Any patient post-discharge whose medical and/or psychosocial problems are complex enough to require TCM services qualifies for these codes. Here are the specifics:
1. Location: “TCM is for higher-risk patients being discharged from an inpatient or observation status to their home, rest home, or assisted living facility,” says Raemarie Jimenez, CPC, CPMA, CPC-I, CANPC, CRHC, director of education for the American Academy of Professional Coders. Basically, this means transitioning from a location where the patient is under the watchful eye of nursing staff 24/7, to a setting where there is less nursing care available (for example, a rest home where the patient is monitored far less frequently).
2. Age: While elderly patients may be more likely to need transitional care management services, “99495 and 99496 can be used for any patient that meets their criteria regardless of age,” Jimenez adds.
3. New vs. Established: CPT’s guidelines clearly state that TCM codes can only be used for established patients. However, CMS disagrees. David A. Ellington, MD, the American Academy of Family Physicians’ AMA CPT® Editorial Panel member, said at AMA’s 2013 CPT® Symposium in mid-November 2012 that “CMS indicated they will modify the prefatory instructions to allow physicians to bill these codes for new patients, not only established patients as specified in CPT®.”
In summary, CMS’ formal statement reads, “We do not entirely agree with the AMA’s recommendation that the physician must have an established relationship prior to the discharge with the patient .... We are concerned that this would make it impossible for those who do not have an established relationship with a primary care physician to receive the benefit of post-discharge TCM services. These patients may well be among those who would benefit most.”
4. Diagnoses: “Pretty much any diagnosis that points to a medically fragile patient — such as chronic lung disease, ventilator dependence, or immune deficiencies — could be coded with TCM codes,” says Suzanne Berman, MD, FAAP, a member of the American Academy of Pediatrics’ Section on Administration & Practice Management and a practicing pediatrician at Plateau Pediatrics in Crossville, TN.
30 Days From Discharge: TCM codes are reported once per patient within 30 days of discharge. So, if your patient is readmitted within the 30-day post-discharge time frame, you can’t bill the TCM codes again. You have to wait until after the current 30-day period is over. Then, if you provide TCM services, you can use the codes again.
When x-rays are audited on the same date as an E/M encounter we have one of three decisions to make about the work that went into the radiological exam when the practice owns x-ray equipment and does their own interpretations internally. First, we must determine whether the x-ray was...
However, is the coding for the treatment and management of diabetes being adequately captured? Diabetes mellitus (DM) affects over 400 million people worldwide. It is a chronic disease of inadequate control of blood levels of glucose that affects the body’s ability to turn food into energy. Essentially, the...
In 2021, two major ESRD programs became effective, essentially preparing to transform not only risk adjusted services, but also at-home dialysis, health equity among beneficiaries needing transplant services, and improved access to donor kidneys.
Reporting IV infusion services can be complicated, especially when multiple infusions are reported in a single encounter. Take a few minutes to freshen up your knowledge on IV hydration coding with a review of the guidelines and a few coding scenarios.
Overlapping extrapolations require providers to pay twice. Some Medicare auditors have been caught “double-dipping,” the practice of sampling and extrapolating against the same set of claims. This is like getting two traffic tickets for a single instance of running a red light. This seedy practice doubles the amount...
Although HIPAA Security protocols have been in effect for some time, as technology advances, if we are not diligent, gaps can be left available for intruders. On top of that, on February 23, 2022, the American Hospital Association issued a cybersecurity advisory. They stated, “there is concern that Russia may retaliate against the U.S. and allied nations with disruptive cyberattacks.”
It’s important to remember that Medicare manuals are not binding, and they can’t “require” anything, including signatures. Regulatory framework is constantly changing. Never assume you know all of the rules, even if you carefully study them all the time. New things are constantly appearing....