Care Coordination Services Could Create Opportunities for RTs

December 11, 2013

New Medicare services may provide additional opportunities for respiratory therapists and complement the AARC’s Part B initiative that focuses on self-management education for Medicare beneficiaries with certain chronic lung diseases.

The Centers for Medicare and Medicaid Services (CMS) began paying for Transitional Care Management Services (TCM) in January 2013 and released final rules on November 27 to pay separately for Chronic Care Management Services (CCCM) in 2015. With continued emphasis on reducing hospital readmissions and improving the transition of patients from hospital to home, physicians are concerned that primary care non-face-to-face services usually bundled into the evaluation and management codes for office/outpatient visits do not adequately reflect the services and resources required to furnish coordinated comprehensive care for certain categories of beneficiaries.

Here’s what’s involved.

TCM Services

The idea behind TCM services is care based on a 30-day period post discharge. It requires 1) communication with the patient within 2 business days of discharge either directly, via telephone or electronic contact; 2) moderate or complex medical decision-making during the period of service; and,3) a face-to-face visit with the physician or other qualified practitioner at least 7 or 14 days post discharge depending of the degree of medical complexity.

Non-face-to-face services such as communication, referrals, self-management education, identification of community resources and medication management can be provided by licensed clinical staff. This could mean additional opportunities for RTs outside of the acute care setting.

CCM Services

With respect to CCM services, the criteria are more detailed but still relate to services furnished in a physician’s practice. To be eligible, among other things, a patient must have 2 or more chronic conditions expected to last at least 12 months or until death and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.

At least 20 minutes of CCM services must be provided during a 30-day billing cycle to qualify for coverage. CMS plans to establish a new code rather than use current CPT codes since they do not adequately describe the CMS services. CMS had proposed a 90-day billing cycle with a minimum of 1 hour of services but based on public comment changed the coverage criteria in the final rule to reduce the administrative timekeeping burden on physician practices.

The scope of CCM services includes the following:

• 24/7 access to needed care, which can be provided by members of the chronic care team that could include a respiratory therapist.
• Continuity of care with a designated practitioner or member of the care team (i.e., respiratory therapist) with whom the patient is able to get successive routine appointments.
• Care management for chronic conditions that includes an assessment of the patient’s needs, development of a patient-centered plan of care, medication reconciliation, and oversight of patient self-management of medications. For pulmonary patients with multiple chronic conditions, the respiratory therapist could play a much needed role.
• Management of care transitions that include referrals to other clinicians or visits following a patient visit to an emergency department or visits following a hospital discharge.
• Coordination with home and community-based clinical service providers as appropriate.
• Enhanced opportunities for patients and/or caregivers to communicate with the provider that include use of secure messaging, internet or other non-face-to-face consultation methods, in addition to the telephone.

Because 24/7 patient access to needed care means care would be provided after normal business hours, CMS would make an exception to the “incident to” rules and allow “general” supervision by the physician (i.e., the services would be performed under the overall supervision and control of the physician or practitioner but he or she would not have to be present when the service is being furnished). To qualify, the clinical staff person providing the service, such as a respiratory therapist, would have to be employed by the physician or practice. The services cannot be provided by an independent contractor.

Although many of the CCM provisions to be effective in 2015 have been finalized, CMS plans to propose in future rulemaking specific standards to ensure physician practices are capable of providing the necessary services and to address use of the patient’s electronic health record based on recent public comments.

HR 2619 - The Medicare Respiratory Therapist Access Act

Although TCM and CCM care coordination services complement our legislative activity on the Hill because they include some aspects of self-management education, they do not replace the need for HR 2619, the Medicare Respiratory Therapist Access Act. One of the most significant aspects of our bill is to recognize respiratory therapists in the Medicare statute. It also ensures Medicare beneficiaries with certain chronic lung disease have access to self-education and training taught by respiratory therapists so these patients have the proper skills they need to prevent acute exacerbations that can lead to costly acute care interventions.

The problem with the current system is that Medicare will not pay separately for self-management education and training in the outpatient setting. If covered, it would have to be bundled into another service the beneficiary receives, such as the TCM and CCCM services which have very defined coverage criteria.

Our bill would fix the problem. It is designed to establish separate payment specifically for pulmonary self-management education and training when provided by respiratory therapists, as long as the physician deems the service to be medically necessary for the patient. We would expect CMS to establish new codes for the service like they did for the diabetes self-training benefit that sets it apart from other services. That’s why it’s important to get behind our legislation and push for its passage.

These are exciting times for RTs as emphasis on improving care transitions, discharge planning (discussed in a previous article) and reducing hospital readmissions take center stage. As continued emphasis is placed on primary care, these care coordination services and our Part B initiative place the respiratory therapist in a perfect position as the “RT of the future” expands beyond the acute care setting.