Recognize Post-discharge TCM Services and Varying Requirements
Reporting post-discharge transitional care management services correctly depends on conflicting guidance.
By Maryann C. Palmeter, CPC, CENTC and Cynthia Stewart, CPC, CPC-H, CPMA, CPC-I, CCS-P
CPT® 2013 introduced two new codes to describe post-discharge transitional care management (TCM) services. The Centers for Medicare & Medicaid Services (CMS) recognizes these codes, but reporting requirements differ from the American Medical Association’s (AMA). We’ll clarify the requirements for billing Medicare for TCM services and explain the differences between CPT® and CMS guidelines.
Identify Qualifying Patients
TCM services are for patients whose medical and/or psychosocial problems require moderate or high complexity medical decision-making (MDM) during transitions in care from an inpatient hospital setting to the community setting. As such, not every patient will require post-discharge TCM services.
CPT® codes 99495 and 99496 represent the oversight, management, and/or coordination of services for all medical conditions, psychosocial needs, and activities of daily living support by providing first contact with the patient and conti-nuous access by the provider for 30 days post-discharge. TCM is comprised of one face-to-face visit within the specified time frames and non-face-to-face services that may be performed by a physician, a non-physician practitioner (NPP), or licensed clinical staff under the direction of the physician or NPP.
99495 Transitional Care Management Services with the following required elements:
- Communication (direct contact, telephone, electronic) with the patient and/or caregiver within two business days* of discharge
- Medical decision making of at least moderate complexity during the service period
- Face-to-face visit, within 14 calendar days of discharge
99496 Transitional Care Management Services with the following required elements:
- Communication (direct contact, telephone, electronic) with the patient and/or caregiver within two business days* of discharge
- Medical decision making of high complexity during the service period
- Face-to-face visit, within 7 calendar days of discharge
*Business days are defined as Monday through Friday, except holidays, without respect to normal practice hours or date of discharge notification.
For these codes, transitions in care include discharges from an inpatient hospital setting (including acute hospital, reha-bilitation hospital, long-term acute care hospital), partial hospitalization (including community mental health center), and hospital observation status. Also included are transitions from a skilled nursing facility (SNF) or nursing facility to the patient’s community setting (home, domiciliary, rest home, or assisted living community). Transitions from an inpatient hospital setting to a SNF are not included.
Report Once per 30 Days, Maximum
TCM services are payable only once in the 30 day post-discharge period. Both CPT® and CMS require TCM services to be billed by only one individual during the 30-day period after discharge to ensure coordinated post-discharge care.
The individual billing for TCM services may also report hospital or observation discharge services; however, CMS differs from CPT® in stipulating that the face-to-face evaluation and management (E/M) visit required for the TCM code cannot be furnished by the same physician or NPP on the same day as the discharge management service. CPT® allows the same individual to report TCM services and hospital or observation discharge services, when rendered on the same day.
Medicare stipulates that billing for TCM services should occur after the conclusion of the service (i.e., 30 days post-discharge or thereafter), even if the plan of care is established prior to the end of the 30-day post-discharge period. CPT® states, “Only one individual may report these services and only once per patient within [emphasis added] 30 days of discharge.” The AMA’s definition is a bit more liberal in that it does not stipulate that billing is restricted until the end of the 30-day period. A recently published CMS FAQ clarified that the reported date of service should be the 30th day, not the date of the initial face-to-face visit.
Document Time, Face-to-face, MDM, and Medical Necessity
Documentation for TCM must include the timing of the initial post-discharge communication with the patient or caregivers, date of the face-to-face visit, and the complexity of MDM. The documentation also should support that medication reconciliation was performed. Lastly, be sure the documentation supports the relevant non-face-to-face services performed over the post-discharge period.
Even if Not Mandatory, Try Patient Communication
Both CPT® and CMS allow billing for TCM services if two or more separate attempts are made to contact the patient or caregiver in a timely manner, but are unsuccessful, as long as the other TCM criteria are met. CMS expects initial com-munication attempts post discharge to continue until they are successful. From a best practice perspective, attempts to contact the patient or caregiver should be documented.
Medication Reconciliation and Management is Required
Medication reconciliation and management is also a required component of TCM services. Medication reconciliation is the process of comparing a patient’s medication orders to all of the medication the patient has been taking. This is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions.
CPT® and CMS agree that medication reconciliation and management must occur no later than the date of the face-to-face visit.
Note Non-face-to-face Services
Table A lists non-face-to-face activities that may be performed as part of a TCM service. CMS expects the services in these two lists will be routinely provided as part of a TCM service unless the practitioner’s reasonable assessment of the patient indicates that a particular service is not medically indicated or needed.
CPT® does not stipulate this additional requirement; although, it’s expected that some of the non-face-to-face services would be provided as they are inherent in the definition of TCM services. Note which of these services may be performed only by a physician or NPP, and which may be performed by clinical staff under supervision of a physician or NPP.
Determine MDM Level
MDM expended over the entire service period is used to define the medical decision-making level of the TCM service. The CMS 1995 and 1997 Documentation Guidelines for Evaluation and Management Services define the levels of MDM based on the following factors:
- The number of possible diagnoses and/or the number of management options that must be considered
- The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed
- The risk of significant complications, morbidity, and/or mortality as well as comorbidities associated with the patient’s presenting problem(s), the diagnostic procedure(s), and/or the possible management options
MDM of moderate complexity requires multiple possible diagnoses and/or management options, moderate complexity of the medical data (tests, etc.) to be reviewed, and moderate risk of significant complications, morbidity, and/or mortality, as well as comorbidities.
MDM of high complexity requires an extensive number of possible diagnoses and/or management options, extensive complexity of medical data (tests, etc.) to be reviewed, and a high risk of significant complications, morbidity, and/or mor-tality, as well as comorbidities).
More detail on the MDM component may be found in the CMS Documentation Guidelines for Evaluation and Management (E/M) Services web page.
Know the Limits
Although CPT® does not exclude specific service providers from reporting TCM services, it does qualify who may report these services by defining a qualified healthcare professional and by stressing that TCM services need to fall within the scope of practice of the performing provider.
CMS provides guidelines on practitioners restricted from billing TCM services. Clinical psychologists may not bill TCM services because these services involve medical E/M, which psychologists are not licensed to perform. Regarding other NPPs, CMS believes that physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse midwives may furnish the full range of E/M services and complete medical management of a patient unless otherwise limited by their state’s scope of practice.
Unlike medical doctors or osteopathic physicians, providers such as optometrists, podiatrists, and doctors of dental sur-gery or dental medicine may not bill this service because their limited license does not allow them to provide the com-prehensive level of services required to bill TCM services.
Several services are bundled into a TCM service and may not be reported separately. See Table A on the preceding page for a complete list of these services.
CPT® states that it would be appropriate to report the TCM service in addition to the procedure that carries the global period; however, per CMS guidelines, a physician or NPP billing for a procedure with a 10- or 90-day global period would not be permitted to bill TCM services in addition to that procedure.
Both CPT® and CMS agree that the face-to-face visit required for TCM services may not be reported in addition to the TCM codes, but additional E/M services after the first face-to-face visit may be reported separately.
Identify the Community Physician or NPP
The terms “community physician” and “practitioner,” as used within the context of TCM, refer to the community-based physician or NPP who is managing and coordinating a patient’s care in the post-discharge period.
Any physician or NPP who is enrolled in Medicare and furnishes a TCM service may bill for the service. CMS expects most community physicians and practitioners who are furnishing TCM services will be primary care physicians and NPPs. There may be occasions, however, when cardiologists, oncologists, or other specialists will be in the best position to furnish transitional care coordination after a hospital discharge.
TCM services require management and coordination of all relevant aspects of a patient’s health status in the post-discharge period. Physicians or qualified NPPs should not undertake TCM services unless they are capable and willing to assume comprehensive responsibility for a patient’s care during the period of the service.
Use this case scenario as an example:
Mr. Matthews is a 72-year-old male recently admitted for hypertensive heart disease. He also has type II diabetes mellitus and is insulin dependent. He is discharged in stable condition after a four-day hospital stay, during which two new medications were started, and two were discontinued. He is instructed to follow up with his primary care doctor, cardiol-ogist, and endocrinologist. A copy of the discharge summary is faxed to all three physicians.
Three physicians were notified of the patient’s hospitalization. Who has the authority to decide which physician can bill for TCM services?
Any of the three physicians may bill for the TCM services, but physicians or qualified NPPs should not undertake TCM services unless they are capable and willing to assume comprehensive responsibility for a patient’s care during the period of transition. The discharging provider should identify a single community physician for follow up whenever possible.
For Payment, Timing Matters
CMS acknowledges concerns about a potential “race to bill” scenario among practitioners. In essence, the first TCM claim in the door will be paid. CMS also acknowledges concerns that provider offices cannot track whether they are the first to submit a claim, but believes the circumstances under which more than one provider might be able to bill the TCM codes is limited.
CMS has used a “first claim” policy in other areas, such as a radiology interpretation and the annual wellness visit. Multi-specialty organizations may find it beneficial to establish and distribute a policy to all providers who assist discharging physicians in selecting the appropriate TCM provider, as well as educating the primary care providers to prevent multiple billings for TCM services. Organizations with centralized billing services should also be made aware of such a policy.
CMS expects discharging physicians to discuss post-discharge services with the patient and to inform the patient that Medicare pays for TCM services. As part of this disclosure to patients, CMS also expects the discharging provider to ask the patient to identify the physician or NPP whom the patient wishes to furnish the TCM services.
If the patient does not have a preference, the discharging provider may suggest a specific provider who is in the best position to furnish the TCM services. Recording this information could also help in the transitional care coordination ac-tivities, and provides discharging providers an opportunity to route patients to providers within a preferred network. The community physician or NPP may have limited impact on the discharging provider’s compliance with these expectations. For this reason, it’s important to discuss with patients this new benefit. Patient educational efforts may lead to more specific discharging practitioner documentation.
Impact on the Primary Care Incentive Payment (PCIP)
The new TCM service codes do not qualify for the Medicare Primary Care Incentive Program (PCIP). To avoid disad-vantaging providers who furnish post-discharge TCM services to their patients, CMS will exclude the allowed charges for TCM services from the denominator when calculating a physician’s or NPP’s percent of allowed charges that were primary care services for PCIP purposes.
A Brief History of the New TCM Codes
The Comprehensive Primary Care initiative—a cooperation between governmental and commercial healthcare payers created to strengthen primary care—seeks to refine the physician fee schedule to allow for the appropriate value of primary care and coordination within Medicare’s statutory fee-for-service and quality reporting structure.
CMS sought public comment on how to further improve care when a patient transitions from the hospital to the community setting. The physician community response was that office or other outpatient E/M services do not adequately represent the services, work, or payment for the comprehensive care coordination services necessary to meet the quality care and reporting initiatives.
The American Medical Association (AMA) and the American Academy of Family Physicians (AAFP) created workgroups to consider new options for coding and payment for primary care services. The AAFP Task Force recommended CMS create new primary care E/M codes and pay separately for non-face-to-face E/M CPT® codes. As a result, the AMA’s Chronic Care Coordination Workgroup (C3W) completed development of two new transitional care management codes: 99495 and 99496.
CMS considered creating two new HCPCS Level II codes because their proposed requirements were different than the AMA’s. In the end, CMS decided to stay with the codes developed by the AMA, but some reporting requirements differ between CPT® and CMS.
Maryann C. Palmeter, CPC, CENTC, has over 29 years of experience in the healthcare industry, with emphasis on federal and state government payer billing and compliance regulations. She has experience working on both the billing and government contractor ends of the healthcare industry spectrum. Ms. Palmeter is employed with the University of Florida Jacksonville Healthcare, Inc. as the director of physician billing compliance, where she provides professional direction and oversight to the billing compliance program of the University of Florida College of Medicine – Jacksonville. She is a member of the National Advisory Board and was named AAPC’s 2010 “Member of the Year.”
Cynthia Stewart, CPC, CPC-H, CPMA, CPC-I, CCS-P, former president of the 2010-2012 National Advisory Board of AAPC, has over 25 years experience in the medical profession. Ms. Stewart is a revenue cycle systems manager of coding and charge entry with St. Vincent Health, Indianapolis.