Billing for transitional care management

Q: Can you give us more information about transitional care management (TCM) codes? We know they reimburse at a high rate and would like to set up a process in our practice to use these codes.

A: In 2013, the Centers for Medicare and Medicaid Services (CMS) estimated that two-thirds of all hospital discharges would be eligible for Transitional Care Management (TCM) services. Additionally, CMS estimated that TCM reimbursements would generate a 4% increase in payments to family practice physicians, 3% each for internal medicine and pediatrics, and 2% each for gerontologists, nurse practitioners and physician assistants.

Why is CMS willing to allot this much money for TCM services? To increase the quality of patient care and reduce hospital re-admissions.

TCM codes 99495 and 99496 are used to report physician or qualified non-physician practitioner care management services for a patient following the patient’s discharge from:

• an inpatient hospital,

• partial hospital,

• observation status in a hospital,

• skilled nursing facility/nursing facility, or

• community mental health center

to the patient’s community healthcare setting, including:

• home,

• domiciliary,

• rest home, or

• assisted living.

TCM codes do not apply to patients who have only been seen in the emergency department.

Documentation and other rules

Requirements for billing TCM codes 99495 and 99496 include:

• the services are performed during the first 30 days of the beneficiary’s transition to the community setting following particular kinds of discharges;

• the healthcare provider accepts responsibility for the beneficiary’s care post-discharge from the facility setting without a gap; and

• the (new or established) patient has medical and/or psychosocial problems that require moderate or high complexity medical decision-making.

Documentation must include:

• date of initial discharge;

• date of post-discharge communication with patient or caregiver;

• date of the first face-to-face visit;

• medication reconciliation; and

• complexity of medical decision-making (moderate or high)

The TCM service period begins on the day of discharge and continues for the next 29 days. The reported date of service should be the 30th day.

The only codes bundled with TCM codes are care plan oversight services (CPT codes G0181 and G0182), and end-stage renal disease services (CPT codes 90951-90970). Additional services provided during the 30-day period (i.e., diagnostic tests, evaluation and management [e/m]services following the initial visit) can be billed separately.

The place of service reported on the claim should correspond to the place of service of the required face-to-face visit.

Medicare encourages practitioners to follow Current Procedural Terminology (CPT) guidelines when reporting TCM services. Medicare also requires that when a practitioner bills Medicare for services and supplies commonly furnished in physician offices, the practitioner must meet the “incident to” requirements described in Chapter 15, Section 60 of the Benefit Policy Manual 100-02.

It is important to emphasize that non-face-to-face services may be provided by licensed clinical staff members (i.e., an RN, LPN, CRN, but not an MA.) Such services include:

• communication with patient, family, guardian, caretaker, and/or other professionals;

• communication with home health agencies and other community services used by the patient;

• patient and/or family/caretaker education to support self-management, independent living, and activities of daily living;

• assessment and support for treatment regimen adherence and medication management;

• identification of available community and health resources; and/or

• facilitating access to care and services needed by the patient and/or family

Medicare will pay only the first eligible claim submitted during the 30-day period beginning with the day of discharge. Other practitioners may continue reporting other reasonable and necessary services, including other E/M services, provided to beneficiaries during those 30 days.

If the patient is readmitted during the 30-day period, 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 or 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.

Because the TCM codes describe 30 days of care, if  the beneficiary dies prior to the 30th day, practitioners should not report TCM services but may report any face-to-face visits that occurred using the appropriate E/M service code.

While Federally Qualified Health Centers (FQHC) and Rural Health Centers (RHC) are not paid separately by Medicare under the Physician Fee Schedule, the face-to-face visit component of TCM services could qualify as a billable visit in a FQHC or RHC.

Additionally, physicians or other qualified providers who have a fee-for-service practice separate from the RHC or FQHC may bill the TCM codes, subject to the other requirements for billing under Medicare’s fee schedule.

While commercial payers are still catching up in paying these codes, Medicare’s reimbursement makes it worth the time to establish a process for billing TCM codes.

Next: billing requirements for TCM

Proper billing for TCM services using the 99495 code must include:

• communication (direct contact, phone, or electronic) with the patient and/or caregiver within 2 business days of discharge;

• a face-to-face visit within 14 calendar days of discharge; and

• medical decision-making of at least moderate complexity during the service period.

Proper billing for TCM services using the 99496 code must include:

• communication (direct contact, telephone, or electronic) with the patient and/or caregiver within 2 business days of discharge;

• a face-to-face visit within 7 calendar days of discharge; and

•     medical decision-making of at least high complexity during the service period.

The answer to the reader’s question was provided by Renee Dowling, a billing and coding consultant with VEI Consulting in Indianapolis, Indiana. Send your coding and billing questions to medec@advanstar.com.