Medical Coding for Transitional Care Management Services – Provider – Patient Requirements

by | Published on Jul 26, 2016 | Resources, Medical Coding News (A) | 0 comments

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TCM or Transitional Care Management services are provided to enable patients to transition successfully from a hospital stay back to a community setting. They are provided for an established or new patient whose medical and/or psychosocial problems necessitate moderate or high complexity medical decision making during transition in care from an inpatient hospital setting (acute hospital, long-term acute hospital, rehabilitation hospital), partial hospital, observation status in a hospital/skilled nursing facility/nursing facility to the patient’s community setting which may include home, rest home, domiciliary, or assisted living. A new patient, according to CMS, is one who has not received a face-to-face service from the physician/qualified healthcare professional or another physician/qualified healthcare professional of the very same specialty and subspecialty who belongs to the same group practice, within the past three years. Transitional care management starts on the date of discharge and continues for the next 29 days.

TCM services are to be clearly documented using the CPT codes 99495 and 99496. Medicare will pay for these services only with proper documentation and billing. Many healthcare providers who already meet the requirements to bill TCM face denials and delays in reimbursement because of inappropriate documentation and lack of billing information. These code descriptions have subtle nuances that providers may overlook, and which can be avoided by utilizing medical billing and coding services.

Meet These Requirements to Ensure Timely Reimbursement

Here are some requirements to ensure that you are properly reimbursed.

  • CPT code 99495 for Transitional Care Management Services requires:
    • Communication with the patient and/or caregiver (telephone, direct contact, electronic) 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
  • CPT code 99496 for Transitional Care Management Services requires:
    • Communication with the patient and/or caregiver (telephone, direct contact, electronic) within 2 business days of discharge
    • Medical decision making of high complexity during the service period
    • Face-to-face visit within 7 calendar days of discharge

Both these TCM codes require direct communication with the patient and/or caregiver within 2 business days of discharge. Speaking of business days, weekends and Federal holidays are not considered as business days. This stringent time requirement may be waived if the provider has made 2 or more separate attempts to contact the patient in a timely manner and documented the same in the medical record but has not been able to reach the patient. In such instances, the TCM service can be reported provided all other TCM criteria are met. Nevertheless, CMS is quite strict on the communication requirements to be met by the provider. They expect the providers to attempt to communicate with the patient until they are successful, and have stated that TCM cannot be billed if the face-to-face visit is not furnished within the mandatory timeframe.

An important thing to note is that the face-to-face visit is compulsory with regard to both the TCM codes. This visit is part of the TCM and cannot be reported separately.

Are These Provider – Patient Requirements Met?

Let us now consider the requirements that the healthcare provider and the patient receiving the services must meet to ensure proper reimbursement.

  • Physicians belonging to any specialty can provide TCM services. Legally authorized, qualified non-physician practitioners (NPPs) that include clinical nurse specialists (CNSs), certified nurse-midwives (CNMs), physician assistants (PAs) and nurse practitioners (NPs) can also perform TCM. TCM services may also be performed “incident to” the services of a physician and other CNMs, CNSs, Pas and NPs.
  • TCM services can be provided to patients who are moving from:
    • Inpatient acute care hospital
    • Long-term care hospital
    • Inpatient psychiatric hospital
    • Skilled nursing facility
    • Hospital outpatient observation or partial hospitalization
    • Inpatient rehabilitation facility
    • Partial hospitalization at a community mental health center

Into a community setting such as the following:

  • The patient’s domiciliary
  • The patient’s home
  • A rest home
  • Assisted living

Medical codes for TCM services can be reported if the patient is on hospice as when a patient is discharged home on home-hospice services. However, these codes cannot be used when the patient is discharged from a hospital setting and transferred to a skilled nursing facility.

The healthcare professional should accept care of the beneficiary post-discharge from the healthcare facility setting without a gap, and take responsibility for the beneficiary’s care.

There are some other rules and requirements healthcare providers need to be aware of, which we will be discussing in a follow-up to this blog. Do check back later for more information.

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Being an experienced medical billing and coding company in the U.S., OSI is dedicated to staying abreast of the latest industry guidelines. Our services provide comprehensive support for the success of your practice.

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