Wiki TCM denials and changing to a regular E&M

[aimes]

If we bill out a TCM (99496 or 99495) and it is a denied service by the insurance provider, can we rebill it as either a 99215 or 99214 after the denial?
We bill them out as a regular E&M when TCM criteria is not met prior to submitting the claim. But I am wondering about after getting a denial. Any help would be appreciated.
Thanks!

 

[Cynthia Hughes]

Yes. You should submit the appropriate office E/M code if the transitional care management (TCM) service was appropriately denied based on the payer's policy. It may also be appropriate to report any other services provided directly by the reporting physician or QHP (eg, telemedicine visits, virtual check-ins) and any reportable incident-to staff services (eg, 99211 for nursing visits in continuance of the plan of care from the physician's face-to-face visit) that were provided and documented during the period reported with the TCM code. If the TCM service was reported with the date of the TCM face-to-face visit, it may be necessary to follow the payer's instructions for submitting a corrected claim.
I hope that helps. Cindy

 

[aimes]

Thank you so much!