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Field Guide to Physician Coding 3rd Edition



Codapedia Editor
Transitional Care Management Services (TCM) UPDATE
Citations: No citations found
Resources: CMS FAQ (pdf)   CMS FAQ UPDATED (pdf)  
Total Reviews: 13
Current Rating: •••••••••

CMS Frequently Asked Questions posted as a resourse 3/8/13.

DATE of Service:  counting the discharge as day 1, bill on day 30.  That is, after 29 days after the date of discharge has passed.

PLACE of Service:  place where the mandated, bundled, non-reportable E/M service took place.

By now, you’ve heard the news that one of the ways in which Medicare plans to support primary care practices is by paying PCPs to provide post-discharge care of patients. (Although the service is not limited to PCPs as you’ll see if you read further.) The new service, defined by CPT®, includes both face-to-face and non-face-to-face component in the definition. Medicare rarely defines a covered service that does not require a face-to-face service with a beneficiary, so this service stands out

Lets start with the CPT® definitions. When Medicare first proposed the service in the summer of 2012, they intended to develop a HCPCS GXXXX code. However, instead they decided to use CPT® codes 99495 and 99496. These are new codes in the 2013 CPT® book.

99495: Transitional Care Management Services with the following required elements:
  • Communication (direct contact, telephone, electronic) with the patient and/or caregiver 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.

99496: Transitional Care Management Services with the following required elements:
  • Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge
  • Medical decision making of at least high complexity during the service period
  • Face-to-face visit, within 7 calendar days of discharge.

These services are provided to patients who are discharged from inpatient or observation status admissions, skilled nursing facilities (SNF) and partial hospitalization programs back into the community. The payment is for the work of the physician or Non-Physician Practitioner who accepts the care of the patient post-discharge without a gap and takes responsibility for the patient’s care. TCM may not be billed for transfer from a hospital to a SNF. TCM may not be billed by a surgeon when the patient is in the global period. TCM may be billed by the same physician who discharged the patient from the hospital. TCM may be billed by any specialty physician.

The physician may only bill the service 30 days after the discharge and only one provider will be paid TCM for any one patient discharge. Although CPT® defines these as services to new patients, CMS states they may be reported for new or established patients. The service is for patients whose medical and/or psychosocial problems require high or moderate complexity.

Here is how CMS describes the components of TCM in the 2013 Final Rule:

Transitional care management is comprised of one face-to-face visit within the specified time frames, in combination with non-face-to-face services that may be performed by the physician or other qualified health care professional and/or licensed clinical staff under his or her direction. It is our expectation that the services in the two lists of non-face-to-face services below will be routinely provided as part of transitional care management service unless the practitioner’s reasonable assessment of the patient indicates that a particular service is not medically indicated or needed.

Non-face-to-face services provided by clinical staff, under the direction of the physician or other qualified health care professional, may include:
  • Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge.
  • Communication with home health agencies and other community services utilized 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
  • Facilitating access to care and services needed by the patient and/or family.

Non-face-to-face services provided by the physician or other qualified health care provider may include:
  • Obtaining and reviewing the discharge information (for example, discharge summary, as available, or continuity of care documents).
  • Reviewing need for or follow-up on pending diagnostic tests and treatments.
  • Interaction with other qualified health care professionals who will assume or reassume care of the patient’s system-specific problems.
  • Education of patient, family, guardian, and/or caregiver.
  • Establishment or reestablishment of referrals and arranging for needed community resources.
  • Assistance in scheduling any required follow-up with community providers and services.
Transitional care management requires a face-to-face visit, initial patient contact, and medication reconciliation within specified time frames. The first face-to-face visit is part of the transitional care management service and not reported separately. Additional E/M services after the first face-to-face visit may be reported separately. Transitional care management requires an interactive contact with the patient or caregiver, as appropriate, within 2 business days of discharge. The contact may be direct (face-to-face), telephonic, or by electronic means. telephonic, or by electronic means. Medication reconciliation and management must occur no later than the date of the face-to-face visit.

Some of the work of TCM may be performed by “clinical staff under the direction of the physician or other qualified health care professional” according to CPT® and CMS. This includes communication and education with the patient and/or caregiver, communication with home health agencies, assessment and support for treatment and adherence to medication regimen, assessment of available community and health resources, and facilitating care. The physician or NPP would obtain/review the discharge documents, review the need for follow up or pending diagnostic tests, interact with other health care professionals involved in the patient’s care, educate the patient/family as needed, establish or reestablish community resources and assist in scheduling medical or community resources.

TCM does require a face-to-face service within the time frames above and the first face-to-face service is not separately billable. Subsequent E/M services during the 29 day period or other diagnostic or therapeutic services may be billed separately. Note that medication reconciliation must be done no later than the first E/M service and that E/M service must occur within the time frame for each code.

Finally, how do we define the difference between moderate and high complexity? Again, from the 2013 Physician Rule, CMS reminds us that the source is the Documentation Guidelines, and reviews the difference between moderate and high.

Medical decision making is defined by the E/M Services Guidelines. The medical decision making over the service period reported is used to define the medical decision making of transitional care management. Documentation includes the timing of the initial post discharge communication with the patient or caregivers, date of the face-to-face visit, and the complexity of medical decision making.

(The E/M Services Guidelines define levels of medical decision making on the basis of the following factors:
  • The number of possible diagnoses and/or the number of management options that must be considered;
  • The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed; and
  • The risk of significant complications, morbidity, and/or mortality as well as comorbidities associated with the patient’s presenting problem(s), the diagnostic procedure(s), and/or the possible management options.?Medical decision making of moderate complexity requires multiple possible diagnoses and/or the management options, moderate complexity of the medical data (tests, etc.) to be reviewed, and moderate risk of significant complications, morbidity, and/or mortality as well as comorbidities. Medical decision making of high complexity requires an extensive number of possible diagnoses and/or the management options, extensive complexity of the medical data (tests, etc.) to be reviewed, and a high risk of significant complications, morbidity, and/or mortality as well as comorbidities)

Before we end this discussion, remember to document the work that is done. Document the non-face-to-face services, the contact at two days, the medication, the phone calls, the education, the coordination.
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Click Here to Comment, Clarify and Rate this Article

Wed, Apr/08/2015
Ratings: •••••
How does my provider date their note
Hi. What date(s) are my providers suppose to use for their documentation? I know we can bill until after the 30 days from date of discharge but how should the date(s) of service be reflected on our notes/documents?


Sat, Dec/21/2013
NGS paying on TCM
We just trans. from NHIC to NGS. We are billing and getting paid for the TCM. We have discrepancies in the office re: DOS; some billers say DOS on claim doesn't matter; others say, "Guidelines say DOS=30 days AFTER discharge"; but the DOS we are using is varying. One claim I saw the dos was 2-days after dc. We are 'reporting' 30-days later.

We are now wondering if they are paying out now; auditing and recouping later. :-| ?

I haven't done a complete search on the codes/dos/but this will be a topic of discussion of the upcoming week.

Fri, May/03/2013
2 business days
If the patient is SEEN within two business days, can the initial contact and face-to-face service be combined into one encounter?

Wed, Apr/10/2013
office manager
Looks like they denied b/c they did not get any hospital billing yet. But they did not wait the 21 days for my claim they just denied a few days after I submitted. I have a few claims that paid and several pending but so far only one denial.

Codapedia Editor
Thu, Mar/28/2013
Re-read the article and the note that the date on the claim for TCM must be day 30, starting with the date of discharge being day one.

The Medicare FAQ are attached.

Thu, Mar/28/2013
Billing Coordinator
The billing date of service, as far as I can understand it, should be when the face to face is encoutered, either 7 or 14 days after discharge. You are receiving the N237 denial because the physician who discharged the patient from the hospital has not billed. Medicare will receive the bill for the 99495 or 99496 and will hold it for 21 days, pending the discharge billing has been received by them. If none is received in 21 days Medicare will then deny the claim with the N237. It is nothing you have done, unless of course, the physician didn't see the patient within the required time frame. In the article we are all commenting on, she states to hold the bill for 30 days from the date of the face to face. That, I beleive, Medicare is waiting for the physicians or hospitals discharged bill. (info given me from Medicare). Hope this helps....its all so new!

Tue, Mar/26/2013
denied n357
I just rcvd a denial from novitas medicare for a 99495 the denial was N357 time frame requirements not met. I think I was too many days past the 30 days, patient was d/c on 01/28/13 and I billed 02/28/2013 but should have billed 02/26/13. I am going to call and correct this tomorrow and I will post and let you know what happens.

Wed, Mar/20/2013
Ratings: •••••
sucess??? anyone??
Has anyone billed a TCM code and had a payment?

Tue, Mar/12/2013
Medical biller
Has anyone had a denial from Medicare regarding payment on the Transitional Care codes pending submittal of discharge bill from the physician that discharged the patient? Medicare stated before they can process our charges, they first need the bill from the discharge doctor. Sometimes it is not our Primary care doctors that discharge the patient, but then are taking over their care from the hospital.

Sun, Mar/03/2013
Ratings: •••••
tcm audit
If medicare audits a TCM claim, what do they want to see. I understand the lengthly list of required components in the article but that does not answer the question precisely. All those things can be done but what should be documented. For example, a 99214 audit has specific items to be ON THE NOTE.

Can we dicate a 99214 note (thats moderate complexity TCM), add afew lines on the note that discharge summary was reviewed and contact made in 48 hours to coordinate care. Is there anything else we should WRITE on the progress note? Or do we need to copy paste your article with a check box, and add a 99214 level note with moderate MDM.

What would stand up to a medicare documentation audit for TCM encounters?

Wed, Feb/27/2013
Invalid POS for TCM?
We are a provider based billing facility and we must submit our claims with a POS 22. We submitted the TCM code 99496 with a POS 22 and received an X5 denial from Palmetto Medicare for invalid POS? How should we handle this or is this something they are working on?

Wed, Feb/13/2013
Ratings: •••••
Error in Article
Hi, Just thought you might like to know that the second code you have listed, you have listed as 99465, not 99496.

Codapedia Editor
Thu, Jan/10/2013
Place of service
I had a question from someone about what POS to bill. I suggest POS 11. CMS hadn't released the transmittal last time I looked.

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