Transitional Care Management

Table of Contents:

• Eligibility Rules
• CPT Rates
• Consent
• Add TCM Episode
• Manage TCM Episodes
• View TCM Episode
• Clinical Time Logging
• Approve Time

Eligibility Rules:

• One should be hospitalized as an inpatient
• Should have an active insurance
• And, should be 40 years and above

CPT Rates:

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1. There are only two CPT codes for TCM.
2. Below are the details of these CPT codes with their complexities and rates.

Instructions:

1. To add TCM, go to Patient Dashboard. Click on TCM tab

Consent:

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1. Click on "New TCM Episode" Button. Consent screen appears.

1. If the patient agrees to take TCM service, click on "Accepted by patient" and submit.

1. We can view the Consent in Dual Languages - English and Spanish. By default, we have English Language selected. Below, the Language selected is Spanish.

2. If the patient disagrees, then click on "Rejected by patient" and submit. This can be later edited, when the patient wants to take the service.

Add TCM Episode:

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1. After submitting consent, you'll see the Discharge info screen (Only when the Consent is accepted by the Patient).

1. Inpatient facility type, Inpatient facility name and Discharge date are auto-populated.
2. To add any attachments, click on the Upload Button in the "Continuity-of-care documents" field. You can add only one file with formats - .pdf, and .doc.
3. If we want to add any medications, we can click " Add Medication" Button. Add Medication pop-up appears. Search the medicine you want to add and fill the other medication details and add the medicine.

1. Once after filling all the data, check the box on the bottom-left to confirm you have reviewed the Discharge Summary Instructions and click on the Submit Button. The Initial Communication screen appears.

1. You can see

• TCM Episode List on the top-left : To view and manage the TCM episodes.
• Discharge Info: To see an overlay, you can edit it by clicking the Edit Button.
• Clock ticker on top-right: Starts from the date the patient gets discharged.

1. If there are other calls associated with this TCM episode, click the Add Call button, and add information about each call.
2. You can schedule call for F2F Visit, on clicking the Schedule button. You can view the following pop-up. Fill the details and click on the Save Button.
3. Fill all other details and check the boxes to confirm that you have reviewed the patient information, identified problems and scheduled a Face-to-Face call. Once done, click on submit.

1. Medication reconciliation will be displayed. You will see a table with the list of active medicines, you can search medicines by the search bar located at left, right above the table or add medicines by clicking " Add Medicine" Button above the table, on the top-right.

1. You can edit, delete and inactivate the medicines using the actions and toggle at the right in the table. Here, we can view the active medicines at the top and inactive medicines at the bottom.
2. After making your changes, click on the Next Button to proceed to Face-to-Face Visit screen.
3. If you try to add F2F before the Scheduled Call date, we get to see a pop-up which asks you to confirm if you still want to add F2F. You can view the date on which the Call is scheduled.
4. Clicking on 'Cancel' will direct you back to Medication Reconciliation screen. And, continue button will take you to the F2F screen.

1. Located in the top right corner, you will find the "Call Scheduled List" button. Upon clicking, a pop-up model will appear, displaying the list of scheduled calls along with a "Join Now" button.

1. You will view this pop-up, to join the meeting. Once the provider joins the call, patient will receive an email and SMS to join the call.

1. When the patient requests to join the call, you will be asked to let the patient in as follows:

1. Once both Provider and Patient join the call, the timer on the left starts. You can now turn the PIP on.

1. Fill all the details, below in the Notes section, Assessment field will get the patient's diagnoses populated.

1. After you enter the details, check the box confirming the details to be accurate, end the call and submit. Entire TCM Episode is submitted.

1. You can see "Non Face-to-Face Interaction" button at the top-right below Clock Ticker.

1. Click on "Add Interaction" Button in the overlay. It redirects you to the Non-Face-to-Face Interactions Page.

1. Enter the details and check the box confirming the details to be accurate and submit.

1. Submitted Non Face-to-Face Interaction will be viewed as "Interaction 1". You can add other interactions by clicking " Add Interaction" Button.

Manage TCM Episodes:

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1. Now that the TCM episode is added, we can navigate between the 3 sections. - Initial Communication, Medication Reconciliation and Face-to-Face Visit.

1. We can view the list of TCM Episodes on the top-right as follows:

1. We can see that there is only one active TCM episode, for this patient. And two buttons - Close episode and Discontinue episode.
2. To discontinue the TCM episode, click on the Discontinue Button. You can view a pop-up as follows:

1. We can select the reason for discontinuing the TCM Episode from the dropdown - Readmission, Deceased and Others. And then, click on the Discontinue button.

1. The TCM episode is now discontinued, and can only be viewed but not edited.
2. You can also Close the Episode, click on the Episode list option on the left, you will view Close Episode option.

1. You will view the following confirmation pop-up. Clicking on Close button will close the episode and the episode can only be viewed and not edited. On clicking Cancel, you will redirected back to the episode.

1. To add a new TCM Episode, click on the "TCM Episode" Button at the left. You can view "Add Episode" Button.

View TCM Episode:

1. To edit the details, click on Edit button at the top-right, you will see the following screen where you make your edits and click on Update button to Submit Changes once done or click on Cancel to discard the changes.

1. In Medication Reconciliation screen, you can edit/ delete Medicines using the actions buttons in the table. To end the course duration or if the medicine is no longer needed to be taken by the patient, you can click on the toggle to inactivate the medicine.

1. If you want to make the medicine active again, you will be asked to set Course Duration again as follows. After you set the End Date, click on the Update button.
2. Moving forward, in Face-to-Face visit, to enable editing, click on the Edit Button at the right.

1. On clicking the Edit button, you can Edit the TCM Face-to-Face Visit section. Once you make your changes, click on Submit Changes to save and update the changes.
2. You can view Consent, Discharge Info, Non Face to Face Interaction in all the sections, Questionnaire in Initial Communication.
3. You can Edit Discharge Info , by clicking on the Edit button.

1. It will redirect to Discharge Info Screen, you can view the following screen. Once you make your changes, click on the Submit Changes button to save the changes you made.

1. To submit Questionnaire, click on the Questionnaire button at the top-right in Initial Communication, you can see the following pop-up. Once you enter all the details click Submit Button.
2. Submitted Questionnaire can be viewed but not edited.

Clinical Time Logging:

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1. To view the Clinical Time Logging (Billing) for TCM, go to the Patient Dashboard and click on the Clinical Time Tab. Following screen can be viewed.

1. There are 4 sub tabs - RPM, CCM, Others and TCM, billing logs for each program. Click on TCM tab.
2. Clicking on RPM, CCM, TCM and Others tab, will display calls list with checkboxes for each row with details as follows:

• CPT code
• Time
• Interactive contact date
• Face-toface visit date
• Topic
• Summary
• Status
• Action

1. CPT codes are different for all types i.e., RPM, CCM, and TCM. CPT codes for all reimbursement types are different.
2. Billing Period - By default, we have the Monthly filter selected, and the month will be the previous month. We also have a Quarterly filter.
3. If Monthly is selected, then we can select the Month from the picker.

1. If the Quarterly is selected, we can select the Quarter. On selection, we can view the Bills accordingly.

1. User can use the Add Row option to add a row in the given list with entering the details like Billing Type, CPT code, topic, Provider, Patient, Date, Start Time, End time, Meeting Notes and call type.

1. To edit the call details click on the Edit icon in Action, allows user to edit the details like Billing type, CPT code, topic, Date, Provider, Meeting Notes, call type for selected row in the list.

1. User can select the calls from the list and click on Submit.

1. You will be asked confirmation before submitting the bill that the patient was not readmitted. On clicking Yes, the bill will get submitted and on clicking no, you will be redirected back to Bills tab. The submitted bills cannot be edited.

1. You can view and download the Episode Summary by clicking the eye icon. You can view the pop-up as follows:

1. Click on the Download button to download the bill. You can later view the downloaded bill in your downloads.
2. You can also download the records document by clicking on the download icon, which is located beside the delete option for each record.
3. We can also download all the selected records at once by clicking on the "Download Supporting Documents" button, which is located at the top of the table.
4. Each reimbursement type tab have filters as shown:

• All - Shows all the TCM call logs
• New - This displays all the newly submitted calls/bills and is represented by the colour blue.
• Submitted - It displays all the submitted calls/bills and is represented by the light green colour.
• Rejected - It displays all the rejected calls and they are represented by the colour red
• On-Hold - Displays the calls that are kept on hold and are represented by amber colour
• Approved - Displays all the approved calls and is represented by the colour green

1. On clicking the Rejected calls/bills, User can view the Rejected reasons, which shows the date with rejected reason.

Approve Time:

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1. The calls logs that are being submitted are saved in the Billing Portal. When the Admin logs in he can view the following screen.
2. By default, we have All Programs and All Providers selected. You can change it based on your preferences.

1. On the dashboard, count for Patients enrolled, Patients billed, Bills accepted, Bills pending will be displayed.

2. On the left-hand side, there is a table icon. Upon clicking on it, a pop-up will appear where you can select the required table columns, as shown below.

   

   

3. There are 5 filters - Status, Program, and Provider, Duration and Search Bills, using which we can search the bills to review.
4. User can filter the submitted billing list based on the Status of the bill in 4 categories.

• Submitted Bills
• Bills on Hold
• Accepted bills
• Rejected bills

1. Patients which are qualified by rules engine for the set of rules mentioned for respective CPT code, will be ready to Bill and patients which do not qualify the set of rules mentioned are rejected by rules engine.
2. User can filter the submitted billing list based on the type of billing or product (All/RPM/CCM/RTM/TCM/PMPM)
3. Click on the Status filter and select Submitted Bill option and Program filter and select CCM . The following screen can be seen.

1. User can filter the submitted billing list based on the selected duration of Date from and Date to. We can view the bills based on the Duration type - Monthly or Quarterly, by default, we have Monthly selected.

1. User can filter the submitted billing list based on the provider name for the specific center.
2. Search field will be available to search the required data on the dashboard.
3. Below the filters, we can see the table with following headers:

• Checkbox - To select all the records
• Patient EMR ID
• Patient Name
• Date of Service ( Date on which the service was provided)
• CPT Type (RPM/CCM/TCM/Others CPT code and Topic)
• Note (Meeting Notes while scheduling)
• Provider Name
• Bill details (Bill ID and Month Date, Year on which billing was submitted )
• Actions (Approve /On Hold /Reject)

1. All the submitted bills in the list, in the checkbox form, user can select the bulk actions to mark the selected bills as Approved or Rejected. And also can download the bills by clicking on the Download option.
2. Click on the checkbox and click on the Accept selected bills at the right, to submit the bills. You will view a pop-up to confirm if you want to accept the bill or not. Click on Yes to accept the bill.

3. We can also reject bulk bills by selecting the records and clicking on the "Reject selected claims" button, which will be visible in the headers once you select the bills. Upon clicking the button, a pop-up will appear where you have to enter the reason for rejecting the bills and click submit. The bills will then be seen under rejected bills.

   

4. You can perform actions - Approve, On Hold and Reject for individual calls. After the call log is being Approved/ is On Hold / Rejected. Those call logs will be categorised into Accepted/Rejected/On Hold respectively.

1. If there are no calls logs, you will see an empty state showing No records found.

1. After the bills are accepted, we can view them by selecting the Status as Accepted.
2. Here, to download the Bill report, check the box for an individual record or check the box in the header to download report for all the reports.
3. We can download the report w.r.t any Status - All, Ready to bill, Submitted, On-Hold, Rejected and Approved.

1. You can view download option at the right, click on the download to download the report. You can view it in your downloads.

2. We can also add the Billed Amount, Allowed Amount, Adjusted Amount, Balance Amount for each bill in the input field where you can enter the amount and click outside the field. It will be saved, but it is only for reference and will not be referenced anywhere else.

   

3. We also have the options of Claim Denied, Claim Failed, Closed, Patient Pending, Secondary Pending, and Claims On Hold to change the payment status of each claim. To access these options, select the submitted claim status and click on the more icon as shown in the below image.

   

   
   

4. We also have the option to upload the billing reconciliation file. You can upload an Excel file with the claims data of each patient and check the history of the uploaded file. Additionally, you can download a sample file or sample reconciliation template by clicking on the "Download Reconciliation Template" button.

   

   

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