User
I see the Medicare agency using the abbreviation CHI, in the context of things like chronic illness and social determinants of health. How is it using CHI, I need to know the abbreviation.
ChatGPT
The abbreviation "CHI" in the context of Medicare and chronic illness is not explicitly listed in the common acronyms used by the Centers for Medicare & Medicaid Services (CMS). It's possible that CHI could refer to a specific program, initiative, or concept related to chronic illness within the Medicare system, but without a clear reference in the CMS's glossary or common acronym list, its exact meaning remains uncertain. It's advisable to refer directly to the specific context or document where you encountered "CHI" for a more accurate interpretation.
User
It turns out it’s community health integration, CHI, and as part of abroad effort to have better support for primary care, and especially the integration of basic care among patients with multiple needs such as for example, heart failure, plus cancer
ChatGPT
"Community Health Integration" (CHI) in the context of Medicare and chronic illness refers to efforts aimed at enhancing primary care support, particularly for patients with multiple health needs. This approach focuses on integrating basic care for individuals who may be dealing with complex health conditions, such as the coexistence of heart failure and cancer. The goal is to streamline and improve the overall healthcare experience for these patients by ensuring cohesive and comprehensive care management across different health issues.
User
The center for Medicare innovation had a special program in oncology for a number of years, called the oncology care model, the OCM …and quite a bit was written about this. One feature was that physician practices and oncology got an additional fee for the more global management of the patient, such as $100 per month, With the idea that this better global management would actually decrease total cost year by year. Here is my question. To the extent possible, what was the value of that extra monthly payment that went to physician practices who were participating in the oncology care model.
ChatGPT
Based on a quick search, here's what I found.
In the Oncology Care Model (OCM), physician practices received a Monthly Enhanced Oncology Services (MEOS) payment. This payment was set at $160 per beneficiary per month. The MEOS payments were designed to assist participating practices in managing and coordinating care for oncology patients during episodes of care. These payments were also included as part of the total episode expenditures and counted against each participant's total cost of care target.
The goal of these payments was to incentivize practices to provide comprehensive care and address complex needs of cancer patients undergoing chemotherapy, thus potentially reducing the overall cost of care while improving patient outcomes. The OCM was part of a broader effort by the Center for Medicare & Medicaid Innovation to improve effectiveness and efficiency in specialty care, including cancer care.
User
In Medicare what does the abbreviation AWV mean, I think it has something to do with dementia care. Or some kind of chronic care organization
ChatGPT
The abbreviation "WV" in the context of Medicare, especially related to dementia care, stands for "Annual Wellness Visit" (AWV). This visit is a part of Medicare's preventive care services, and it includes, among other assessments, the detection of cognitive impairment which could be crucial in the early diagnosis of dementia and Alzheimer's disease. The AWV is designed to create and update a personalized prevention plan for the beneficiary, helping to address and manage various health-related issues, including cognitive health.
User
In Medicare, what does the abbreviation TCM mean. I think it has something to do with the organization of chronic care.
ChatGPT
In Medicare, the abbreviation TCM stands for "Transitional Care Management." TCM services are designed to ensure effective coordination of care for Medicare patients as they transition from an acute care setting, like a hospital or inpatient facility, to a community setting. This transition period is critical, especially for patients dealing with a medical crisis, new diagnosis, or changes in medication therapy.
TCM services include a range of activities, such as contacting the beneficiary or caregiver within two business days following discharge, conducting a follow-up visit within 7 or 14 days of discharge (depending on the medical complexity), medication reconciliation and management, reviewing discharge information, and coordinating with community providers and services.
The two CPT codes used for billing TCM services are 99495 (for moderate medical complexity) and 99496 (for high medical complexity). These services can be furnished by physicians of any specialty, nurse practitioners, physician assistants, clinical nurse specialists, and certified nurse midwives, as long as they are legally authorized and qualified to provide TCM services in their state.
The primary goals of TCM are to reduce the likelihood of hospital readmissions, ensure continuity of care, and manage the overall health and well-being of patients during this vulnerable period. It's part of a broader shift in healthcare from volume-based to value-based care, emphasizing the importance of coordinated care and patient outcomes.
For more detailed information, you can refer to the American Academy of Family Physicians AAFP and Noridian Medicare.
User
Why can’t this simply be built as a E and M visit of similar complexity, and length? Giving it a separate number and calling it a separate thing, the TCM, seems just to complex it, when really not necessary.
ChatGPT
Transitional Care Management (TCM) services are distinct from regular Evaluation and Management (E&M) visits due to several key factors, and this distinction is why they are not simply billed as a regular E&M visit.
- Scope of Services: TCM involves more than just the face-to-face encounter. It includes comprehensive services that start from the day of discharge and continue for the next 29 days. These services entail managing and coordinating various aspects of a patient's care, including medical conditions, psychosocial needs, and daily living support.
- Coordination and Complexity: TCM is specifically designed to address the complexities and coordination challenges that arise during the transition from an inpatient setting to community care. This period is critical and often involves higher risks of complications and readmissions. TCM ensures that various aspects of care, such as medication reconciliation, management of new or exacerbated health problems, coordination with community resources, and follow-up on pending tests and treatments, are adequately addressed.
- Billing and Reimbursement Structure: TCM has a specific billing and reimbursement structure that recognizes the additional work and coordination efforts required post-discharge. By having separate billing codes, Medicare acknowledges the unique challenges and additional time and resources needed for effective transitional care, which are not typically part of a standard E&M visit.
- Prevention of Readmissions: One of the main goals of TCM is to reduce hospital readmissions, which are both costly and potentially harmful to patients. The comprehensive nature of TCM services aims to ensure that patients' needs are fully met in the critical post-discharge period, reducing the likelihood of readmission due to unaddressed medical issues or poor coordination of care.
- Specialized Training and Expertise: TCM services may require specialized training and expertise in managing transitions of care, which goes beyond the scope of a standard E&M visit. This specialized focus is essential in ensuring that all aspects of the patient's care are considered and managed effectively during the transition period.
While it might seem that having a separate category for TCM complicates billing, it actually provides a structured and comprehensive approach to manage the high-risk period following a patient's discharge from a hospital or similar facility. This distinction helps in ensuring that patients receive the necessary attention and care coordination, ultimately improving their health outcomes and reducing the risk of readmissions.
For more detailed insights into the rationale behind TCM services and their billing, you can refer to the resources provided by American Academy of Family Physicians and Noridian Medicare.
User
What are the Medicare payment values for the codes? 99495 and 99496
ChatGPT
As of January 2022, the Medicare reimbursement rates for the Transitional Care Management (TCM) codes were:
CPT code 99495: Provides a one-time reimbursement of $209.02. This code is used for TCM with moderate medical decision complexity, requiring a face-to-face visit within 14 days of discharge.
CPT code 99496: Offers a one-time reimbursement of $281.69. This code is used for TCM with high medical decision complexity, requiring a face-to-face visit within seven days of discharge.
Please note that these rates are subject to change and may vary based on the annual updates to the Medicare Physician Fee Schedule. For the most current rates, it's advisable to check with Medicare or the appropriate Medicare Administrative Contractor (MAC).
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