Wiki 99496 Transitional Care Management

[june616]

Hello,

I'm hoping someone can help clear this up for me

We have received a couple denials stating that this service cannot be billed until 30 days after hospital discharge. According to CPT guidelines, this code can be used for a face to face visit within 7 days of discharge. We are following the CPT guidelines and getting the denial reason above. I'm very confused. Any help?

Thank you!

 

[mhstrauss]

Hello,

I'm hoping someone can help clear this up for me

We have received a couple denials stating that this service cannot be billed until 30 days after hospital discharge. According to CPT guidelines, this code can be used for a face to face visit within 7 days of discharge. We are following the CPT guidelines and getting the denial reason above. I'm very confused. Any help?

Thank you!

The denial is correct. Although one of the requirements of TCM is that a face-to-face visit must be performed within x calendar days after discharge, the codes encorporate all work performed by the physician and his ancillary staff during the 30 days after discharge. So the code cannot be billed until all 30 days' worth of work is completed.

Here's an FAQ sheet from CMS with lots of other good info:

http://www.cms.gov/Medicare/Medicar...ment/PhysicianFeeSched/Downloads/FAQ-tcms.pdf

 

[ajgibson]

Correct

The DOS needs to be the 30th day from the patients discharge. Count the date of discharge as "1".
These codes are for the management of this patients care for 30 days, so you can not bill it out until the 30 days have passed.

 

[june616]

Thank you! I will pass this information on to my office...

 

[susie09]

TOC charge

hope somebody can clarify a question on readmission, if the patient was seen for TOC and then readmitted within 30 days of the first discharge, do we need to use a regular E&M code for the first TOC visit and then bill the 2nd discharge with a TOC charge?

 

[Peter Davidyock]

hope somebody can clarify a question on readmission, if the patient was seen for TOC and then readmitted within 30 days of the first discharge, do we need to use a regular E&M code for the first TOC visit and then bill the 2nd discharge with a TOC charge?

That is at the discretion of your office Susie. You could bill it either way, you just cannot bill two TOC's in the 30 day period. The physicians I know that use TOC always bill it for the first dc. It's a cash flow issue for most of them.