BBH Service Center Improves Transitions of Care for Medicare Patients

Pictured left to right, Service Center team: Karrie Sawyers; Lakita Barron; Summer Rahman; Donna Clay; Kimberly Arrington

When higher quality care meets higher revenue for physicians, it's a win all the way around. Brookwood Baptist Health (BBH) has managed to achieve this with the development of a cost-effective program for discharged Medicare patients that is proving successful at reducing readmission rates.

Transitional Care Management Services has been a reimbursable service since January 1, 2013. Under the Physician Fee Schedule (PFS), Medicare pays for two CPT codes (99495 and 99496) that are used to report physician or qualifying non-physician practitioner care management services for a patient following a discharge from a hospital, SNF, or CMHC stay, outpatient observation, or partial hospitalization.

"Our team found that very few primary care physicians were billing for this service because they were unclear about the requirements," said John Gardner, Executive Director of Operations at Hoover BBH. "Many of them were providing the care management service but not meeting the specific time frames required for billing. The common challenge we found was the ability to know a patient was discharged within the required time frame for implementing TCM services."

Recognizing this need, Gardner and his staff developed a program wherein the Hoover BBH Service Center team pulls a list of discharged patients belonging to the BBH primary care physicians from all five BBH hospitals, and then calls all Medicare and Medicare Advantage patients within two business days of discharge. After asking a series of medical questions, the service team member schedules an appointment with the patient's primary care physician. The service center later checks to make sure the patient showed up for the appointment.

One of the requirements to bill the TCM codes is that an interactive contact must be made with the beneficiary and/or caregiver, as appropriate, within two business days following the beneficiary's discharge to the community setting. The contact may be via telephone, email, or face-to-face. This interactive contact must address the patient's status and their needs. So the medical questions go beyond a simple how-are-you-feeling approach.

"We have a different series of questions depending on the reason they were admitted to the hospital," said Summer Rahman, clinical office manager for Hoover BBH Service Center. "For congestive heart failure, we'll ask about worsening symptoms, but we will also ask if they have gained weight, because we are looking for fluid retention. We ask about chest pain and whether they are compliant with medications. We even have them get their medicine bottles and go over what the hospital might have taken them off of or added upon discharge. It can be very confusing to a Medicare patient who has been sick."

The goal is to catch those patients who are at risk of returning to the hospital. Sometimes they may be experiencing symptoms that need to be checked by their PCP sooner than the hospital suggested or they may be at risk of being readmitted because they were unable to afford their medications or did not understand their discharge instructions.

On several occasions, Rahman has ascertained during the phone call that the patient needed to go back to the hospital. "It's like a telephone triage," she said. "Just like when we see a patient in person, we can hear if they are short of breath or disoriented and confused, and we can respond."

Those kinds of calls are not the norm, however. Most are straightforward follow-up calls. In addition to assessing the status of the patient, the service team member will review any discharge instructions and answer questions. Before hanging up, they make an appointment with the primary care physician. Later they check to see how the follow-up appointment went and make sure the doctor has billed appropriately.

"We started doing this as a pilot project over a year ago," Rahman said. "Baptist Health had received a Practice Transformation Network grant prior to the joint venture with Brookwood. While the medical community has known that follow-up appointments play an important role in quality of care, the grant helped BBH implement a more effective plan."

"Timely notification of primary care physicians when a patient has been discharged from the hospital has always been a challenge," said Theresa Keller, Administrator for the Practice Transformation Network team. "In order to improve patient outcomes and decrease unnecessary readmissions, we had to not only notify the physicians of the discharges timely, but also ensure the patients had access to their primary care provider within seven to 14 days, and that they kept their appointments. Our Practice Transformation Network team worked with several departments including admitting, case management, nursing staff and hospitalists to determine the best process to improve coordination of care.

"The team developed this program, and now we are rolling it out system-wide to over 200 BBH primary care physicians."

If patients are discharged to a rehab or skilled nursing facility, the center contacts the physician's office with that information. When the facility notifies the center that a patient has been released from rehab, the center provides the same follow-up service.

The program is successful from a patient standpoint, with high compliance for follow-up appointments and a reduced readmission rate, but it benefits doctors as well. They can now get reimbursed for the care management services they were already performing as well as improve their patient outcomes and MIPS score.


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Summer Rahman; Brookwood Baptist Health; Hoover BBH; John Gardener; Practice Tra


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