Wiki Transitional Care Management - the CPT codes

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99495 tcm

So the face to face visit that must be performed with 14 calendar days of discharge can then not be billed for If we bill a 99495?

It almost seems like too much trouble to bill the 99495 if we are not going to get paid for the appointment afterwards.

Also, is this a FQHC billable encounter or would this be billed FFS?

:confused:
 
Payment

Has anyone received payment from the TCM charges from Medicare yet? I recieved a denial on one and they told me I billed it 6 days too late that it has to be billed exactly on the 30th day afer discharge. What are we supposed to do if that date occurs on the weekend and our clearing house doesnt send claims on the weekend?
 
Yes, the date of service has to be the 30th day. It doesn't matter what day of the week it is. You don't have to submit the claim that day, but the date of service on the claim has to be that day.
 
TCM ER visit?

Can someone supply documentation where it states that ER does not qualify as TCM? thanks! Need to provide it to higher-ups!:)
 
Tcm

In the CPT book there is a description and list of requirements just before the two codes are listed. In mine, the first paragraph describes the services as being for a patient transitioning from an Inpatient setting (ER is out pt) to home. That should be enough.
 
wow...my cpt book

Wow, my cpt book does not state that before the 2 codes....it lists items it includes, but not that... which version are you using, who is the manufacturer? ours is OPTUM
 
Tcm

We use AMA's Professional Edition. There is about a whole page and a half of info before the actual codes, including coding tips after the codes.
 
Patricia Belew said:
Has anyone received payment from the TCM charges from Medicare yet? I recieved a denial on one and they told me I billed it 6 days too late that it has to be billed exactly on the 30th day afer discharge. What are we supposed to do if that date occurs on the weekend and our clearing house doesnt send claims on the weekend?
Click to expand...

Have you called Medicare on this yet? I have seen denials for billing the codes prior to the 30th day but not after? The date Medicare is looking at is the dos not the date they received your claim.

I'd call them if I were you to get clarification.
 
Tcm

DOES THE DR BILLING THE TCM HAVE TO SEE THE PT IN THE HOSPITAL?
WE HAVE A SITUATION WHERE THE PT WAS IN THE HOSPITAL BUT WE DID NOT SEE HIM AND HE CALLED THE DAY AFTER HE WAS DISCHARGED TO TELL OUR OFFICE HE WAS IN THE HOSPITAL. MY OFFICE WANTS TO BILL A TCM VISIT BECAUSE NO WHERE DOES IT SAY THAT THE DR BILLING THE TCM HAD TO SEE THE PT IN THE HOSPITAL. PLEASE HELP!!!!:confused:
 
The physician billing the TCM does not have to be the physician who attended in the hospital, but has to be the provider who will be overseeing the post-discharge care that is reportable during the 30 days following the discharge.
 
correct way to bill?

I am needing just a clear cut way on the proper way to bill these claims. (probably everyone else too:) Say the patient is discharged on May 31st they follow up in our office on June 3rd. Do we bill the e/m say 99214 on the June 3rd visit and then bill the transition of care code on the 30th day on June 30th? Or does the June 3rd visit not get billed at all? Or do I hold it and bill everything together? Thank you in advance.
 
Additional office visit during TCM face to face

My doctor is asking if he can bill an office visit during the TCM face to face if the patient has additional issues unrelated to TCM. When his patient came in for TCM, he happened to burn himself 3 days prior to coming in. It was a 2nd degree burn and the physician treated. Since this has nothing to do with the TCM, I am unsure if I can carve out that part of the visit or if it cannot be billed at all since the first TCM visit cannot be billed separately. Any suggestions?
 
same question as above, more or less

I have more or less same concern: has anyone gotten denials on EM codes that fall within that 30 day period range from Medicare? I see in CPT book it says other EM can be billed separately, but my contractor these days (Palmetto) has been doing all kinds of screwy things. Clinically I am not sure why they made this 30 days as opposed to 14 days, since that is when provider is required to see patient, other than the fact the patient is still at high risk of re-admission. :eek:
 
Just for clarification.. Should the actual billing date be 30 days from the date of discharge? We are having a lot of problems with this code being paid.
 
jnieto625 said:
My doctor is asking if he can bill an office visit during the TCM face to face if the patient has additional issues unrelated to TCM. When his patient came in for TCM, he happened to burn himself 3 days prior to coming in. It was a 2nd degree burn and the physician treated. Since this has nothing to do with the TCM, I am unsure if I can carve out that part of the visit or if it cannot be billed at all since the first TCM visit cannot be billed separately. Any suggestions?
Click to expand...

That F-2-F must be bundled into the TCM code, so billing out a visit at the same time might be a challenge. I've seen no guidance that says you can't, however. The trick would be to keep the documentation separate so that you bill the E&M based only on the burn treatment. I'd even go so far as to document two separate notes. However it might be clearer (and we may get better guidance in 2014) to have the patient come back for his TCM visit. Good question, for which I've seen no answer!
 
teabowdoe said:
I have more or less same concern: has anyone gotten denials on EM codes that fall within that 30 day period range from Medicare? I see in CPT book it says other EM can be billed separately, but my contractor these days (Palmetto) has been doing all kinds of screwy things. Clinically I am not sure why they made this 30 days as opposed to 14 days, since that is when provider is required to see patient, other than the fact the patient is still at high risk of re-admission. :eek:
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So far, no denials that I'm aware of. Our contractor is NHIC, and I've found that they aren't really up to speed on the concept of TCM.
They made the timeframe 30 days because the facility doesn't get reimbursed for the second admission if the patient is re-admitted for the same condition as the previous admission within 30 days. This is an attempt to keep that patient out of the hosptial during that 30-day time frame. It's a win-win, really.
 
Twixle2002 said:
Just for clarification.. Should the actual billing date be 30 days from the date of discharge? We are having a lot of problems with this code being paid.
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Day 30, following discharge. Many commercial payers are not covering this, we've found.
 
TCM billing

While I understand the Transitional Care Management billing; I do have a question when it comes to the balance. Should we bill the patient the 20% or is the patient not to be billed?

Thank you in advance.

Anne
 
TCM - communication within 2 business days

I don't belive I have seen an answer to this and if it is listed, please forgive me.

What are your offices doing when the initial communication has not been done even when there is adequate documentation on attempts but the patient was in for their initial face-to-face visit by at least day 14?

For example if a patient no longer has a phone or maybe staying with a friend or family member and isn't home to receive messages.

I've seen in a different thread that if by day 4, no contact is made then they do not bill out the TCM. My concern is having the provider lose out on the service because of something they cannot control.

All thoughts are greatly appreciated!!

Missy
 
Transitional Care Codes

[I have started to bill the 99495 code and have 2 questions:

1. Does anyone know if the contact made within the 2 days must have specific information documented? Or can the office just note they spoke with pt on "that date"

2. I had Medicare pay for a TCM/99495 code only to have them take the money back because the 30th day patient was back in the hospital. Has anyone heard of this happening? If yes, can we appeal? or we would just change to an E&M visit?

thank you! Donna
 
I have a question about which billing provider to use.

We have PA's in our practice as well as physicians. Our physicians rotate schedules and end up seeing each other's patients, or the physicians have a PA see the patient. Also, one of our physicians works two weeks and then is off two weeks. The physicians sometimes disagree on who is really "overseeing" the patient's care.

My question is - As a general rule, should the provider who provided the first face-to-face visit (7 or 14 days post-discharge) be the billing provider?

With all the "sharing" of patient care that goes on in our practice, we have an endless number of possible scenarios. We usually see TCM patients weekly post-discharge, and I understand that the visits after the initial face-to-face can be billed separately, but the weekly visits, including the initial face-to-face, could be by any of the physicians or it could be a PA. I also sense trouble if we bill TCM under a physician if the PA does the initial face-to-face. Additionally, with the physician who works two weeks and then takes two weeks off, can we bill TCM under this doctor at all?

Any suggestions?

Thanks -
 
another e&m within 30 days

Pam Brooks said:
They can't, technically, and I'm not aware of any modifier. I guess providers are expected to be prudent and not unbundle that first E&M...but the guidelines are very clear that additional E&M services may be billed during that post-discharge time frame.
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Have you gotten any clarification on this? we saw patient within 7 days and did not bill to medicare because it is "bundled", saw the patient a few weeks later for unrelated condition so we billed (applied to deductible), now i am ready to bill TCM but won't they deny since i billed an e&m during the 30 days, as they don't know of the face to face that i didn't bill......

also do i put the discharge date somewhere on the claim so they know the tcm is at the 30 day mark?

bridget.brown@casanovamd.com
 
99496-99495

We have a question we have a physician that is billing out 99495 14day after discharge our question is do you count the discharge date as day one or is it the day after discharge to set up appt for a follow up for face to face thank you
 
Discharge day is day one and the date you would bill as the DOS is the 30th day. CPT 99495 is for moderate complexity with a face to face within 14 days.
 
Question about TCM

If a patient is discharged from inpatient to outpatient rehab, do the transitional care rules apply while he is in outpatient rehab (in other words, is outpatient rehab the same as home, domiciliary, rest home or assisted living.

Or does he actually have to be done with outpatient rehab before that 30 days begins.

thanks to all
 
Tcm

emma021785 said:
If a patient is discharged from inpatient to outpatient rehab, do the transitional care rules apply while he is in outpatient rehab (in other words, is outpatient rehab the same as home, domiciliary, rest home or assisted living.

Or does he actually have to be done with outpatient rehab before that 30 days begins.

thanks to all
Click to expand...

From what I have read in the CPT book the pt must be discharged to their community (home) setting. If the patient is at home and having outpt rehab I would think you could still bill the TCM code and the rules then apply (since the patient is no longer inpt and is in the home setting). This is just what I am thinking. Hope it helps.
 
drmpurple said:
From what I have read in the CPT book the pt must be discharged to their community (home) setting. If the patient is at home and having outpt rehab I would think you could still bill the TCM code and the rules then apply (since the patient is no longer inpt and is in the home setting). This is just what I am thinking. Hope it helps.
Click to expand...


I believe that they cannot be in a facility setting...so outpatient rehab would not apply. The TCM codes are to be reported to help manage patients when they are in a post-discharge environment where they do not have any direct medical care and support, thus the care management model that TCM reimburses. If anyone understands this differently, perhaps they could comment.

Also regarding this post:
We have not received payment for any transitional care claims.
Can someone post simple exact directions for me?
Thanks


If you read through this entire thread, you will get the answers to most, if not all of your questions about TCM. Also, CMS has several publications that address both FAQs as well as guidelines. Go to you local contractor's site and use the search engine to locate the guidance.
 
paid!!! but a different question

yay, i was paid for our first billed tcm.. communicated and noted, saw pt within 10 day time frame and then billed tcm code counting 30 days from date of discharge and using that as date of service...


now different patient, discharged, phone call made, patient seen, should be billing tcm today (day 30), but patient was readmitted a few weeks ago-- did not do tcm phone call or face to face after second discharge because patient went to a nursing home.

can i bill tcm for first discharge on day 30 for first discharge? in the faq on medicare site it says
If the patient is readmitted in the 30-day period, can TCM still be reported?
Yes, TCM services can still be reported as long as the services described by the code are furnished by the practitioner during the 30-day period, including the time following the second discharge. Alternatively, the practitioner can bill for TCM services following the second discharge for a full 30-day period as long as no other provider bills the service for the first discharge. CPT guidance for TCM services states that only one individual may report TCM services and only once per patient within 30 days of discharge. Another TCM may not be reported by the same individual or group for any subsequent discharge(s) within 30 days.

this is a little confusing to me--should i bill 30 days after 2nd discharge even though work was done for first discharge?
 
shannon.annapolisinternalmed@gmail.com said:
We have a question we have a physician that is billing out 99495 14day after discharge our question is do you count the discharge date as day one or is it the day after discharge to set up appt for a follow up for face to face thank you
Click to expand...
I have the same question.

For billing 99495 the date of billing is the 30th day counting the discharge day as day one.

However, for communicating with the patient "within 2 business days," CMS's FAQ are clear that the day after discharge is counted as day one.

I suspect that F2F "within 14 calendar days" would count the day after discharge as the first day. For example, if the patient is discharged on Tuesday a Face to face visit on Tuesday 2 weeks later would count for 99495.

Does anyone know for sure, especially from any communication from CMS?

David

See references below

http://www.cms.gov/Outreach-and-Edu...-Management-Services-Fact-Sheet-ICN908628.pdf

If a beneficiary is discharged on Monday at 4:30 p.m., does Monday count as the first business day and
then Tuesday as the second business day, meaning that the communication must occur by close of
business on Tuesday? Or, would the provider have until the end of the day on Wednesday?
In the scenario described, the practitioner must communicate with the beneficiary by the end of the day on
Wednesday, the second business day following the day of discharge.
 
To determine the date you bill the TCm code, you count the discharge day as Day 1. So a patient discharged on March 13, the TCM would be billed on April 11.

The FAQ's state: The 30-day period for the TCM service begins ON the day of discharge and continues for the next 29 days. The reported date of service should be the 30th day.

The FAQ's also say:
If a patient is discharged on Monday at 4:3opm, does Monday count as the first business day and then Tuesday as the second business day, meaning that the communication must occur be close of business on Tuesday? Or, would the provider have until the end of the day on Wednesday?
Answer: In this scenario, the practitioner must cimmunicate with the patient by the end of the day on Wednesday, the second business day following the day of discharge.
 
Can we bill TCM code 99495/99496 instead of Care plan Oversite for home health pts

Can we bill TCM code 99495/99496 instead of Care plan Oversight services for home health,Assisted living and Hospice patients?




Pam Brooks said:
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.
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No because the purpose of TCM is to manage the patient when they are in their community home settings. If the patient is in a nursing or assisted living facility, they are not eligible for TCM.
 
According to an article in Medicare Learning Network, the patient IS eligible for TCM if discharged to a nursing home (or at least a "rest home") or to assisted living. Here's the article:

http://www.cms.gov/Outreach-and-Edu...-Management-Services-Fact-Sheet-ICN908628.pdf

We've been billing Medicare for TCM for a few months now and have gotten paid on all of them so far. We've really had to dot our i's and cross our t's - in other words, document and double-check everything. Make sure the follow-up phone call is done within two business days and documented. And obtain a copy of the hospital discharge summary with the date of discharge. That is what Medicare will go by and if your records don't match, I guarantee you'll have problems.

We did hit a bump in the road this week. Medicare requested a refund on a 1/28/14 TCM charge. The patient was readmitted in 1/20. Our billing staff didn't know that at the time because the doctors hadn't turned in hospital charges but our doctors billed hospital visit charges for that hospitalization, including a visit on 1/28/14. If you look on page 6 of the article linked above, Medicare says you CAN bill TCM even if the patient is readmitted before the 30 days are up. However, when I called Medicare I was told "the patient can't be in two places at once - they can't be both in the hospital and in the office on the same day." That's actually wrong - we see rehab hospital patients in our office - they are inpatients but they are brought to our office to see the doctor. But that's another story. On the TCM, I'm not sure, but it appears that maybe you have to only count out-of-the-hospital days for TCM. In other words, you can only count up to the readmit, then resume after the patient is again discharged - ? Does anyone know? This patient hasn't gotten out of the hospital since the readmit. Somehow I doubt Medicare will allow us to resume the counting a few months down the road.
 
Tcm

Can we bill 99495/99496 TCM codes for Care plan oversight services for patient in Home health,Hospice and Assisted living.
Anyone please do reply asap.

Thanks,
Susila
 
debkidcks said:
According to an article in Medicare Learning Network, the patient IS eligible for TCM if discharged to a nursing home (or at least a "rest home") or to assisted living. Here's the article:

http://www.cms.gov/Outreach-and-Edu...-Management-Services-Fact-Sheet-ICN908628.pdf

We've been billing Medicare for TCM for a few months now and have gotten paid on all of them so far. We've really had to dot our i's and cross our t's - in other words, document and double-check everything. Make sure the follow-up phone call is done within two business days and documented. And obtain a copy of the hospital discharge summary with the date of discharge. That is what Medicare will go by and if your records don't match, I guarantee you'll have problems.

We did hit a bump in the road this week. Medicare requested a refund on a 1/28/14 TCM charge. The patient was readmitted in 1/20. Our billing staff didn't know that at the time because the doctors hadn't turned in hospital charges but our doctors billed hospital visit charges for that hospitalization, including a visit on 1/28/14. If you look on page 6 of the article linked above, Medicare says you CAN bill TCM even if the patient is readmitted before the 30 days are up. However, when I called Medicare I was told "the patient can't be in two places at once - they can't be both in the hospital and in the office on the same day." That's actually wrong - we see rehab hospital patients in our office - they are inpatients but they are brought to our office to see the doctor. But that's another story. On the TCM, I'm not sure, but it appears that maybe you have to only count out-of-the-hospital days for TCM. In other words, you can only count up to the readmit, then resume after the patient is again discharged - ? Does anyone know? This patient hasn't gotten out of the hospital since the readmit. Somehow I doubt Medicare will allow us to resume the counting a few months down the road.
Click to expand...


A nursing home is considered a facility. A rest home is not a facility, (it's a private home where patients live with the family, and receive supportive care). An assisted living facility is considered a facility when it's part of a nursing home. So you have to be careful to know how the facility is licensed.
 
I've never seen "facility" being a determining factor by Medicare when it comes to what constitutes a community setting. In the article I referenced, as well as other literature I've seen on TCM billing, the explanation has always been that the patient must be being discharged FROM an inpatient setting (hospital inpatient, rehab hospital inpatient, skilled nursing, etc.) TO a community setting (including assisted living, etc.). If the facility reference has already been addressed in this thread I apologize for not seeing it, (it's a long thread!), but could you tell me where that is explained by Medicare?
 
debkidcks said:
I've never seen "facility" being a determining factor by Medicare when it comes to what constitutes a community setting. In the article I referenced, as well as other literature I've seen on TCM billing, the explanation has always been that the patient must be being discharged FROM an inpatient setting (hospital inpatient, rehab hospital inpatient, skilled nursing, etc.) TO a community setting (including assisted living, etc.). If the facility reference has already been addressed in this thread I apologize for not seeing it, (it's a long thread!), but could you tell me where that is explained by Medicare?
Click to expand...


I think this would make more sense to everyone if we consider the point of TCM--that is to keep the patient from being re-admitted into another costly facility setting by managing them through a nurse care manager program while they are in their typical community/home setting. So if we're discharging them from an inpatient hosptial setting and sending them to another facility----i.e. a nursing home, we've not yet gotten them to their community setting (home, domiciliary home, etc.) Both the Federal Register and a CMS MLM article discuss that the community setting does not include a nursing home. Hope this helps.
 
Thanks for the response. I'm still having trouble with this, though. Medicare doesn't pay for all facility services - they don't pay for most nursing home services. They just pay for medically necessary skilled nursing services while in a nursing home. If Medicare's purpose for paying for TCM is cost management by minimizing readmissions to an inpatient setting they have to pay for, why would they care if the patient is released to an expensive nursing home or a less expensive private residence - as long as they aren't paying for it?

I'll admit, I don't usually read the Federal Register, but I've searched the MLN articles for everything I could find on the subject of TCM and have yet to see
that nursing home patients don't count as patients in a community setting. I'll keep my eyes open, but if you can find a link and can pass it on I'd sure appreciate it.
 
Tcm

Hello, has anyone had questions regarding contact made before the patient is discharged? some of my providers are being contacted before patient is discharged, appointments are made. Can this be considered an appropriate contact even though it not done within the 2 day window after discharge? thank you
 
Tcm

Thank you so much,

Kindly provide me the details as under which settings we could bill TCM codes?
Also how to bill CPO services for HOME HEALTH,Assisted living and Hospice patients.
99374/99375,99380,G0181,G0182-Please help.


Susila
 
suzriley said:
Hello, has anyone had questions regarding contact made before the patient is discharged? some of my providers are being contacted before patient is discharged, appointments are made. Can this be considered an appropriate contact even though it not done within the 2 day window after discharge? thank you
Click to expand...

The initial contact must be after the patient is discharged from the facility. CMS has a TCM guide on their website.
 
susila said:
Thank you so much,

Kindly provide me the details as under which settings we could bill TCM codes?
Also how to bill CPO services for HOME HEALTH,Assisted living and Hospice patients.
99374/99375,99380,G0181,G0182-Please help.


Susila
Click to expand...

Susila-

If you take a look at your CPT book, it gives a listing of the codes that cannot be reported with TCM. Also there are several MLN Matters documents relating to TCM as well as a guide to TCM on CMS website.
 
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