Forum - Questions & Answers

Jan 21st, 2016 - smilsdo 1 

Transitional care code questions

2 separate questions re:99496

1) Pt with commercial insurance for all of 2015. Discharge date of 12/3/15. Seen for hospital fu within 7 days for 99496. As claim needed to be held x 30 days post d/c date, it was submitted after 1/1/16. As of 1/1/16, patient lost his commercial insurance and is now on managed Medicaid, Gateway. Claim was submitted originally to his commercial insurance (UPMC Health Plan) as that was last insurance presented to office when seen. They denied claim as pt "no longer has coverage" with them. Then tried to resubmit to Gateway and gets denied as Gateway didn't cover the original hospitalization. What can I do? The games are infuriating.

2) 99496 claim submitted to Gateway Medicare Assured product for a mental health admission for flair of bipolar disorder and schizoaffective disorder. Submission timing accurate yet insurance states they cannot find admission information in system. Are behavioral health admissions not covered under transitional care coding?

Thank you.

Jan 21st, 2016 - LBAROGIANIS 250 

re: Transitional care code questions

Can't you just bill it as an established patient? Ex: 99213.

Jan 22nd, 2016 - smilsdo 1 

re: Transitional care code questions

Why would I sacrifice the time spent and revenue generated to code this as a payment of nearly 1/3 of what I should be collecting?

Jan 22nd, 2016 - Codapedia Editor 1,399 

re: Transitional care code questions

I completely agree with reporting TCM.

99496 requires that the patient's condition had "high MDM" at least one day during the 30 day TCM period. That is, you would have billed it as a 99215 as an office visit, or the patient's condition at discharge was still highly complex.

In the first situation, with TCM crossing the coverage of two insurance companies--I agree it is infuriating. I'd probably just go back and pick up the E/M on the day you saw the patient.

For the second question, according to CPT® rules, transitions from inpatient, OBS, nursing facility and partial hospitalization to non facility (home) qualifies. There is no reason that a psychiatric admission should be denied.


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