Coding Transition Care Management

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Original story posted on: July 8, 2019

New patient management service codes.

The Medicare Physician Fee Schedule (MPFS) recently added several patient management service codes that have face to face and non-face-to-face components to them for physician reimbursement. One of those services is transition care management (TCM). These CPT® codes allow for reimbursement of the care provided when patients transition from an acute care or hospital setting back into the community setting (home, domiciliary, rest home, assisted living).

TCM commences upon date of discharge and then for the next 29 days. There is a combination of face to face and non-face to face services within this time frame. There has been some misinformation out there on the requirements to report these codes that has triggered some payer audits, so we wanted to clear up any confusion.

CPT Code 99495 covers communication with the patient and/or caregiver within two business days of discharge. This is a reciprocal communication of direct contact that can be done by phone or electronic means. It involves medical decision making of at least moderate complexity during the service period and a face-to-face visit within 14 days of discharge. The location of the visit is not specified, but where the face to face occurs is the POS that is used for reporting purposes. The work RVU is 2.11 or an approximate reimbursement of $75.96

CPT Code 99496 covers the same code details, involves medical decision making of high complexity and a face-to-face visit within seven days of discharge. The work RVU is 3.05. or an approximate reimbursement of $109.80

Although the Centers for Medicare & Medicaid Services (CMS) continues to fine-tune expectations for the services provided during the TCM time period, in addition to the above, the following required non-face-to-face services may differ for physician/midlevel provider and the clinical staff.

Clinical staff (under the supervision of a physician or other qualified clinician) may include the following:

  • Communicate with a home health agency or other community services 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
  • Communicate with the patient or caregiver regarding aspects of care. Check your local MAC carrier for their LCD on who can make the 48-hour call. In some states, it has to be either an MD/DO or a mid-level who has direct knowledge of the patient’s care plan.

The physician or other qualified clinician services may include the following:

  • 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.

Some additional service that would be expected to be documented in regarding use of these codes would be:

  • Medication reconciliation and management should happen no later than the face-to-face visit.
  • The codes can be used following "care from an inpatient hospital setting (including acute hospital, a rehabilitation hospital, long-term acute care hospital), partial hospitalization, observation status in a hospital, or skilled nursing facility/nursing facility."
  • The codes cannot be used with G0181 (home health care plan oversight) or G0182 (hospice care plan oversight), Home and outpatient INR monitoring, (93792-93793), Medical Team Conferences, Education and training, telephone services, ESRD services, CCM, and medication therapy management services because the services are duplicative.
  • Billing should occur at the conclusion of the 30-day post-discharge period. Now CMS put out on their website FAQ’s in 2018, saying that the date of the face to face can be the date the entire service is billed. But I would use caution and common sense here. Once all of the 30 days of service is met, then report the code. By reporting prior to the 30-day period, you run the risk of staff not finishing the tasks that are part of the code compliance.
  • 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.
  • The reporting provider provides or oversees the management and/or coordination of services as needed, for all medical conditions, psychosocial needs and ADL support providing first contact and continuous support.

Can these codes be billed in the post-operative period? Not for the physician that reported the global service.

CPT versus. Medicare on two-way Interactive Contact

The contact must include the capacity for prompt interactive communication addressing patient status and needs beyond scheduling follow up care. If two or more separate attempts are made to contact the patient and are unsuccessful, but other TCM criteria are met, CPT instructs to report the service, however, CMS frowns on this direction. There must be evidence of direct patient reciprocal contact to report these services to Medicare.

Per CPT, these services, “address any needed coordination of care performed by multiple disciplines and community service agencies. The reporting individual provides or oversees the management and/or coordination of services needed, for all medical conditions, psychosocial needs and activity of ADL support by providing first contact and continuous access”.

Before you make the decision to take this on, your practice should have a conversation, is it worth it to bill for these services based on the reimbursement offered? You are taking on the entire “transitional care” of this patient. If you plan to do so, realize the work, clinically and administratively, the cost, the reimbursement, and the payer expectation.  

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Terry Fletcher, BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, CMCS,  ACS-CA, SCP-CA, QMGC, QMCRC

Terry Fletcher, BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, CMCS, ACS-CA, SCP-CA, QMGC, QMCRC, is a healthcare coding consultant, educator, and auditor with more than 30 years of experience. Terry is a past member of the national advisory board for AAPC, past chair of the AAPCCA, and an AAPC national and regional conference educator. Terry is the author of several coding and reimbursement publications, as well as a practice auditor for multiple specialty practices around the country. Her coding and reimbursement specialties include cardiology, peripheral cardiology, gastroenterology, E&M auditing, orthopedics, general surgery, neurology, interventional radiology, and telehealth/telemedicine. Terry is a member of the ICD10monitor editorial board and a popular panelist on Talk Ten Tuesdays.

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