General Surgery Coding Alert

Clarify reporting details with CMS FAQs.

When your general surgeon oversees a very ill patient’s transfer from facility to home, you didn’t have a way to claim that service until CPT^® 2013 added two new transitional care management (TCM) codes.

If questions about when and how to use these codes has stopped you from securing the pay your surgeon deserves, now’s the time to get those questions answered, at least for Medicare beneficiaries. CMS’sRyan Howealerted practices to the new information during the agency’s March 12 Open Door Forum, noting several important points about the TCM codes to keep in mind when completing your claims.

Charge-Up Your TCM Code Knowledge

The new TCM codes are as follows:

• 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 decisionmaking 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 decisionmaking of high complexity during the service period, face-to-face visit within  7calendar days of discharge.

The codes are intended to apply when a physician oversees a patient whose health issues necessitate moderate to high complexity medical decision making (MDM) during the shift from a healthcare facility setting back to the patient’s community (home) setting.

“A face-to-face visit is required within a specific time frame after the patient’s discharge, depending on which code you’re reporting,” saidDavid A. Ellington, MD,an AMA CPT^® Editorial Panel member who presented E/M changes at the CPT^® and RBRVS 2013 Annual Symposium (www.ama-assn.org/resources/doc/cpt/04-e-and-m-ellington.pdf). “The initial interactive contact — face-to-face, phone call, or email — should be within two business days of discharge. If you make two attempts to contact the patient or caregiver within that time but are unsuccessful, CPT^® states that you can still report transitional services if the other criteria are met.” Medicare, however, requires that you actually make contact in order to bill TCM.

Example:A surgeon performs repeated debridement for a hospitalized patient who received partial thickness burns to both arms. Upon discharge from the hospital, the surgeon speaks with the patient’s family by phone the day after discharge to review pain medication and schedule for dressing change. Nine days after discharge, the patient comes to the surgeon’s office for an appointment that includes drug management, infection supervision, a physical therapy referral, and a plan for subsequent skin grafting. The surgeon continues to monitor the patient’s progress via phone calls and physical therapy charts for the 30-day TCM period.

You can bill the service as 16030 (Dressings and/or debridement of partial-thickness burns, initial or subsequent; large [e.g., more than 1 extremity, or greater than 10% total body surface area]) for each debridement, and 99495.

Reminder:“Some codes are mutually exclusive with the transitional care management codes, so you’ll have to look at CCI to look at additional services that may be bundled,” saidJim Bavosoof NGS Medicare during a Feb. 7, 2013, “Ask the Contractor” conference call. Also, you can’t billTCM codes with surgical codes if the discharge date is part of a 10 or 90 day global period — a stipulation that will often have an impact on surgical practices billing for TCM.

Factor In These New FAQ Pointers

During the March 12 CMS forum, Howe emphasized the following areas:

• When determining which place of service (POS) code to use on your TCM claim, you should use the location that “required the face-to-face visit.”
• The 30-day TCM period begins on the date of discharge and continues for the next 29 days. Your date of service should be the thirtieth day of care — not the first, Howe said during the CMS call.
• CMS will reject any claims with dates of service prior to Jan. 30, 2013, because the codes became effective on Jan. 1 and only cover 30-day periods.
• You can report TCM codes for both new and established patients, Howe said, which is a departure from CPT^® rules. “CPT^® guidance suggests that the codes are only for established patients, but for Medicare purposes, they can be reported for new patients as well,” he said.
• If 30 days pass between discharge and the initial communication with the TCM practitioner, you cannot report TCM codes, Howe said during the call.
• Medicare will pay only the first TCM claim received per beneficiary in one 30-day period beginning on the date of discharge, so if more than one practitioner reports the code for the same patient, only the doctor whose claim is received first will get paid.
• If the patient dies before the thirtieth day of TCM, you cannot report the TCM codes because they cover a full 30 days. Instead, you’d report the appropriate E/M code.
• For more on the TCM codes, read the FAQs at www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/FAQ-TCMS.pdf.