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Transitional Care Codes (99495, 99496)

  1. Default Transitional Care Codes (99495, 99496)
    Medical Coding Books
    The Final Rule states a "licensed clinical staff" can perform the non face to face portion of transitional care. Does anyone one know what Medicare considers "licensed clinical staff'? Can a certified CMA perform it?

  2. #2
    Dover Seacoast New Hampshire
    We're specifically using registered nurses who have already been implementing a chronic care management program (now we can get paid for some of their work!!).
    However the level of "license" is not clarified. I would interpret this to mean that the employee under physician supervision who provides the non-face-to-face service have to hold some sort of clincial license or certification: LNA, CNA, MA, LPN, RN or BSN, and be practicing within the scope of their licensure. The decision as to whether the licensed staff is qualified to provide the care would be up to the provider, since they are responsible for the overall patient care and documentation of the work being done. This would elminiate any work done by non-clinical certified staff (such as coders) or any non-certified staff, such as practice managers or billers or non-certified MAs.
    Pam Brooks, MHA, COC, PCS, CPC, AAPC Fellow
    Coding Manager
    Wentworth-Douglass Hospital
    Dover, NH 03820

    If you can dream it, you can do it. Walt Disney

  3. #3
    Newtown, PA
    Red face Transitional Care Management Services
    Hi there!

    Here is the info I located on the Federal Register website at:
    Listed in Section H under "Primary Care and Care Coordination" subsection
    C. "Proposed Payment for Post-Discharge Transitional Care Management Services"

    regarding the definition of Qualified Healthcare Professional and Clinical Staff:

    "For practice expense, we are accepting the AMA RUC-recommended practice expense inputs for these codes with one refinement to clinical labor time for CPT code 99496. We are refining the 60 minutes of recommended clinical labor time for a RN/LPN nurse blend dedicated to non-face-to-face care management activities from 60 minutes to 70 minutes. We believe that the total clinical labor staff time and physician intra-service work time that the AMA RUC-recommended for non-face-to-face care management activities was accurate, but that the proportionality between physician work and clinical staff time should be refined to reflect greater clinical staff time. In response to the comment on appropriate clinical staff type for non-face-to-face care management services, we note that we are accepting the AMA RUC recommended clinical labor staff type of an RN/LPN for conducting non-face-to-face care coordination activities. The AMA RUC did not include additional costs for computer, EHR, and telephone in their recommendations. We believe accounting for the infrastructure required to furnish advanced primary care services is an issue we will consider as we pursue the broader HHS and CMS multi-year strategy to recognize and support primary care and care management under the MPFS"

    Hope this helps!

    Nancy Roche (Lynch), BA, CPC, CBIS
    Compliance Billing and Coding Auditor
    Abington Memorial Hospital
    Abington, PA 19053
    Last edited by nkroche; 02-04-2013 at 03:42 PM. Reason: credentials

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