Transitional Care Management codes 99495 and 99496

StuC2018

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I am looking for any information regarding a real-life situation when either of these codes would be used. Would these pertain to PCPs for physical health or mental health are providers?
 

jhendrix08

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We are a PCP/Internal Medicine office; this code is used for our patients that come in to see us for a follow up after being discharged from the hospital. There are time requirements to be able to bill these codes so be sure to look at that but yes, a PCP can certainly bill for transitional care management. Keep in mind this is billable to Medicare only.

Hope this helps.
 
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NWCoder64

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I work for a large healthcare organization (inpatient/outpatient, clinics), and we use transitional care management codes all the time in our family medicine clinics when the patients are following up post-discharge after their hospital stay. Generally their PCP in the family med clinic furnishes the service but any healthcare provider (MDs, DOs, NPPs) of any specialty may render service. Both of these codes are based off the medical decision making - they're not time-driven. Moderate decision making is 99495 (must be seen face-to-face within 14 days post-discharge); high is 99496 (must be seen within 7 days post-discharge).

There are other specific criteria that need to be met in order to bill including timing of interactive patient contact (usually a phone call) as well as discharge disposition (must be to home/domiciliary not SNF or inpatient rehab - although you can bill TCM after discharge from one of those facilities). Often the most common reason we need to change a provider's TCM to a regular p/f visit is because one or both of these components wasn't met. For example, the interactive patient contact must be made within two business days post-discharge. If patient/caregiver isn't reached, a 2nd attempt must be made during that 2-day period. Our care managers may only attempt one phone call during that time or they may not make contact until the third business day, if at all. Or patient contact was made in the appropriate amount of time but patient was discharged to SNF or a rehab facility, and they come in for their follow-up during the 7- or 14-day timeframe. It's ok to bill a TCM after they've been discharged from one of these facilities (as long as the other criteria is met), but this never happens in our clinics.

Medicare does have a nice, easy-to-read/understand booklet on the components & criteria that make up TCM:

https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/transitional-care-management-services-fact-sheet-icn908628.pdf

Finally, after using these codes for several years and tracking payment, we have found that commercial insurance will also pay for these visits, not just Medicare.
 
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