Transitional Care Management Codes

I need some help with the new transitional care management codes. Does anyone know where I can find some information? I have the latest information from CMS, but It doesn't really answer all of the questions that I'm being asked...

re: Transitional Care Management Codes

You do not code the first office visit after discharge, it is part of TC. These services are for a patient whose medical and/or psychosocial problems require moderate or high complexity medical decision making during transitions in care from an inpatient hospital setting (including acute hospital, rehabilitation hospital, long-term acute care hospital), partial hospital, observation status in a hospital, or skilled nursing facility/nursing facility, to the patient’s community setting (home, domiciliary, rest home, or assisted living). Transitional care management commences upon the date of discharge and continues for the next 29 days. You bill the codes at end of 29 days. CMS has made it clear that the physician billing for TCM services should have an ongoing relationship with the beneficiary and the intent is for community based primary care physician billing.
99495 Transitional Care Management Services (Moderate Complexity):
o Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days post-discharge.(The nurse can do and document this.)
o Medical decision making of at least moderate complexity during the service period.
o Face-to-face visit, within 14 calendar days post-discharge.

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

The hospital discharge date can be billed separate. It is the first face-face after discharge that is included in Transitional Care Management. After that any E/Ms can be separately billed.
These services may be billed by only one individual during the 30 day period after discharge.

The TCM codes may not be billed when patients are discharged to a SNF. For patients in SNFs there are E/M codes for initial, subsequent, discharge care, and the visit for the annual facility assessment,
specifically CPT® codes 99304-99318.

http://www.aafp.org/online/etc/medialib/aafp_org/documents/prac_mgt/codingresources/tcmfaq.Par.0001.File.dat/TCMFAQ.pdf

The AMA estimates the higher-level billing code requiring a face-to-face visit with the patient within a week of discharge and would pay roughly $230. The lower-level code includes a face-to-face visit within two weeks and would pay about $160.