Wiki Transitional Care Management

[jmartin106]

I have read and researched and cannot find the answer to this for a provider: Does the TCM have to be provider-initiated? The patient contacted us before we could contact her. Can we still bill for TCM?

 

[chantal777]

I believe you can as long as the TCM visit is within 7-14 calendar days of discharge.

 

[mnuhfer04]

I have read and researched and cannot find the answer to this for a provider: Does the TCM have to be provider-initiated? The patient contacted us before we could contact her. Can we still bill for TCM?

A brief overview of the codes shows three key requirements:

99495 Transitional care management services with the following required elements:

• Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 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 Transitional care management services with the following required elements:

• Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge
• Medical decision making of high level during the service period
• Face-to-face visit, within 7 calendar days of discharge

CPT® clarifies, “Within 2 days of discharge is Monday through Friday except holidays without respect to normal practice hours or date of notification of discharge.” This means that if your provider conducts normal practice hours on Saturdays, it counts as a normal business day during which you have a chance to make contact with your patient. If the provider attempts communication by any means (telephone, email, or face-to-face), and after two tries is unsuccessful and documents this in the patient’s chart, the service may be reported.

In relation to providing the first face-to-face visit, calendar days mean every day of the week regardless of operating hours: For 99495, the provider has up to 14 days after discharge to see the patient face-to-face. For 99496, the provider has up to seven days to see the patient face-to-face to evaluate their status post-discharge. The first face-to-face visit is an integral part of the TCM service and may NOT be separately reported with an E/M code; however, you may separately report other medically necessary E/M services to manage the patient’s clinical issues. If in the next 29 days additional E/M services are medically necessary, these may be reported separately. You cannot report an E/M visit and a TCM service on the same day.

Why Bot​