Forum - Questions & Answers

Aug 17th, 2015 - Sha12 62 


Pt was discharge on 07/08/15. Pt called the office on 07/09/15 & scheduled him on 07/15/15. I know that we have to bill the face to face visit within 30 day period. Can I still bill the TCM code even if its over 30 days or just bill the E/M code bcoz I missed track of the billing period?

After post discharge, were supposed to contact or pt has to contact us within 2 days. Is the weekend counted as business days? What if we are in contact over 2 days, we can't bill TCM? Thanks!

Aug 17th, 2015 - rhansen 1 

re: TCM

Transitional Care Management is based on medical complexity, moderate (99495) or high complexity (99496). Below is some info I created for our clinic in a table format which didn't paste here very well. Hope it helps.

CPT® *99495-99496
Transitional Care Management


These services are for a new or established patient whose medical and or psycho-social problems require MODERATE or HIGH complexity medical decision making during transitions in care from an inpatient hospital setting (including acute care hospital, rehabilitation hospital, long-term acute care hosp, partial hosp, observation status in hospital or skilled nursing facility/nursing facility to the patient’s community setting (home, domiciliary, rest home, or assisted living. TCM commences upon the date of discharge and continues for the next 29 days.

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

**Provider: Review discharge information and determine the medical complexity of the patient, assign management code.(Refer to E&M Coding Sheet for MDM guide)
• Document the face-to-face visit as you would any E&M visit, making sure that the
medication reconciliation is adequately documented, as well as the plan of care.

• Although the face-to-face visit does not need to meet the requirements for existing
E&M codes, documentation should support the medical necessity and complexity
of the overall transitional care management services.


**Communication: May be by the physician or qualified health care professional or clinical staff. Within 2 business days of discharge Monday through Friday except holidays without respect to normal practice hours or date of notification of discharge. Contact must include capacity for prompt interactive communication addressing patient’s status and needs beyond scheduling follow-up care. If two or more attempts are made in a timely manner, but are unsuccessful and other transition care management criteria is met, the service may be reported. (CPT® 2014, pg. 49)
**Call documentation is imperative

**Medication Reconciliation and Management must be furnished no later than the date you furnish face to face visit. MA can obtain information during initial phone call.

Additional E&M Services
Reasonable and necessary evaluation and management (E/M) services (other than the required face-to-face visit) to manage the beneficiary’s clinical issues should be reported separately; with the exception of those services that cannot be reported according to CPT® guidance and Medicare HCPCS codes G0181 and G0182.

To a Skilled Nursing Facility (SNF)
Cannot bill TCM if patient is going to a Skilled Nursing Facility.
Use codes for initial, subsequent, discharge care and annual facility assessment.

Who Initiates TCM:
• No specific mention in final rule
• Discharging Physician is referenced in communications
? Discharge Planner by default seems appropriate
? No phone call from hospital for patient appointment

Billing Discharge Care
• 99217, 99234-99236, 99238-99239 or 99315-99316
• MAY NOT use visit on date of discharge as required E&M
• May provide and bill TCM subsequently
• Discharging physician would communicate with the primary care as necessary

Non-Discharging Physician or NPP
• May be primary care physician or NPP
• May perform the required TCM face-to-face E&M visit on date of discharge
• May provide remainder of TCM services subsequently

Clinical Staff services provided under the direction of the provider:
• Communication:
• With patient, family, guardian, or caretaker regarding aspects of care
• Home health agencies and other community service utilized by patient
• Education to patient and/or family 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
• Face-to-face – If patient scheduled within the 7 day time period the provider can
assign medical complexity at the initial F2F.
• Documentation with all parties is critical throughout the 30 day period (care taker, home
health, etc)

Date of service - 30th day

CPT® Codes
Moderate MDM - 99495 – 14 day Face-to-Face
High MDM – 99496 – 7 day Face-to-Face

Additional E&M as medically necessary

Documentation Requirements:
• Two day phone call
• Medication Management (no later than F2F visit)
• Complexity of medical decision making

Note: If 2 day phone call is not documented services may not be billed.

RHansen 10/14
CPT® American Medical Association

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