Wiki Transitional Care Documentation

[kls1027]

When charging for Transitional Care Management, does all the information need to be included in the dos note for the TCM? or does the EMR with the call date and the follow-up visit notes suffice? What actual details need to be in the TCM dos note?
The guidelines say we must have all of the information but does not say if it can be part of the EMR or if it must be all detailed on the date of the TCM charge.
Thanks for any insight!
Karen

 

[mreach]

My understanding of this service is that certain things have to happen within the 30 day time frame. The initial contact has to be within a certain time frame and the only way that can happen is if the call is documented with the date is was completed. The visit would of course be documented on the date it was performed and any other events that happen should be documented the date it occurs. What Medicare will be looking for if they audit is all services that occured wihtin that thirty day period.

 

[Pam Warren]

What we've done is to provide our nurse care managers with a TCM flow sheet, on which they can document their call and associated work, and then this form is scanned against the Electronic health record that documents the face to face visit. That way, everything is all in one space.