Wiki TCM with POS 32

[sminer]

Our provider submitted a claim with CPT 99496 in a nursing home (POS 32). The claim has been rejected by Medicare as 99496 SMARTEDIT POS PROCEDURE CODE 99496 IS NOT TYPICALLY PERFORMED BY A PHYSICIAN AT PLACE OF SERVICE 32 NURSING FACILITY. (99496). From what I have been able to gather, TCM can be billed if the patient is discharged to a nursing home. Has anyone else had this issue or does anyone have any information that might be helpful?

 

[Pam Warren]

TCM cannot be billed if the patient is in the nursing home. That's because a nursing home is a Part A stay, and the point of TCM is to keep the patient from being in a Part A stay. They must return to their community setting (see below) From CMS:

You may provide TCM services, beginning the day of the beneficiary’s discharge from one of these inpatient hospital settings:
● Inpatient Acute Care Hospital
● Inpatient Psychiatric Hospital
● Long-Term Care Hospital
● Skilled Nursing Facility
● Inpatient Rehabilitation Facility
● Hospital outpatient observation or partial hospitalization
● Partial hospitalization at a Community Mental Health Center

After inpatient discharge, the beneficiary must return to their community setting:
● Home
● Domiciliary
● Rest home
● Assisted living facility