TCM: New 2013 Codes, Significant 2014 Changes

Secure payment for transitional care management by documenting all of the required elements.

By Wendy Grant, CPC

The purpose of transitional care management (TCM) services is to improve care coordination between inpatient and primary care settings, with the ultimate goal of reducing hospital readmissions. Last year, two CPT® codes were created to facilitate reporting of TCM services:

99495  Transitional Care Management Services with the following required elements:

  • Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 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 2 business days of discharge
  • Medical decision making of high complexity during the service period
  • Face-to-face visit, within 7 calendar days of discharge

Codes 99495 and 99496 describe care transition and care coordination activities for patients who are discharged from an inpatient hospital setting, acute hospital, rehab hospital, observation setting, or skilled nursing facility (SNF) to home, a domiciliary, a rest home, or an assisted living center. The 30-day TCM period begins on the patient’s discharge day from the hospital setting and continues for the next 29 days.

Note: TCM services are not appropriate when a patient is discharged from the hospital setting and transferred to an SNF.

Know the Requirements

In 2013, the Centers for Medicare & Medicaid Services (CMS) allowed payment for 99495 and 99496 furnished to established Medicare patients only. Beginning in 2014, providers may report TCM services furnished to new and established patients. Payment will hinge on how well providers fulfill and document the requirements outlined in these codes.

To report 99495, you must show:

  • Communication with the patient and/or caregiver occurred within two business days of discharge. This communication must be through direct contact, telephone, and/or email;
  • Medical decision-making (MDM) of at least moderate complexity during the 30-day service period; and
  • A face-to-face visit within 14 days of discharge, in addition to the routinely provided non-face-to-face services.

To report 99496, you must show:

  • Communication with the patient and/or caregiver occurred within two business days of discharge. This communication must be through direct contact, telephone, and/or email;
  • MDM of at least high complexity during the 30-day service period; and
  • Face-to-face visit within seven days of discharge, in addition to the routinely provided non-face-to-face services.

The patient communication within two business days of discharge must be interactive. For instance, the communication can’t be a voicemail or email without a response from a patient. You may not bill for TCM if successful interactive communication within the 30-day period isn’t documented.

The face-to-face visit must be furnished and documented within the time frame CPT® specifies. For 99495, a face-to-face visit must occur within 14 days of discharge; for 99496, the face-to-face visit must occur within seven days of discharge. This face-to-face visit is part of the TCM and may not be reported separately. Other subsequent visits provided within the 30-day TCM period are billable.

Non-face-to-face services are provided in combination with the face-to-face service. CMS considers these services to be an essential component of billing TCM codes. The non-face-to-face services distinguish TCM from services that are predominately or exclusively face-to-face in nature.

Who May Bill?

The physician or mid-level provider, or a licensed clinical staff under the physician’s direction, may provide TCM services (see “TCM at a Glance”).

Typical non-face-to-face services that may be performed by clinical staff:

  • Communicating (direct, phone, or email) with patient and/or caregiver within two days of discharge
  • Communicating with home health agencies or other community services utilized by the patient
  • Educating the patient and/or family caretaker to support self-management, independent living, and activities of daily living
  • Assessing and supporting for treatment regimen adherence and medication management (must occur no later than the face-to-face visit)
  • Identifying community and health resources
  • Facilitating access to care and services needed by the patient and/or caregiver

Typical non-face-to-face services that may be performed by physician or midlevel:

  • Obtaining and reviewing the discharge summary, as available, or continuity of care documents
  • Reviewing the need for, or follow up on pending, diagnostic tests and treatments
  • Interacting with other healthcare professionals who will assume or resume care of the patient’s system-specific problems
  • Providing education to the patient, family, guardian, and/or caregiver
  • Establishing or re-establishing referrals and arranging for necessary community resources
  • Assisting in scheduling of required follow up for necessary community resources

MDM must meet the elements of either moderate or high complexity. Patients without the minimum complexity do not qualify for this service.

Have an Action Plan

If your office provides TCM services, make a plan to capture and code the services. Discuss the plan with your providers and get their buy-in by stressing that proper documentation can aid reimbursement and patient care.

For example:

  • Verify on a daily basis all discharged patients and determine which ones would be candidates for TCM. Contact those patients within two business days, and schedule face-to-face visits with them within either seven or 14 days from discharge.
  • Make a template to guide you in covering all of the required elements for documentation and billing (see the Transitional Care Management 30-Day Worksheet at www.aafp.org/dam/AAFP/documents/practice_management/payment/TCM30day.pdf). Fields to include: date of discharge, date to bill (29 days from discharger), date of communication (within two days of discharge), date of the face-to-face visit, and any of the care coordination performed.
  • Bill the TCM service within the date of service of the 30th day. Remember to report the place of service where the face-to-face visit occurred.

Relate this guidance to the physicians and clinical staff in your practice to ensure appropriate reporting and reimbursement for the TCM services they provide.

 

TCM at a Glance

Who may furnish transfer care management (TCM) services?

  • Physicians (any specialty)
  • Non-physician practitioners who are legally authorized and qualified to provide the services in the state where services are furnished
  • Certified nurse midwives
  • Clinical nurse specialists
  • Nurse practitioners
  • Physician assistants

Who may receive TCM services?

  • Medicare patients who meet requirements

How do you bill for TCM services?

  • Only one healthcare professional may report TCM services per patient (no split-billing).
  • Only one TCM service may be billed, per patient, during the TCM period.
  • The same healthcare professional may discharge the patient from the hospital, report hospital observation discharge services, and also bill the TCM services. Remember that the required face-to-face visit may not take place on the same day the discharge day management is billed.
  • Use the billing date of service as the 30th day from the date of the patient’s facility discharge.
  • If the patient gets re-admitted to the hospital during this 30-day period, only one TCM can be billed. The date of the second discharge should be used as the starting date for the TCM period.
  • Document the initial post-discharge communication, the date of the face-to-face visit, and the non-face-to-face services provided, as well as the MDM (such as number of diagnoses managed, the amount of data reviewed, and the risk involved over this 30-day period).
  • The patient is responsible for 20 percent of the Medicare allowable if he or she does not have a Medicare supplement policy to pick up the cost share.

Note: Do not bill care plan oversight codes (G0181, G0182) or end-stage renal disease codes (90951-90970) during a TCM period for which you billed.

Wendy Grant, CPC, has more than 30 years of experience in coding and reimbursement. She is the western division accounts receivable manager for Health Management Associates, where she provides analysis of coding trends and denials. Grant is president-elect of the Little Rock, Ark., local chapter.

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John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

About Has 404 Posts

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.

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