Wiki Transitional Care Management - the CPT codes

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jssilver1204

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I understand that Medicare is encouraging Transitional Care management. Codes 99495, 99496. This is what the AOA has to say about it: The requirements of the CPT codes are:
99495, TCM: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within two business days of discharge; Medical decision-making of at least moderate complexity during the service period; face to face visit within 14 calendar days of discharge.

99496, TCM: Communication (direct contact, telephone, electronic) with patient and/or caregiver within two business days of discharge; Medical decision-making of high complexity during the service period, face to face visit within seven calendar days of discharge.

Does anyone have any other info about this? I'm wondering if you have to talk to the patient/caregiver within 2 days of discharge AND see the patient face to face.

Jennifer
 
I haven't yet seen anything from CMS about these codes other than that they're going to be implementing a G-code for TCM without a face-to-face component. CPT has a great description of the guidelines, but I'm still waiting for CMS to either embrace these guidelines or come up with their own. Since the fee schedule lookup still shows 2012B, I don't even know if/how much they're going to cover the TCM and CCCM CPT codes.

Does anyone else have any information?
 
TCM requires a couple of things. First: physician or staff must contact the patient within 2 business days of discharge. This can be done by phone, e-mail, or in person. Medication must be reconciled by their first face to face visit. 99495 is to be used for patients with moderate complexity medical decision making, and must be seen face to face in 14 days of discharge. 99496 is to be used for patients with high complexity medical decision making and must be seen face to face within 7 days of discharge. The rule lists several things that physician and or staff can do such as education of the patient and/or caregiver, establishing or re-establishing community and social services, coordinating office appointments with physicians that previously cared for the patient, referrals to social services. They are covering the TCM and it pays about $30 more than a 99214 and requires less physician work.
 
In the new CPT book I see it says that the medical complexity is for the service reporting period. Do you think the service reporting period is the time the patient is in the hospital, or just the time between discharge and being seen face to face?
 
The 'service period reporting' is the time following the date of discharge through the next 29 days, according to CPT. So if the patient has moderate or high MDM for services during those days, they'd qualify. Follow your MDM grid from your carrier's audit tool to determine if they meet at least the moderate.
 
Does anyone know how the contact with the patient for TCM with 2 business days is known/documented since it is a requirement? Or is the 99495/99496 the only thing to bill?
thanks
C
 
The contact within in 2 business days should be communication via phone, electronic such as e-mail, or direct face to face. There is no additional code to bill this as proof. It becomes part of your documentation toward the visit.
 
RE: TMC Documentation
I am seeing that it needs to include: Date of patient's discharge, Initial patient contact within 2 days-either phone or email, MDM must be documented-using CMS guidelines, Documented face-to-face encounter. No separate code for the E/M should be billed. That at the end of the 30 days the appropriate TMC code can be billed. Is this correct? Anything new with the CMS G-code?
Thank you
 
Hi, I'm attaching a guide I put together for our Internal and Family practice groups to assist with billing understanding and documentation criteria in our EHR for these codes. I hope it's helpful. I think it will clear up a lot of confusion.


Also, read Debra Seyfried, MBA, CMPE, CPC's article about TCM at
http://blogs.aafp.org/fpm/gettingpaid/entry/cms_approves_new_codes_for

Have a good weekend, everyone. Pam
 

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dseyfried said:
TCM requires a couple of things. First: physician or staff must contact the patient within 2 business days of discharge. This can be done by phone, e-mail, or in person. Medication must be reconciled by their first face to face visit. 99495 is to be used for patients with moderate complexity medical decision making, and must be seen face to face in 14 days of discharge. 99496 is to be used for patients with high complexity medical decision making and must be seen face to face within 7 days of discharge. The rule lists several things that physician and or staff can do such as education of the patient and/or caregiver, establishing or re-establishing community and social services, coordinating office appointments with physicians that previously cared for the patient, referrals to social services. They are covering the TCM and it pays about $30 more than a 99214 and requires less physician work.
Click to expand...
Does this apply to patients discharged from inpatient settings to Community Mental Health Centers?
 
The language in CPT says, "patient's community setting: Home, domiciliary, rest home or assisted living".

If you note, none of these have a resident medical component. So it may be that a community mental health center would not be appropriate, because there is usually a psychiatrist or psychiatric nurse practitioner available. Check with your CMS contractor to be sure.
 
efuhrmann said:
who is "they" in "they are covering the TCM charges $30 more than 99214"?
Click to expand...

She probably means CMS fee schedule. Allowable fee for 99495 is $163.00, and for 99496 is $230.00 (depending on your geographical location), with 4.82 and 6.79 total RVUs respectively.
 
Medicare TCM services

If you are billing Medicare for TCM, be sure to read the final rule for the Medicare Physician Fee Schedule before reporting. CMS will allow TCM for both new and established patients (same codes are reported), require all TCM activities be provided or documented by the physician as not necessary, face-to-face visit cannot be on same date as hospital discharge, and charges for TCM are billed after the end of the period.

https://www.federalregister.gov/art...physician-fee-schedule-dme-face-to-face#t-124

PS No G codes for TCM services. CMS accepted the CPT codes for these services.
 
Cynthia Hughes said:
If you are billing Medicare for TCM, be sure to read the final rule for the Medicare Physician Fee Schedule before reporting. CMS will allow TCM for both new and established patients (same codes are reported), require all TCM activities be provided or documented by the physician as not necessary, face-to-face visit cannot be on same date as hospital discharge, and charges for TCM are billed after the end of the period.

https://www.federalregister.gov/art...physician-fee-schedule-dme-face-to-face#t-124

PS No G codes for TCM services. CMS accepted the CPT codes for these services.
Click to expand...

Yes, CMS will allow for new patients...however CPT indicates established patients, so you'll have to be aware of this if providing services to commercial payers who might have other guidelines from CMS. Check your payer guidelines before you submit, just in case! Not all of our patients who will receive this services are Medicare recipients, so we have to be cautious, until we know for sure with our commercials.

I got the RVUs from an article from the AAFP by Debra Seyfried, MBA, CMPE, CPC, who referenced CMS. http://blogs.aafp.org/fpm/gettingpaid/entry/cms_approves_new_codes_for
I also got the RVUs from our Fee Calc Software, released 11/1/12.
 
Does anyone know if in the final rule we must wait 30 days from discharge before we can submit the 99495 for instance? Waiting would require us to manually hold a charge for potentially a couple of more weeks. Usually our bills generate a claim as soon as they are posted.

Thanks
Cherry Pence
Saint Luke's Medical Group
 
You must wait the full 30 days. The charge includes all related work done by your nurse care managers and non-face-to-face provider work during that entire month. Submitting it early will cause a denial.
 
Can you tell me if I have to wait until after the 30 TCM period to bill for this? Also, would the correct diagnosis code be the codes used for the hospital stay?
 
Business days

If a person is discharged on Monday (anytime that day), do the 2 business days start on Tuesday? I just want to make sure it is truly 2 days vs 48 hours from discharge.

Linda Beeson, CPC
 
Per CPT (2013 Professional Edition, page 45), "TCM requires an interactive contact with the patient or caregiver, as appropriate, within two business days of discharge." If they're discharged on a Monday, I would interpret this to mean that you have until the end of business on Wednesday to reach the patient/caregiver. We have a plan to review our facilitiy's discharge reports on a daily basis and work with our hospitalist department to abstract our own patients for this purpose. The RVUs for this service are significant, so I'm expecting that we're going to have to work for it!
 
Does anyone know of the G code yet for TCM? Also my understanding is that if you billed 99495/496 during the first 30 days then you cant bill 99487/88/89 until after the first 30days.

99366 is this a payable code during the first days?


Any help will be greatly appreciated.

Thanks
 
99395/99396

Does anyone know if we can bill an office visit along with the TCM? Also can we add a 25 modifier to a TCM when another procedure is done??
 
I hope I answer everyone here:

Although I've seen no clear direction, it appears to me that TCM is billed as a to-from date of service, which would not be how you'd report another single date of service. Basically, they'd need to be on different claims. So modifiers wouldn't apply.

Medicare decided to use the 2013 CPT codes, so no G code was assigned.

You have to bundle in the first physician face-to-face, but after that, all medically-necessary physician visits may be billed independent of this service using the same coding conventions as usual.

CPT lists the codes that cannot be billed during the same time period (care plan oversight, for example).
 
Can these codes be billed with 99420 for Humana Assesments?

Also what about specialties: cardiology, urology or hematology/oncology?


Any help will be appreciated.


Thanks
 
Are these codes used for ER follow ups? We aren't real sure what exactly the definition of "partial hospitalization" would be. Would an ER visit fall into that bucket?
 
TCM & the 72 hour rule

Does anyone have documentation about billing the TCM code after discharge, but then the patient is readmitted within the next 72 hours after the TCM?

I know I append modifier PD to visits within that 72 hour timeframe, but do I still append modifier PD to the TCM code? Or do I need to report the TCM code differently since the patient was readmitted.
 
crump05 said:
Can these codes be billed with 99420 for Humana Assesments?

Also what about specialties: cardiology, urology or hematology/oncology?


Any help will be appreciated.


Thanks
Click to expand...


Specialists can bill, as long as they are doing the post-hospitalization care and as long as the PCP isn't also billing for this. Also, specialists cannot bill this service if they were the hospital discharging physician or if they are within the global days.
 
nc_coder said:
Are these codes used for ER follow ups? We aren't real sure what exactly the definition of "partial hospitalization" would be. Would an ER visit fall into that bucket?
Click to expand...


Partial hospitalization refers to psychiatric care in a program designated as such. ER visits do not fall into this bucket.
 
cgneff72 said:
Does anyone have documentation about billing the TCM code after discharge, but then the patient is readmitted within the next 72 hours after the TCM?

I know I append modifier PD to visits within that 72 hour timeframe, but do I still append modifier PD to the TCM code? Or do I need to report the TCM code differently since the patient was readmitted.
Click to expand...


If the patient is re-admitted, you cannot bill the TCM code for the 30 days following the previous discharge....but you can go back and bill the bundled face-to-face physician visit. Essentially, you have to start over again. You then wait for the second discharge and begin again with your 30-day timeframe. The -PD would never apply here (isn't that to report the diagnostics (not visits) affected by the 72-hour rule for owned entities?)

Remember, this code is to be billed to report significant care-management work done by your physician and ancillary staff for post-discharge care. You can't simply bill it just because you're the attending, PCP or other related provider. There are some very significant documentation requirements in CPT (please read this thoroughly) to understand what is entailed in reporting this code. The RVUs are high for this service, and rightfully so: the patient has to have a risk of re-admission, and must require post-discharge care that involves a lot of phone calls, coordination of care, medication reconciliation, and psychosocial support, just to name a few of the requirements.

Again, read CPT, read the final rule, and check out some of the articles that have recently been published from medical societies to thoroughly understand these codes. Lots of good information out there...you just have to do the research, which as coders, we've all been trained to do.

Although Medicare is paying for this service, you'll have to check with your individual commercial payers to see if they are also going to cover these codes. They will be able to answer questions about bundling with other payer-specific codes, so I don't feel comfortable addressing those specific questions here.
 
So let me make sure I have this straight... Would I be coding this scenario correctly?

If patient is discharged 1/10/13, the clinical staff/care manager RN contacts the patient non-face-to-face by 1/11/13 and communicates with patient/family/other professionals/home health agencies/community services regarding aspects of care, education to support self-management/independent living etc, assessment & support of treatment plan & medication management, available community/health resources, facilitate access to care/services needed by the patient/family.

Questions:

#1 Does the provider's non-face-to-face services (review discharge documents/pending diagnostic tests & treatments/interaction with other professionals who will address specific problems/education of pt/family, referrals/arrange community resource, and assistance/scheduling with community providers/services) all have to be performed on 1/11/13 also?

#2 Do the services by the clinical staff/care manager RN & Provider provided during this 2 day window constitute the appropriate 99495 or 99496 billing with the date of service 01/11/13?

#3 Then would the face-to-face encounter being billed out 1/15/13 with the appropriate E&M level be billed to the insurance (99214)?

#4 After 30 days have gone past the discharge date, the code from question #2 could be sent to the insurance carrier to indicate the appropriate code for the face-to-face visit & MDM level on 1/15?

Thank you so much for your help on this. It seems like the more articles I read on this, the more opposing information I find.
 
Questions:

#1 Does the provider's non-face-to-face services (review discharge documents/pending diagnostic tests & treatments/interaction with other professionals who will address specific problems/education of pt/family, referrals/arrange community resource, and assistance/scheduling with community providers/services) all have to be performed on 1/11/13 also?

No: these services can be done throughout the 30-day timeframe as appropriate based on the needs of the patient. It's assumed that the patient is going to need a significant amount of support throughout that time frame, and these non-face-to-face services are expected to be carried throughout this time frame.

#2 Do the services by the clinical staff/care manager RN & Provider provided during this 2 day window constitute the appropriate 99495 or 99496 billing with the date of service 01/11/13? No, the date of the physician face to face determines the code (1-7, 8-14 days post-discharge) as well as his assessment as to whether the patient is moderate or high complexity. The nursing staff should NOT be determining complexity. This is the physicians role.

#3 Then would the face-to-face encounter being billed out 1/15/13 with the appropriate E&M level be billed to the insurance (99214)? no, the first face-to-face (by physician) is bundled in. You document the visit, but do not bill it out. It's included int he 99465 and 99496.

#4 After 30 days have gone past the discharge date, the code from question #2 could be sent to the insurance carrier to indicate the appropriate code for the face-to-face visit & MDM level on 1/15? The TCM code is billed out on day 30....29 days following the date of discharge.
 
I haven't seen any clear direction on reporting the DOS...however we've decided to bill on the 30th day, and see what happens!

I'm wondering if any of the other contractors have come out with clarification. NHIC has not.
 
Transition of care

If one of my primary care physicians sends a patient to one of our specialists for consult/new patient-eg. CHF. Is this a TOC visit? If it occurs within the correct timeframe.
 
Transitional Care Management (not transition of care) is not a single-encounter charge.
These two codes (99495 and 99496) are designed to report services provided by RN Care managers, under the supervision of physicians and NPPs who are doing comprehensive post-discharge care for complex chronically ill patients. The reporting period is 30 days post- discharge. If your practice does not already employ nurse care managers who are doing this kind of chronic disease management work, I'd suggest you first attempt to get a program up and running in order to bill these services.

CPT actually does a pretty good job of explaining what is involved to bill these services.

A transfer to another provider is definitely not TCM.
 
TCM info

Hi Pam!

You are the best!!! Thank you so much for sharing your info:)

My understanding is that only one doctor can bill for this service during that discharge period of 29 days after the discharge day, correct?

Also, the info reads that there is an "initial" face-to-face (F2F) which is not billable. It then sounds like in order to bill the TCM the physician or other Qualified Healthcare Provider (QHCP) needs to see the patient again either 7 days or 14 days depending on the Medical Decision Making (MDM) complexity. The "interactive contact" within 2 business days that is just part of the TCM correct? That is not considered this "initial" F2F because it is through phone, email but is also says or "face-to-face". This is the verbage that I need clarification regarding.

Also, the medication reconciliation and management must occur no later than the date of the F2F visit, which one? The initial non-billable or the one that is performed either 7 or 14 days depending on complexity?

I also read that the physician can see the patient the day of discharge i.e. while at the hospital or facility being discharged from and that would count as the "initial" F2F. They can bill for a discharge day service on that day as well because the "initial" F2F is included in the TCM.

Again, thanks for your help and I look forward to your reply Pam:)

Nancy Roche (Lynch), BA, CPC, CBIS
Compliance Billing and Coding Auditor
Abington Memorial Hospital
Abington, PA 190001
 
Hi Pam!

You are the best!!! Thank you so much for sharing your info:) Why thank you, *blush*.

My understanding is that only one doctor can bill for this service during that discharge period of 29 days after the discharge day, correct? Yes, that's correct. However, if that or any provider sees the patient again within those additional 29 days, (unless there's a bundling issue), then the additional E&M visit can be billed.
Also, the info reads that there is an "initial" face-to-face (F2F) which is not billable. It then sounds like in order to bill the TCM the physician or other Qualified Healthcare Provider (QHCP) needs to see the patient again either 7 days or 14 days depending on the Medical Decision Making (MDM) complexity. not again....the single face to face is bundled into the code. The "interactive contact" within 2 business days that is just part of the TCM correct? Basically that 2-day contact is a phone call for medication reconciliation, to review the discharge plan and to check to see if the patient's doing OK at home. The Nurse Care manager might check to see if they have support, if they need to weigh themselves, if they have to follow a special diet...that kind of information.
Then they'd set up the F2F. That is not considered this "initial" F2F because it is through phone, email but is also says or "face-to-face". This is the verbage that I need clarification regarding. you've got it.

Also, the medication reconciliation and management must occur no later than the date of the F2F visit, which one? The initial non-billable or the one that is performed either 7 or 14 days depending on complexity?
The medication management has to take place prior or on the F2F regardless if the visit is 1-7 or 8-14 days from the discharge date. We're shooting to always meet the 7 day timeframe, just because there's the opportunity to bill the 99496 if the patient has high complexity.
I also read that the physician can see the patient the day of discharge i.e. while at the hospital or facility being discharged from and that would count as the "initial" F2F. They can bill for a discharge day service on that day as well because the "initial" F2F is included in the TCM. I did not hear that, nor have I read that anywhere. It was my understanding that the initial F2F had to happen post-discharge.

Here's our plan....

We get a list of patients (by PCP) who have been recently discharged. The nurse care managers within each PCP practice---we have several, contact the patient (day one or day two) post-discharge, to check on their post-discharge progress. If we can't reach the patient within two days, we will document our attempts until we do reach them.....I understand that will be sufficient to still be able to bill the code. But the F2F at the very least has to happen in 14 days. At that time, they might do medication reconciliation, but often patients have a bazillion pill bottles, and they can't sort through. So we make an appointment, which is the initial F2F, with the PCP. At that time, the patient comes in, with their shopping bag full of meds, and we reconcile at that time. Also, the PCP sees them, determines the plan of care, identifies MDM (based on the # of diagnoses, data and risk). That visit is not billed out, however we identify day #30 for billing purposes.
During the following 29 days, the provider and nurse care manager work together to monitor the patient, get them the support and resources they might need, make appropriate referrals, etc (see CPT for other interventions). The nurse care manager documents this information in our EHR and keeps a paper log, which she scans in against the first F2F. (I know, very archiaic, but our EHR doesn't have a TCM template---go figure).

We are tracking the billing date through a shared spreadsheet (since our EHR doesn't cooperate) that will ID the billing date, and we drop the charge on day 30. If the patient is re-admitted, we will bill out the first E&M, and start over again with the new process after the second discharge. Hopefully, that won't happen very often.


Again, thanks for your help and I look forward to your reply Pam:)
 
Hi Pam:

Thanks for all of your help with this. I had a quick question regarding your response above to Nancy's post. In the final paragraph you indicate if the patient is re-admitted within the 30 days the TCM goes away and the first E/M is billed just as an E/M (makes sense). But in Debra Seyfried's article she indicates that the TCM can be billed even if the patient has another hospitalization within 30 days. I'm wondering if I'm just not interpreting something correctly and would appreciate your input.

Thanks!
 
According to CPT: only one visit can be reported within 30 days of discharge, an another TCM may not be reported by the same individual or group for any subsequent discharge within the 30 days. So if the patient is re-admitted within that first 30 day period, then you can't bill the first TCM and then another less than 30 days later. So it would make sense to bill the first E&M out, and then begin the 30 day TCM following the second discharge. It wouldn't be appropriate to bill the first TCM less than 30 days.
 
Hi Pam:

I had another quick question for you. I'm trying to explain to the providers that they have to obtain the discharge summary and I'm having trouble justifying why that would be (they understand why they would have to review it, but the "obtaining" is causing issues). What is your take on this?

Thanks!
 
Hi Pam:)
Here's a question..... so I have a provider who saw the patient on day 31 instead of day 29!!! I have been looking for info to see if the 99495 can still be billed but so far no luck. Any one have any info?

Pam you have been such a great asset to us through this!! Thanks a million (again):)

Nancy
 
Transitional care management is only for patients that are discharged from an inpatient status. TCM following an ER visit would not be appropriate.
 
nklynch said:
Hi Pam:)
Here's a question..... so I have a provider who saw the patient on day 31 instead of day 29!!! I have been looking for info to see if the 99495 can still be billed but so far no luck. Any one have any info?

Pam you have been such a great asset to us through this!! Thanks a million (again):)

Nancy
Click to expand...


The requirement for the face to face visit is either 1-7 edays or 8-14 days. There is no other face-to-face requirement (just documentation requirements based on your nurse care manager's work). You don't have to drop the code on a day when there's been a visit....in fact, we have set up a schedule to drop codes exactly on day 30. So if you met the 2-day contact and medication reconciliation, the 14 day face to face requirement, the patient was discharged from an inpatient setting, the MDM is moderate or high, and the nurse care managers have documented the patient-specific criteria as outlined in CPT, then you can drop the code on day 30. In fact, any additional face-to-face provider visits can be billed additionally. Does this help?
 
maddismom said:
Hi Pam:

I had another quick question for you. I'm trying to explain to the providers that they have to obtain the discharge summary and I'm having trouble justifying why that would be (they understand why they would have to review it, but the "obtaining" is causing issues). What is your take on this?

Thanks!
Click to expand...

The whole point of TCM is to follow the recommendations of the discharging physician to avoid re-admission. Without that summary, it will be difficult for you to create the patient's care plan. If your provider's patient was discharged from a facility, then it's standard practice (not to mention professional courtesy) to forward a copy of the discharge summary to the patient's PCP---if the patient indicated that they would be following up with their PCP post-discharge. Maybe you need to contact the hospital to see why you're not included in the distribution list for those documents.
 
Hi...apparently my question was not worded correctly. In a perfect world, we DO get the discharge summaries sent to us and of course we DO understand the whole point of TCM. I was wondering about the cases where the discharge summary does not get delivered and if you knew why it would have to be the provider who contacted medical records to request a copy as opposed to clinical staff was all.
 
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