at the American Nurses Association. “That’s what we think is so historic. It’s the first time CMS has decided to reward general transitional care management.”

Karen Cabezudo, RN, Robert Wood Johnson Visiting Nurses-RWJUH transitional care program liaison (standing), and Teresa De Peralta, MSN, NP-C, transitional care program coordinator at RWJ University Hospital, provide discharge instructions to patient Richard Lightfoot.

Teresa De Peralta, MSN, NP-C, transitional care program coordinator at Robert Wood Johnson University Hospital in New Brunswick, N.J., said of the CMS decision, “It’s great. It’s about time.”

As many as 20 percent of Medicare patients are readmitted to the hospital within 30 days of discharge. CMS has placed a major emphasis on reducing that number and recently stopped paying for readmissions within 30 days for certain conditions, including congestive heart failure and pneumonia.

“Transition is a big problem,” De Peralta said. “Patients rebound to hospitals. They go home and get confused about their medications.”

De Peralta’s Robert Wood Johnson Foundation grant-funded transition program, which started earlier this year, provides a nurse practitioner visit with the patient before discharge and follow-up home visits by a master’s-prepared nurse from the Robert Wood Johnson Visiting Nurses, a partnership between Robert Wood Johnson University Hospital and Visiting Nurse Association Health Group. Transition care focuses on ensuring patients take the right medications and follow-up promptly with their physician or primary provider.

The hospital and home health agency share access to the same electronic medical record system, which helps the program identify high-risk patients and the home nurse look up medications and other care. 

Patients who have enrolled in the transitional care program have experienced approximately half the readmissions of other patients.

“It’s proven when you follow the patients diligently, it will have an impact,” De Peralta said.

In the Medicare Physician Fee Schedule Final Rule, issued November 1, 2012, and effective January 1, 2013, CMS has approved new current procedural terminology (CPT) codes, defined by the American Medical Association’s CPT Editorial Panel, and payments for transitional care management and psychiatric services.

“The American Nurses Association has been advocating for years that government and private insurers need to recognize nurses’ contributions to transitional care and care coordination, and pay appropriately for these essential services,” said ANA President Karen A. Daley, PhD, MPH, RN, FAAN, in a written statement. “This Medicare rule is a giant step forward for nurses whose knowledge and skills play major roles in patients’ satisfaction and quality of care.”

Under the Transitional Care Management provision, physicians and “qualified non-physician practitioners” must contact the patient needing moderate or highly complex medical decision making within two business days, and then deliver the transitional care in a face-to-face visit within days of discharge from a hospital, skilled nursing facility or community mental health center. That care must include care coordination and medical decision-making. The care must take place within 30 days, with the Medicare provider.

However, Carlson said, the physician could hire a registered nurse to perform the care coordination.

“It’s nurses, primarily, who do the care coordination,” Carlson said.

ANA anticipates mostly primary-care providers will use the new codes and nurse practitioners represent about 5 percent of Medicare primary care providers. The CPT panel left the definition of transitional care broad, but other payors might define what would qualify, Carlson said.

The panel also approved new codes for complex chronic care coordination, but CMS did not include that in the physician schedule but said it would consider paying for these services in the future. However, private insurers can opt to pay for such services. ANA expects that could increase demand for nurses skilled at care coordination.

The complex chronic care coordination would apply to care of patients with chronic conditions, not necessarily immediately after discharge. The provider could bill for the services monthly.

“It could be used more broadly,” Carlson said. “We believe private payors, health insurers, may pay for that.”

The new rules also allow certified registered nurse anesthetists (CRNAs) be paid by Medicare for providing all services that they are permitted to furnish under state law, such as chronic pain management.

The American Nurses Association represented the nursing profession on the CPT Editorial Panel and the RUC (Relative Value System Update Committee), and helped develop and value the new codes, Carlson said.

“There’s no doubt that ANA’s involvement on these panels had a strong influence on the new provisions that account in real dollars for nurses’ crucial contributions,” Daley said. “Patients benefit from our work. Now the value of our work is being recognized through payment policy.”



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