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Transitional Care Management (TCM)

L

LOUISE SLACK

Networker
Messages
56
Location
Des Moines, IA
Hi,

Is anybody billing the new TCM codes? 99495 and 99496

Iowa Medicaid does not cover them but I am wondering how other carriers are processing the claims. Getting Paid? Any problems?

Thank You
Louise
 
Tcm

We are billing them and getting paid. We do see some deny by Medicare when the hospital claim is not yet on file or doesn't line up with out date of service (must be 30 days from d/c). The only carrier giving us trouble is Federal BCBS-they state it is a non-covered service.
 
QUESTION?

We have a situation where one of our patients was in the hospital but our physicians were not called in to see this pt. But the day after the pt was discharged he called our office to let us know he was in the hospital. Now my office wants to bill a TCM because the pt was discharged from the hospital, a non face to face was done within two days and we saw him with in the 14 days. Based on the guidelines in the CPC book this does qualify, and it does not speicfy anywhere that the dr billing the TCM has to have seen the pt in the hosp.
 
Tcm

The doc billing the TCM does not have to be the doc that saw the patient in the hospital. Sounds like you are on the right track with this patient. Just make sure the meds were reconciled during the face to face and that the doc reviews the d/c summary from the hospital within 30 days from the date of d/c and that the MDM is at least moderate.
 
TCM Question

How are you billing when a patient is discharged and is seen the next day? Contact would not be necessary but all other rules apply??? Med rec and moderate to high complexity required. Correct?
 
tcm

Can you clarify the service date being 30 days from the date of discharge. I interpret that as creating a new registration with the date on the 30th day from the date of discharge to submit the claim. Others interpret to hold the claim for 30 days and you would not have to create a new registration. You could keep the date matching documentation and send it out 30 days from the date of discharge. I have read so many documents that I need other coders to explain. Thank you in advance
Sheila Sweetland, CPC
 
CMS has a medlearn matters article on this code. The DOS is the date of hosp d/c plus 29 days. The office is to hold the claim and then change the DOS before submitting it. Many offices that I audit for are using the wrong DOS. It's simple to understand if everyone took the time to review the documentation guidelines for it and also that MDM can only be moderate or high.
I see post pay reviews being done soon.
 
Tcm

I am a little confuse as of when do the 2 day comunication window starts ..does it start the same day the pt is d/c or the next day ? :confused:
 
the 2 day communication timeframe starts the day after d/c. And it does not count for Saturday and Sunday. So if a pt is D/C'd on a Friday the providers office has until Tuesday of the following week to contact the patient. If no contact is made, as long as the office keeps attempting to contact the pt passed the 2 day window, and documents this, you can still report TCM.
Again, cms.hhs.gov has articles explaining TCM in detail.
 
teresabug said:
CMS has a medlearn matters article on this code. The DOS is the date of hosp d/c plus 29 days. The office is to hold the claim and then change the DOS before submitting it. Many offices that I audit for are using the wrong DOS. It's simple to understand if everyone took the time to review the documentation guidelines for it and also that MDM can only be moderate or high.
I see post pay reviews being done soon.
Click to expand...

I am a little mixed up so if the DOS that the doctor saw the paper is within the 14days. you change the DOS to be the 30th day? no the day the patient was seen?
 
the DOS you report on the claim is the date the pt was discharged from the hospital plus 29 days including the weekends. So if the pt was d/c'd on 7-1 count this date plus 29 more. You will hold the claims for TCM and once the 30th day hits, you have to go into the PM software and literally change the DOS on your claim to that 30th date. If an insurance rep tells you this is wrong, they need more educating on TCM (this happens where I work).The TCM payment covers this "30 day period"; if the pt needs to be seen again within the 30 day timeframe for care related to TCM, the provider cannot bill an ov charge. His payment for the repeat visit is included in what he got paid for on the TCM code ($160 roughly here in MI).
 
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