ED Coding and Reimbursement Alert

Just Because It Doesn't Say You Can't, Doesn't Mean that You Should

CMS, like CPT®, did not explicitly prohibit emergency physician use of transition of care codes. However, it seems unlikely that emergency physicians will meet the requirements to report these codes. (Editor's note: See the ED Coding & Reimbursement Alert, November issue (Vol. 15, No. 11) for a complete explanation of the new code sets.)

The skinny: The new codes capture the non-face-to-face time physicians, non-physician practitioners and other clinical staff spends in the 30 days following a patient's release from a hospital or skilled nursing facility (SNF). Originally labeled a G-code in the proposed fee schedule, TCM services are now CPT® codes 99495-99496.

In the final rule CMS states, "In conjunction with adopting the AMA CPT® TCM, we accept the recommendation to allow reporting of emergency department visits by [qualified primary care physicians] when also billing the CPT® TCM codes." CMS anticipates these new codes will be paid for through 1percent reductions in Medicare payment to specialties.

Jury's still out: It remains to be seen whether the difference in payment between the currently reported codes for coordinating post-discharge care, about $17 to $30, will provide enough incentive for providers to meet the CPT® requirements for reporting the TCM code because the new code doesn't allow separate payment for the face-to-face visit, says Granovsky.

Note What CMS Does Say About TCM And CCCC Code Requirements.

CMS says in the final rule that it believes it is not necessary to develop any further restrictions or complex operational mechanisms to identify one and only one physician or non-physician practitioner who may bill the TCM codes for a specific beneficiary. It will rely on the "first claim" policy it uses in other areas, such as a radiology interpretation and the Annual Wellness Visit.

However, CMS does say that it expects the discharging physician to support TCM services by discussing post-discharge services with the beneficiary and to identify a community physician for follow-up whenever possible.

Specifically, CMS mentions it expects discharging physicians and other physicians seeing beneficiaries in a facility to inform the beneficiaries that they should receive TCM services from their doctor or other practitioner after their discharge and that Medicare will pay for those services.

As a part of this disclosure to patients, there is an expectation that the discharging physician would ask the beneficiary to identify the physician or non-physician practitioner whom he or she wishes to furnish these transitional care management services.

Barriers: This language, along with the requirement for the follow up face to face visit, appears to disqualify the emergency physician from reporting TCM services, says Granovsky. Although at the approved RVUs, the compensation would not make the service cost effective in the ED setting. Check out the following table from the 2013 final rule on how CMS plans to value these codes, he adds.

Look for Silver Lining in Budget Neutrality Adjustments for TCM and CCCC

You need to look at the big picture for the real reimbursement impact of these new codes. For budget neutrality calculations, CMS estimated that physicians or qualified non-physician practitioners would furnish post-discharge TCM services for 10 million discharges in CY 2013. It agreed with the RUC's estimates that 26 percent of patients had at least one visit within seven calendar days of discharge and 44 percent had a visit within 14 days of discharge.

Because these are existing visits that will potentially now be billed as part of the TCM service, CMS plans to partially offset the cost of the TCM services with the cost of the existing visits assumed to be billed as part of the CPT® TCM code language.

New twist: In a surprise move, CMS is bundling the Complex Chronic Coordination of Care codes as "incident to" other services. This removes the need for a significant budget neutrality adjustment related to the payments for those services.

Remember that any new code that is not used by emergency physicians erodes the available pool of funds to apply to the codes we do use because of the required budget neutrality adjustment, says Granovsky.