Transitional Care Management Services
As I understand it, CPT codes 99495 and 99496 are to be used for transitions in care from an inpatient hospital setting to the patient's community setting. I've had a physician inform me that the codes can also be used when the patient received treatment in the emergency department. In fact, he referenced an article (please see below) from ACP Internist. My question is - Since when is the emergency department considered an inpatient hospital setting???
Anyone hear this as well?
Angie Finnigan, CCS-P, CPMA, CPC
From the February ACP Internist, copyright © 2013 by the American College of Physicians
The new Physician Fee Schedule includes transition care management (TCM) codes that allow for reimbursement of the non-face-to-face care provided when patients transition from an acute care setting back into the community.
Two new codes will be used to pay for all services that up until now were done but not reimbursed.
Code 99495 covers communication with the patient or caregiver within two business days of discharge. This can be done by phone, e-mail or in person. It involves medical decision making of at least moderate complexity and a face-to-face visit within 14 days of discharge. The location of the visit is not specified. The work RVU is 2.11, and intra-service time is 40 minutes.
Code 99496 covers communication with the patient or caregiver within two business days of discharge. This can be done by phone, e-mail or in person. It involves medical decision making of high complexity and a face-to-face visit within seven days of discharge. The location of the visit is not specified. The work RVU is 3.05, and intra-service time is 50 minutes.
Although the Centers for Medicare and Medicaid Services may fine-tune the expectations for the services provided during the TCM time period, in addition to the above, the following required non-face-to-face services differ for staff and for the physician.
Clinical staff (under the supervision of a physician or other qualified clinician) may include:
communicate with the patient or caregiver (by phone, e-mail or in person),
communicate with a home health agency or other community service that the patient needs,
educate the patient and/or caregiver to support self-management and activities of daily living,
provide assessment and support for treatment adherence and medication management,
identify available community and health resources and
facilitate access to services needed by the patient and/or caregivers.
The physician or other qualified clinician may include:
obtain and review discharge information,
review need of or follow-up on pending testing or treatment,
interact with other clinicians who will assume or resume care of the patient’s system-specific conditions,
educate the patient and/or caregiver,
establish or re-establish referrals for specialized care and
assist in scheduling follow-up with other health services.
Since there is some overlap, such as education, it is expected that CMS will clarify the documentation requirements for the use of these codes. Once the requirements are known, ACP will provide additional tools and resources, but since the codes are effective now, we encourage all practices to bill them.
Here are some additional tips regarding use of these new codes:
Medication reconciliation and management should happen no later than the face-to-face visit.
The codes can be used following emergency department visits, inpatient or observation care, or skilled nursing facility stays.
The codes cannot be used with G0181 (home health care plan oversight) or G0182 (hospice care plan oversight) because the services are duplicative.
Billing should occur at the conclusion of the 30-day post discharge period.
They are payable only once per patient in the 30 days following discharge, thus if the patient is readmitted TCM cannot be billed again.
Only one individual can bill per patient, so it is important to establish the primary physician in charge of the coordination of care during this time period. If there is a question, then it might be important to contact the other physician’s office to clarify. The discharging physician should tell the patient which clinician will be providing and billing for the TCM services.
The codes apply to both new and established patients. [/i]
from the Final Rule: (bold is my emphasis)
In the rule, CMS refines the PFS payment for post-discharge care management services. Specifically, the agency will explicitly pay community physicians and qualified non-physician practitioners (NPPs) for post-discharge transitional care management services in the 30 days following an inpatient hospital (acute care, psychiatric, long-term care, inpatient rehabilitation), outpatient observation or partial hospitalization, skilled nursing facility (SNF) or community mental health center (CMHC) stay.
According to CPT: Thes services are for......transitions in care from an inpatient hospital setting.......
Although it is a facility setting, the ED is not an inpatient setting. This is why I always caution coders to get their information from regulatory guidance...not from articles or consultants, unless they quote or reference regulatory guidance.
That was my take on it as well.
Thanks for your response!
However note that the final rule does list outpatient observation as a valid location. Any bed in the facility can be designated as an observation bed. It is not the location but the designation that matters. So if the provider orders observation status as a written order the yes transitional care codes can apply and it is possible the patient will still be physically in the ER
I agree, Deb, but the patient would have to have been admitted into observation status...not just an ED visit. I'm not sure that's the intent of the final rule, but if you happen to see anything that validates ED visits as the catalyst for the TCM charges, please let us know.
Yes the provider must write the order to admit to observation. And you are correct an strait er visit you cannot perform the TCM
Can anyone point me to where I can get a copy of the Final Rule? Either here or firstname.lastname@example.org. Also how are those that use this code keeping track of all the requirements for billing?
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