Pediatric Coding Alert

Hint: Fully understand TCM’s core elements before implementation.

When a pediatric patient is finally discharged from an inpatient hospital setting, it doesn’t mean care for that patient has ended. In fact, for many patients in this situation, it means the care needs to continue, though it now has to take a different course.

That’s where transitional care management (TCM) comes in. But a brief glance at the CPT^® guidelines for 99495 and 99496 (Transitional care management services …) will tell you that the codes aren’t that easy to implement.

However, if you understand the core elements of the code, and pay attention to your documentation, you’ll be in great shape to use these evaluation and management (E/M) codes to document ongoing care for the sickest of your patients.

Understand the Core Code Elements 1: Making Contact

A good place to start is to closely read the descriptors for both codes, as they will provide you information about two of TCM’s key elements: timeframes and care levels. The descriptors stipulate that the services must include:

• “Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge”;
• “Medical decision making [MDM] of at least moderate complexity” (99495) or “high complexity” (99496) “during the service period”;
• “Face-to-face visit, within 14 calendar days of discharge” (99495) or “7 calendar days of discharge” (99496).

This means, “at a minimum, you will need to document the date of the beneficiary’s discharge; the date your provider, a qualified healthcare professional [QHP], or a member of your clinical staff initiated interactive contact with that beneficiary or the beneficiary’s caretaker; and the date your provider, a QHP, or member of your clinical staff furnished a face-to-face visit,” says Sherika Charles, CDIP, CCS, CPC, CPMA, compliance analyst with UT Southwestern Medical Center in Dallas.

Coding alert: While both codes stipulate that the initial patient contact must be made within two business days, the higher level of MDM required for 99496 means that the face-to-face visit has to occur within seven calendar days, while 99495 can occur up to 14 calendar days after discharge.

“This first face-to-face visit within the TCM period is included in the TCM codes and cannot be reported separately, but additional face-to-face visits within the TCM period are separately reportable,” notes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

Additionally, for 99496, if the face-to-face visit takes place more than seven calendar days after discharge (i.e., if it takes place between day eight and day 14), you will have to code 99495 instead.

And, if all else fails, and you cannot make contact with the patient after two attempts “made in a timely manner,” you can still bill for TCM providing all the “other transitional care management criteria are met,” according to CPT^®.

Understand the Core Code Elements 2: Evaluating MDM

For MDM, it is important to note that “Patients must meet at least a moderate level complexity MDM to use the codes. Patients with straightforward or low-level complexity MDM do not qualify,” notes Moore. To determine MDM levels, you will follow the formula as described in the CPT^® Evaluation and Management (E/M) services guidelines, meeting or exceeding two of the following three elements per the table in the CPT^® manual.”

• “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.”

Understand What Else to Document

Along with time and the level of MDM complexity, per CPT^® guidelines for 99495 and 99496, you will need to document instances of your pediatrician or QHP:

• “Obtaining and reviewing the discharge information (eg, discharge summary, as available, or continuity of care documents);
• “reviewing need for or follow-up on pending diagnostic tests and treatments;
• “interaction with other qualified health care profes­sionals who will assume or reassume care of the patient’s system-specific problems;
• “education of patient, family, guardian, and/or caregiver;
• “establishment or reestablishment of referrals and arranging for needed community resources;
• “assistance in scheduling any required follow-up with community providers and services.”

Further, you will also need to make sure that other services your pediatrician, or clinical staff under the pediatrician’s supervision, may provide are also documented. These may include any:

• “communication … regarding aspects of care;
• “communication with home health agencies and other community services utilized by the patient;
• “… education to support self-management, independent living, and activities of daily living;
• “assessment and support for treatment regimen adherence and medication management;
• “identification of available community and health resources;
• “facilitating access to care and services needed by the patient and/or family.”

And don’t forget: You can only claim for TCM when a patient is “transitioning from a hospital setting other than the emergency department [ED] or from a skilled nursing facility [SNF]/nursing facility setting to a community setting, such as their home or assisted living. Patients going from one facility setting to another - from a hospital to a SNF, for example - are not transitioning for purposes of TCM,” says Moore.