"Tcm Documentation and Flow Sheet Template"

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TCM Documentation and Flow Sheet
TCM Requirements for
Post-Discharge Contact Deadlines:
2 days post discharge date ____/____/______
Note: To ensure all required documentation to support TCM services is completed, and so
7 days post discharge date ____/____/______
that none of these 4 pages get lost, reproduce this form on the front and back of 11x17
14 days post discharge date ____/____/______
paper and fold it in half to 8 1/2 x 11 booklet size.
Patient Name: ____________________________________________________________________________________
Patient DOB: ____/_____/_______ Discharge Date/Day:____/_____/_______
 M  Tu  W  Th  F  Sa  Su
Patient’s Physician: __________________________________________________________________________________
Reason for Admission: _______________________________________________________________________________
 Patient  Caregiver Name:______________________________ Relationship: __________________
Contact Information:
Preferred method of contact:  phone  cell  text  e-mail
Phone:
Home: (_______)______________________
Cell:
(_______)______________________
Work:
(_______)______________________
E-mail address (if applicable): _____________________________________________________________
Is Home Health Involved?
No
 Yes — if yes, please include home health contact information:
Contact person: ___________________________________ Company name:_________________________________________
Phone: (_______)_________________________________
Fax: (_______)__________________________________________
E-mail (if applicable): _______________________________________________________________________________________
Discharge Information:
Diagnosis(es) at discharge: _____________________________________________________________________________
Discharging physician
: ___________________________________________________________________
(name and phone #)
Discharge Information Obtained:
Discharge summary:
Date rec’d: _____/______/________
Copies of discharge instructions:
Date rec’d: _____/______/________
Most recent diagnostic test results:
Test name: _________________________________ Date rec’d: _____/______/________
Test name: _________________________________ Date rec’d: _____/______/________
Test name: _________________________________ Date rec’d: _____/______/________
Patient Current Location:
 Home  Family member home  Non-family member home  Assisted living facility  Rest home
 Other: _____________________________________________________________________________________________
Initial Communication
First 2 attempts must be within 2 business days of discharge (see discharge date at top of page).
Post-Discharge:
Continue attempting to reach the patient, even if the attempts during the first 2 days are unsuccessful.
1st attempt:
Date: ___/___/____ Time: ____:_____
Method:
 call  fax  e-mail  mail
Initial: _________
□ am □ pm
 call  fax  e-mail  mail
2nd attempt:
Date: ___/___/____ Time: ____:_____
Method:
Initial: _________
□ am □ pm
Add'l attempts: Date: ___/___/____ Time: ____:_____
Method:
 call  fax  e-mail  mail
Initial: _________
□ am □ pm
Date: ___/___/____ Time: ____:_____
Method:
 call  fax  e-mail  mail
Initial: _________
□ am □ pm
Date: ___/___/____ Time: ____:_____
Method:
 call  fax  e-mail  mail
Initial: _________
□ am □ pm
Date: ___/___/____ Time: ____:_____
Method:
 call  fax  e-mail  mail
Initial: _________
□ am □ pm
** Once you reach patient or caregiver go to page 2.
Compliments of Family Practice Coding Advisor, published by Coding Leader. Authorization to reprint by Coding Leader for individual use only.
phone: 800-767-1181; fax: 800-767-9706; e-mail: info@codingleader.com; web: www.codingleader.com.
Reprints must include this footer
Page 1 of 4
TCM Documentation and Flow Sheet
TCM Requirements for
Post-Discharge Contact Deadlines:
2 days post discharge date ____/____/______
Note: To ensure all required documentation to support TCM services is completed, and so
7 days post discharge date ____/____/______
that none of these 4 pages get lost, reproduce this form on the front and back of 11x17
14 days post discharge date ____/____/______
paper and fold it in half to 8 1/2 x 11 booklet size.
Patient Name: ____________________________________________________________________________________
Patient DOB: ____/_____/_______ Discharge Date/Day:____/_____/_______
 M  Tu  W  Th  F  Sa  Su
Patient’s Physician: __________________________________________________________________________________
Reason for Admission: _______________________________________________________________________________
 Patient  Caregiver Name:______________________________ Relationship: __________________
Contact Information:
Preferred method of contact:  phone  cell  text  e-mail
Phone:
Home: (_______)______________________
Cell:
(_______)______________________
Work:
(_______)______________________
E-mail address (if applicable): _____________________________________________________________
Is Home Health Involved?
No
 Yes — if yes, please include home health contact information:
Contact person: ___________________________________ Company name:_________________________________________
Phone: (_______)_________________________________
Fax: (_______)__________________________________________
E-mail (if applicable): _______________________________________________________________________________________
Discharge Information:
Diagnosis(es) at discharge: _____________________________________________________________________________
Discharging physician
: ___________________________________________________________________
(name and phone #)
Discharge Information Obtained:
Discharge summary:
Date rec’d: _____/______/________
Copies of discharge instructions:
Date rec’d: _____/______/________
Most recent diagnostic test results:
Test name: _________________________________ Date rec’d: _____/______/________
Test name: _________________________________ Date rec’d: _____/______/________
Test name: _________________________________ Date rec’d: _____/______/________
Patient Current Location:
 Home  Family member home  Non-family member home  Assisted living facility  Rest home
 Other: _____________________________________________________________________________________________
Initial Communication
First 2 attempts must be within 2 business days of discharge (see discharge date at top of page).
Post-Discharge:
Continue attempting to reach the patient, even if the attempts during the first 2 days are unsuccessful.
1st attempt:
Date: ___/___/____ Time: ____:_____
Method:
 call  fax  e-mail  mail
Initial: _________
□ am □ pm
 call  fax  e-mail  mail
2nd attempt:
Date: ___/___/____ Time: ____:_____
Method:
Initial: _________
□ am □ pm
Add'l attempts: Date: ___/___/____ Time: ____:_____
Method:
 call  fax  e-mail  mail
Initial: _________
□ am □ pm
Date: ___/___/____ Time: ____:_____
Method:
 call  fax  e-mail  mail
Initial: _________
□ am □ pm
Date: ___/___/____ Time: ____:_____
Method:
 call  fax  e-mail  mail
Initial: _________
□ am □ pm
Date: ___/___/____ Time: ____:_____
Method:
 call  fax  e-mail  mail
Initial: _________
□ am □ pm
** Once you reach patient or caregiver go to page 2.
Compliments of Family Practice Coding Advisor, published by Coding Leader. Authorization to reprint by Coding Leader for individual use only.
phone: 800-767-1181; fax: 800-767-9706; e-mail: info@codingleader.com; web: www.codingleader.com.
Reprints must include this footer
TCM Documentation and Flow Sheet
Page 2 of 4
Patient Name: ___________________________________________ DOB: ____/____/______ Discharge Date: ____/____/______
Initial Communication Post-Discharge section continued ...
Disposition: _________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
__________________________________________________________________________ initial: _________ date: ____________
Summary of nursing/licensed clinical staff member's discussion with patient/caregiver
during initial post-discharge communication:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
___________________________________________________________________________ initial: _________ date: ____________
First Face-to-Face
First face-to-face follow-up visit must be no longer than 14-days post-discharge to qualify for TCM.
Follow-up Visit:
Review progress notes in patient's record for information:
First face-to-face visit occurred on:
Date: ____/____/______
Time: ______:_______
□ am □ pm
 Office
 Home  Rest Home  Other_____________________________
Location of visit:
Number of calendar* days since discharge:  7 or fewer  8-14  15 or more
 No
 Yes (If yes, date: ____/____/______)
Medication reconciliation performed?
 High
 Moderate
 Low/Straightforward
Level of medical decision-making :
Face-to-face visit performed by
________________________________________________________
(
):
provider name and credentials
Progress notes signed by the treating provider for the above date of service?  Yes  No
* Calendar days include weekends and holidays.
Summary of recommendations: _____________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
________________________________________________________________________ initial: _________ date: _________
Compliments of Family Practice Coding Advisor, published by Coding Leader. Authorization to reprint by Coding Leader for individual use only.
phone: 800-767-1181; fax: 800-767-9706; e-mail: info@codingleader.com; web: www.codingleader.com.
Reprints must include this footer
TCM Documentation and Flow Sheet
Page 3 of 4
Patient Name: ___________________________________________ DOB: ____/____/______ Discharge Date: ____/____/______
Additional Non-Face-to-Face
Additional non-face-to-face services provided within 30 days post-discharge must be
Services:
performed by licensed clinical staff members, or personally performed by physician or
qualified NPP. Initial and date each entry below, including licensure initials.
Examples of Additional
Non-Face-to-Face Services
Patient Non-Face-to-Face
Initial and Date
Review discharge information:
Services Documentation Record:
Each Entry:
- Document provider name, date and
_______________________________________________________
_______________
findings.
_______________________________________________________
_______________
- Pending diagnostic tests and
_______________________________________________________
_______________
treatments: Document if nothing
_______________________________________________________
_______________
pending or list of pending tests and
_______________________________________________________
_______________
treatments, action recommended
for each, dates and results received
_______________________________________________________
_______________
for each.
_______________________________________________________
_______________
_______________________________________________________
_______________
Communication with other providers
_______________________________________________________
_______________
involved in patient’s care:
_______________________________________________________
_______________
- List each provider communicated
_______________________________________________________
_______________
with, date of each communication,
_______________________________________________________
_______________
and findings and results from each
communication. Document if no
_______________________________________________________
_______________
communication required.
_______________________________________________________
_______________
_______________________________________________________
_______________
Education:
(patient, family, guardian,
_______________________________________________________
_______________
and/or caregiver):
_______________________________________________________
_______________
- Date of education, who was
_______________________________________________________
_______________
educated (and if applicable their
relationship with the patient), who
_______________________________________________________
_______________
provided education, topic of
_______________________________________________________
_______________
education, results and follow-up.
_______________________________________________________
_______________
Document if no education required.
_______________________________________________________
_______________
_______________________________________________________
_______________
Community resource
_______________________________________________________
_______________
arrangement(s):
_______________________________________________________
_______________
- Document resources required, who
arranged each resource, date each
_______________________________________________________
_______________
resource arranged, result of each
_______________________________________________________
_______________
resource. Document if none
_______________________________________________________
_______________
needed.
_______________________________________________________
_______________
_______________________________________________________
_______________
Assess and support treatment
_______________________________________________________
_______________
regimen adherence and medication
_______________________________________________________
_______________
management:
_______________________________________________________
_______________
- Document date, topic, result and
name of staff providing support.
_______________________________________________________
_______________
Document if none needed.
_______________________________________________________
_______________
_______________________________________________________
_______________
___________________________________________________________________________________________ _______________
___________________________________________________________________________________________ _______________
___________________________________________________________________________________________ _______________
___________________________________________________________________________________________ _______________
___________________________________________________________________________________________ _______________
___________________________________________________________________________________________ _______________
___________________________________________________________________________________________ _______________
___________________________________________________________________________________________ _______________
___________________________________________________________________________________________ _______________
___________________________________________________________________________________________ _______________
Compliments of Family Practice Coding Advisor, published by Coding Leader. Authorization to reprint by Coding Leader for individual use only.
phone: 800-767-1181; fax: 800-767-9706; e-mail: info@codingleader.com; web: www.codingleader.com.
Reprints must include this footer
TCM Documentation and Flow Sheet
Page 4 of 4
Patient Name: ___________________________________________ DOB: ____/____/______ Discharge Date: ____/____/______
Additional Non-Face-to-Face Services section continued ...
Patient Non-Face-to-Face
Initial and Date
Services Documentation Record:
Each Entry:
___________________________________________________________________________________________ _______________
___________________________________________________________________________________________ _______________
___________________________________________________________________________________________ _______________
___________________________________________________________________________________________ _______________
___________________________________________________________________________________________ _______________
___________________________________________________________________________________________ _______________
___________________________________________________________________________________________ _______________
___________________________________________________________________________________________ _______________
___________________________________________________________________________________________ _______________
___________________________________________________________________________________________ _______________
___________________________________________________________________________________________ _______________
___________________________________________________________________________________________ _______________
___________________________________________________________________________________________ _______________
__________________________________________________________________________________________
_______________
___________________________________________________________________________________________ _______________
___________________________________________________________________________________________ _______________
___________________________________________________________________________________________ _______________
___________________________________________________________________________________________ _______________
___________________________________________________________________________________________ _______________
___________________________________________________________________________________________ _______________
___________________________________________________________________________________________ _______________
___________________________________________________________________________________________ _______________
___________________________________________________________________________________________ _______________
___________________________________________________________________________________________ _______________
___________________________________________________________________________________________ _______________
___________________________________________________________________________________________ _______________
___________________________________________________________________________________________ _______________
___________________________________________________________________________________________ _______________
___________________________________________________________________________________________ _______________
___________________________________________________________________________________________ _______________
___________________________________________________________________________________________ _______________
___________________________________________________________________________________________ _______________
___________________________________________________________________________________________ _______________
___________________________________________________________________________________________ _______________
___________________________________________________________________________________________ _______________
___________________________________________________________________________________________ _______________
Note: The person who signs below and closes this document has NO bearing on whose name the TCM services should be
billed under. CMS states that TCM services should be billed under the physician or NPP who actually provides the mandatory
face-to-face encounter. Ideally, to ensure continuity of care, it would also be the same person, but this is not required.
TCM 30-Day-Period Closure:
Date range included in this document: Start date: ____/____/______ End date: ____/____/______
Document reviewed and closed by:
________________________________________________
____/____/_____
Physician or NPP Signature and Licensure
Date
Compliments of Family Practice Coding Advisor, published by Coding Leader. Authorization to reprint by Coding Leader for individual use only.
phone: 800-767-1181; fax: 800-767-9706; e-mail: info@codingleader.com; web: www.codingleader.com.
Reprints must include this footer
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