# Transitional Care Management - the CPT codes



## jssilver1204 (Nov 20, 2012)

I understand that Medicare is encouraging Transitional Care management.  Codes 99495, 99496.  This is what the AOA has to say about it:  The requirements of the CPT codes are:
99495, TCM: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within two 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, TCM: Communication (direct contact, telephone, electronic) with patient and/or caregiver within two business days of discharge; Medical decision-making of high complexity during the service period, face to face visit within seven calendar days of discharge.

Does anyone have any other info about this? I'm wondering if you have to talk to the patient/caregiver within 2 days of discharge AND see the patient face to face.

Jennifer


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## Pam Brooks (Nov 26, 2012)

I haven't yet seen anything from CMS about these codes other than that they're going to be implementing a G-code for TCM without a face-to-face component.  CPT has a great description of the guidelines, but I'm still waiting for CMS to either embrace these guidelines or come up with their own.  Since the fee schedule lookup still shows 2012B, I don't even know if/how much they're going to cover the TCM and CCCM CPT codes. 

Does anyone else have any information?


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## dseyfried (Nov 27, 2012)

TCM requires a couple of things. First: physician or staff must contact the patient within 2 business days of discharge.  This can be done by phone, e-mail, or in person.  Medication must be reconciled by their first face to face visit.  99495 is to be used for patients with moderate complexity medical decision making, and must be seen face to face in 14 days of discharge.  99496 is to be used for patients with high complexity medical decision making and must be seen face to face within 7 days of discharge.  The rule lists several things that physician and or staff can do such as education of the patient and/or caregiver, establishing or re-establishing community and social services, coordinating office appointments with physicians that previously cared for the patient, referrals to social services. They are covering the TCM and it pays about $30 more than a 99214 and requires less physician work.


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## jssilver1204 (Nov 30, 2012)

In the new CPT book I see it says that the medical complexity is for the service reporting period.  Do you think the service reporting period is the time the patient is in the hospital, or just the time between discharge and being seen face to face?


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## Pam Brooks (Nov 30, 2012)

The 'service period reporting' is the time following the date of discharge through the next 29 days, according to CPT.  So if the patient has moderate or high MDM for services during those days, they'd qualify.  Follow your MDM grid from your carrier's audit tool to determine if they meet at least the moderate.


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## CMWCODER (Dec 10, 2012)

Does anyone know how the contact with the patient for TCM with 2 business days is known/documented since it is a requirement?  Or is the 99495/99496 the only thing to bill?
thanks
C


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## dseyfried (Dec 11, 2012)

The contact within in 2 business days should be communication via phone, electronic such as e-mail, or direct face to face.  There is no additional code to bill this as proof.  It becomes part of your documentation toward the visit.


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## mobrien (Dec 11, 2012)

RE: TMC Documentation
I am seeing that it needs to include:   Date of patient's discharge, Initial patient contact within 2 days-either phone or email, MDM must be documented-using CMS guidelines, Documented face-to-face encounter.  No separate code for the E/M should be billed.  That at the end of the 30 days the appropriate TMC code can be billed.   Is this correct?   Anything new with the CMS G-code?
Thank you


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## trish53dun@aol.com (Dec 13, 2012)

*TCM question*

Would 99495 be appropriate to use as a follow-up to an Emergengy Room visit?


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## Pam Brooks (Dec 14, 2012)

Hi, I'm attaching a guide I put together for our Internal and Family practice groups to assist with billing understanding and documentation criteria in our EHR for these codes.  I hope it's helpful.  I think it will clear up a lot of confusion.    


Also, read Debra Seyfried, MBA, CMPE, CPC's article about TCM at
http://blogs.aafp.org/fpm/gettingpaid/entry/cms_approves_new_codes_for

Have a good weekend, everyone.  Pam


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## ARAINES (Dec 16, 2012)

dseyfried said:


> TCM requires a couple of things. First: physician or staff must contact the patient within 2 business days of discharge.  This can be done by phone, e-mail, or in person.  Medication must be reconciled by their first face to face visit.  99495 is to be used for patients with moderate complexity medical decision making, and must be seen face to face in 14 days of discharge.  99496 is to be used for patients with high complexity medical decision making and must be seen face to face within 7 days of discharge.  The rule lists several things that physician and or staff can do such as education of the patient and/or caregiver, establishing or re-establishing community and social services, coordinating office appointments with physicians that previously cared for the patient, referrals to social services. They are covering the TCM and it pays about $30 more than a 99214 and requires less physician work.


Does this apply to patients discharged from inpatient settings to Community Mental Health Centers?


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## Pam Brooks (Dec 17, 2012)

The language in CPT says, "patient's community setting:  Home,  domiciliary, rest home or assisted living".  

If you note, none of these have a resident medical component.  So it may be that a community mental health center would not be appropriate, because there is usually a psychiatrist or psychiatric nurse practitioner available. Check with your CMS contractor to be sure.


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## efuhrmann (Dec 17, 2012)

who is "they" in "they are covering the TCM charges $30 more than 99214"?


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## Pam Brooks (Dec 18, 2012)

efuhrmann said:


> who is "they" in "they are covering the TCM charges $30 more than 99214"?


 
She probably means CMS fee schedule.  Allowable fee for 99495 is $163.00, and for 99496 is $230.00 (depending on your geographical location), with 4.82 and 6.79 total RVUs respectively.


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## maryanneheath (Dec 26, 2012)

Pam, where were you able to find the actual RVUs listed on your guide? (very helpful, by the way!!)


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## Cynthia Hughes (Dec 26, 2012)

*Medicare TCM services*

If you are billing Medicare for TCM, be sure to read the final rule for the Medicare Physician Fee Schedule before reporting. CMS will allow TCM for both new and established patients (same codes are reported), require all TCM activities be provided or documented by the physician as not necessary, face-to-face visit cannot be on same date as hospital discharge, and charges for TCM are billed after the end of the period.

https://www.federalregister.gov/art...physician-fee-schedule-dme-face-to-face#t-124

 PS No G codes for TCM services. CMS accepted the CPT codes for these services.


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## Pam Brooks (Dec 27, 2012)

Cynthia Hughes said:


> If you are billing Medicare for TCM, be sure to read the final rule for the Medicare Physician Fee Schedule before reporting. CMS will allow TCM for both new and established patients (same codes are reported), require all TCM activities be provided or documented by the physician as not necessary, face-to-face visit cannot be on same date as hospital discharge, and charges for TCM are billed after the end of the period.
> 
> https://www.federalregister.gov/art...physician-fee-schedule-dme-face-to-face#t-124
> 
> PS No G codes for TCM services. CMS accepted the CPT codes for these services.


 
Yes, CMS will allow for new patients...however CPT indicates established patients, so you'll have to be aware of this if providing services to commercial payers who might have other guidelines from CMS.  Check your payer guidelines before you submit, just in case! Not all of our patients who will receive this services are Medicare recipients, so we have to be cautious, until we know for sure with our commercials.  

I got the RVUs from an article from the AAFP by Debra Seyfried, MBA, CMPE, CPC, who referenced CMS. http://blogs.aafp.org/fpm/gettingpaid/entry/cms_approves_new_codes_for
 I also got the RVUs from our Fee Calc Software, released 11/1/12.


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## 00017883 (Jan 3, 2013)

Does anyone know if in the final rule we must wait 30 days from discharge before we can submit the 99495 for instance? Waiting would require us to manually hold a charge for potentially a couple of more weeks.  Usually our bills generate a claim as soon as they are posted.

Thanks
Cherry Pence
Saint Luke's Medical Group


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## Pam Brooks (Jan 4, 2013)

You must wait the full 30 days.  The charge includes all related work done by your nurse care managers and non-face-to-face provider work during that entire month.  Submitting it early will cause a denial.


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## JudithHines (Jan 8, 2013)

Can you tell me if I have to wait until after the 30 TCM period to bill for this? Also, would the correct diagnosis code be the codes used for the hospital stay?


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## lbeeson (Jan 9, 2013)

*Business days*

If a person is discharged on Monday (anytime that day), do the 2 business days start on Tuesday?   I just want to make  sure it is truly 2 days vs 48 hours from discharge.

Linda Beeson, CPC


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## Pam Brooks (Jan 10, 2013)

Per CPT (2013 Professional Edition, page 45), "TCM requires an interactive contact with the patient or caregiver, as appropriate, within two business days of discharge."  If they're discharged on a Monday, I would interpret this to mean that you have until the end of business on Wednesday to reach the patient/caregiver.  We have a plan to review our facilitiy's discharge reports on a daily basis and work with our hospitalist department to abstract our own patients for this purpose.   The RVUs for this service are significant, so I'm expecting that we're going to have to work for it!


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## meleahjacobson@yahoo.com (Jan 10, 2013)

*Tcm*

So on the 30th day when you bill the TCM code, do you use that 30th day as the date of service for your TCM, even though there will be no face-to-face contact on the 30 day?


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## perkins05 (Jan 10, 2013)

Does anyone know of the G code yet for TCM? Also my understanding is that if you billed 99495/496 during the first 30 days then you cant bill 99487/88/89 until after the first 30days. 

99366 is this a payable code during the first days?


Any help will be greatly appreciated.

Thanks


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## nieves1410 (Jan 14, 2013)

*99395/99396*

Does anyone know if we can bill an office visit along with the TCM? Also can we add a 25 modifier to a TCM when another procedure is done??


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## Pam Brooks (Jan 15, 2013)

I hope I answer everyone here:

Although I've seen no clear direction, it appears to me that TCM is billed as a to-from date of service, which would not be how you'd report another single date of service.   Basically, they'd need to be on different claims.  So modifiers wouldn't apply.  

Medicare decided to use the 2013 CPT codes, so no G code was assigned.

You have to bundle in the first physician face-to-face, but after that, all medically-necessary physician visits may be billed independent of this service using the same coding conventions as usual.  

CPT lists the codes that cannot be billed during the same time period (care plan oversight, for example).


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## perkins05 (Jan 16, 2013)

Can these codes be billed with 99420 for Humana Assesments?

Also what about specialties: cardiology, urology or hematology/oncology?


Any help will be appreciated.


Thanks


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## nc_coder (Jan 24, 2013)

Are these codes used for ER follow ups?  We aren't real sure what exactly the definition of "partial hospitalization" would be.  Would an ER visit fall into that bucket?


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## cgneff72 (Jan 24, 2013)

*TCM & the 72 hour rule*

Does anyone have documentation about billing the TCM code after discharge, but then the patient is readmitted within the next 72 hours after the TCM?

I know I append modifier PD to visits within that 72 hour timeframe, but do I still append modifier PD to the TCM code?  Or do I need to report the TCM code differently since the patient was readmitted.


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## Pam Brooks (Jan 28, 2013)

crump05 said:


> Can these codes be billed with 99420 for Humana Assesments?
> 
> Also what about specialties: cardiology, urology or hematology/oncology?
> 
> ...


 

Specialists can bill, as long as they are doing the post-hospitalization care and as long as the PCP isn't also billing for this.  Also, specialists cannot bill this service if they were the hospital discharging physician or if they are within the global days.


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## Pam Brooks (Jan 28, 2013)

nc_coder said:


> Are these codes used for ER follow ups? We aren't real sure what exactly the definition of "partial hospitalization" would be. Would an ER visit fall into that bucket?


 

Partial hospitalization refers to psychiatric care in a program designated as such.  ER visits do not fall into this bucket.


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## Pam Brooks (Jan 28, 2013)

cgneff72 said:


> Does anyone have documentation about billing the TCM code after discharge, but then the patient is readmitted within the next 72 hours after the TCM?
> 
> I know I append modifier PD to visits within that 72 hour timeframe, but do I still append modifier PD to the TCM code? Or do I need to report the TCM code differently since the patient was readmitted.


 

If the patient is re-admitted, you cannot bill the TCM code for the 30 days following the previous discharge....but you can go back and bill the bundled face-to-face physician visit. Essentially, you have to start over again. You then wait for the second discharge and begin again with your 30-day timeframe. The -PD would never apply here (isn't that to report the diagnostics (not visits) affected by the 72-hour rule for owned entities?) 

Remember, this code is to be billed to report significant care-management work done by your physician and ancillary staff for post-discharge care. You can't simply bill it just because you're the attending, PCP or other related provider. There are some very significant documentation requirements in CPT (please read this thoroughly) to understand what is entailed in reporting this code. The RVUs are high for this service, and rightfully so: the patient has to have a risk of re-admission, and must require post-discharge care that involves a lot of phone calls, coordination of care, medication reconciliation, and psychosocial support, just to name a few of the requirements. 

Again, read CPT, read the final rule, and check out some of the articles that have recently been published from medical societies to thoroughly understand these codes. Lots of good information out there...you just have to do the research, which as coders, we've all been trained to do. 

Although Medicare is paying for this service, you'll have to check with your individual commercial payers to see if they are also going to cover these codes. They will be able to answer questions about bundling with other payer-specific codes, so I don't feel comfortable addressing those specific questions here.


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## gski (Jan 28, 2013)

So let me make sure I have this straight... Would I be coding this scenario correctly? 

If patient is discharged 1/10/13, the clinical staff/care manager RN contacts the patient non-face-to-face by 1/11/13 and communicates with patient/family/other professionals/home health agencies/community services regarding aspects of care, education to support self-management/independent living etc, assessment & support of treatment plan & medication management, available community/health resources, facilitate access to care/services needed by the patient/family.  

Questions:  

#1  Does the provider's non-face-to-face services (review discharge documents/pending diagnostic tests & treatments/interaction with other professionals who will address specific problems/education of pt/family, referrals/arrange community resource, and assistance/scheduling with community providers/services) all have to be performed on 1/11/13 also?  

#2 Do the services by the clinical staff/care manager RN & Provider provided during this 2 day window constitute the appropriate 99495 or 99496 billing with the date of service 01/11/13? 

#3 Then would the face-to-face encounter being billed out 1/15/13 with the appropriate E&M level be billed to the insurance (99214)?

#4 After 30 days have gone past the discharge date, the code from question #2 could be sent to the insurance carrier to indicate the appropriate code for the face-to-face visit & MDM level on 1/15?

Thank you so much for your help on this.  It seems like the more articles I read on this, the more opposing information I find.


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## Pam Brooks (Jan 29, 2013)

Questions: 

#1 Does the provider's non-face-to-face services (review discharge documents/pending diagnostic tests & treatments/interaction with other professionals who will address specific problems/education of pt/family, referrals/arrange community resource, and assistance/scheduling with community providers/services) all have to be performed on 1/11/13 also?

No:  these services can be done throughout the 30-day timeframe as appropriate based on the needs of the patient.  It's assumed that the patient is going to need a significant amount of support throughout that time frame, and these non-face-to-face services are expected to be carried throughout this time frame.     

#2 Do the services by the clinical staff/care manager RN & Provider provided during this 2 day window constitute the appropriate 99495 or 99496 billing with the date of service 01/11/13? No, the date of the physician face to face determines the code (1-7, 8-14 days post-discharge)  as well as his assessment as to whether the patient is moderate or high complexity.    The nursing staff should NOT be determining complexity.  This is the physicians role.  

#3 Then would the face-to-face encounter being billed out 1/15/13 with the appropriate E&M level be billed to the insurance (99214)?  no, the first face-to-face (by physician) is bundled in.  You document the visit, but do not bill it out.  It's included int he 99465 and 99496.  

#4 After 30 days have gone past the discharge date, the code from question #2 could be sent to the insurance carrier to indicate the appropriate code for the face-to-face visit & MDM level on 1/15? The TCM code is billed out on day 30....29 days following the date of discharge.


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## gski (Jan 29, 2013)

Thank you so much Pam!!!  This totally clears up my questions on this!


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## Jesanna Bennett (Feb 4, 2013)

Is the date of service the 30th day afer discharge? Or would it be a from - to date range? 
Jes


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## Pam Brooks (Feb 4, 2013)

I haven't seen any clear direction on reporting the DOS...however we've decided to bill on the 30th day, and see what happens!    

I'm wondering if any of the other contractors have come out with clarification.  NHIC has not.


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## debi (Feb 4, 2013)

*Transition of care*

If one of my primary care physicians sends a patient to one of our specialists for consult/new patient-eg.  CHF.  Is this a TOC visit?  If it occurs within the correct timeframe.


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## Pam Brooks (Feb 4, 2013)

Transitional Care Management (not transition of care) is not a single-encounter charge. 
These two codes (99495 and 99496) are designed to report services provided by RN Care managers, under the supervision of physicians and NPPs who are doing comprehensive post-discharge care for complex chronically ill patients. The reporting period is 30 days post- discharge. If your practice does not already employ nurse care managers who are doing this kind of chronic disease management work, I'd suggest you first attempt to get a program up and running in order to bill these services. 

CPT actually does a pretty good job of explaining what is involved to bill these services. 

A transfer to another provider is definitely not TCM.


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## nkroche (Feb 4, 2013)

*TCM info*

Hi Pam!

You are the best!!! Thank you so much for sharing your info

My understanding is that only one doctor can bill for this service during that discharge period of 29 days after the discharge day, correct? 

Also, the info reads that there is an "initial" face-to-face (F2F) which is not billable.  It then sounds like in order to bill the TCM the physician or other Qualified Healthcare Provider (QHCP) needs to see the patient again either 7 days or 14 days depending on the Medical Decision Making (MDM) complexity.  The "interactive contact" within 2 business days that is just part of the TCM correct?  That is not considered this "initial" F2F because it is through phone, email but is also says or "face-to-face".  This is the verbage that I need clarification regarding.

Also, the medication reconciliation and management must occur no later than the date of the F2F visit, which one? The initial non-billable or the one that is performed either 7 or 14 days depending on complexity?   

I also read that the physician can see the patient the day of discharge i.e. while at the hospital or facility being discharged from and that would count as the "initial" F2F.  They can bill for a discharge day service on that day as well because the "initial" F2F is included in the TCM.

Again, thanks for your help and I look forward to your reply Pam 

Nancy Roche (Lynch), BA, CPC, CBIS
Compliance Billing and Coding Auditor
Abington Memorial Hospital
Abington, PA 190001


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## Pam Brooks (Feb 5, 2013)

Hi Pam!

You are the best!!! Thank you so much for sharing your info Why thank you, *blush*. 

My understanding is that only one doctor can bill for this service during that discharge period of 29 days after the discharge day, correct? Yes, that's correct. However, if that or any provider sees the patient again within those additional 29 days, (unless there's a bundling issue), then the additional E&M visit can be billed. 
Also, the info reads that there is an "initial" face-to-face (F2F) which is not billable. It then sounds like in order to bill the TCM the physician or other Qualified Healthcare Provider (QHCP) needs to see the patient again either 7 days or 14 days depending on the Medical Decision Making (MDM) complexity. not again....the single face to face is bundled into the code. The "interactive contact" within 2 business days that is just part of the TCM correct? Basically that 2-day contact is a phone call for medication reconciliation, to review the discharge plan and to check to see if the patient's doing OK at home. The Nurse Care manager might check to see if they have support, if they need to weigh themselves, if they have to follow a special diet...that kind of information. 
Then they'd set up the F2F. That is not considered this "initial" F2F because it is through phone, email but is also says or "face-to-face". This is the verbage that I need clarification regarding. you've got it. 

Also, the medication reconciliation and management must occur no later than the date of the F2F visit, which one? The initial non-billable or the one that is performed either 7 or 14 days depending on complexity? 
The medication management has to take place prior or on the F2F regardless if the visit is 1-7 or 8-14 days from the discharge date. We're shooting to always meet the 7 day timeframe, just because there's the opportunity to bill the 99496 if the patient has high complexity. 
I also read that the physician can see the patient the day of discharge i.e. while at the hospital or facility being discharged from and that would count as the "initial" F2F. They can bill for a discharge day service on that day as well because the "initial" F2F is included in the TCM. I did not hear that, nor have I read that anywhere. It was my understanding that the initial F2F had to happen post-discharge. 

Here's our plan....

We get a list of patients (by PCP) who have been recently discharged. The nurse care managers within each PCP practice---we have several, contact the patient (day one or day two) post-discharge, to check on their post-discharge progress. If we can't reach the patient within two days, we will document our attempts until we do reach them.....I understand that will be sufficient to still be able to bill the code. But the F2F at the very least has to happen in 14 days. At that time, they might do medication reconciliation, but often patients have a bazillion pill bottles, and they can't sort through. So we make an appointment, which is the initial F2F, with the PCP. At that time, the patient comes in, with their shopping bag full of meds, and we reconcile at that time. Also, the PCP sees them, determines the plan of care, identifies MDM (based on the # of diagnoses, data and risk). That visit is not billed out, however we identify day #30 for billing purposes. 
During the following 29 days, the provider and nurse care manager work together to monitor the patient, get them the support and resources they might need, make appropriate referrals, etc (see CPT for other interventions). The nurse care manager documents this information in our EHR and keeps a paper log, which she scans in against the first F2F. (I know, very archiaic, but our EHR doesn't have a TCM template---go figure). 

We are tracking the billing date through a shared spreadsheet (since our EHR doesn't cooperate) that will ID the billing date, and we drop the charge on day 30. If the patient is re-admitted, we will bill out the first E&M, and start over again with the new process after the second discharge. Hopefully, that won't happen very often. 


Again, thanks for your help and I look forward to your reply Pam


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## maddismom (Feb 6, 2013)

Hi Pam:

Thanks for all of your help with this.  I had a quick question regarding your response above to Nancy's post.  In the final paragraph you indicate if the patient is re-admitted within the 30 days the TCM goes away and the first E/M is billed just as an E/M (makes sense).  But in Debra Seyfried's article she indicates that the TCM can be billed even if the patient has another hospitalization within 30 days.  I'm wondering if I'm just not interpreting something correctly and would appreciate your input.

Thanks!


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## Pam Brooks (Feb 7, 2013)

According to CPT:  only one visit can be reported within 30 days of discharge, an another TCM may not be reported by the same individual or group for any subsequent discharge within the 30 days.  So if the patient is re-admitted within that first 30 day period, then you can't bill the first TCM and then another less than 30 days later.  So it would make sense to bill the first E&M out, and then begin the 30 day TCM following the second discharge. It wouldn't be appropriate to bill the first TCM less than 30 days.


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## maddismom (Feb 7, 2013)

Perfect!  Thank you!


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## maddismom (Feb 12, 2013)

Hi Pam:

I had another quick question for you.  I'm trying to explain to the providers that they have to obtain the discharge summary and I'm having trouble justifying why that would be (they understand why they would have to review it, but the "obtaining" is causing issues).  What is your take on this?

Thanks!


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## nkroche (Feb 12, 2013)

Hi Pam 
Here's a question..... so I have a provider who saw the patient on day 31 instead of day 29!!! I have been looking for info to see if the 99495 can still be billed but so far no luck.  Any one have any info?

Pam you have been such a great asset to us through this!! Thanks a million (again)

Nancy


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## wegrant630 (Feb 12, 2013)

Transitional care management is only for patients that are discharged from an inpatient status.  TCM following an ER visit would not be appropriate.


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## Pam Brooks (Feb 12, 2013)

nklynch said:


> Hi Pam
> Here's a question..... so I have a provider who saw the patient on day 31 instead of day 29!!! I have been looking for info to see if the 99495 can still be billed but so far no luck. Any one have any info?
> 
> Pam you have been such a great asset to us through this!! Thanks a million (again)
> ...


 

The requirement for the face to face visit is either 1-7 edays or 8-14 days.  There is no other face-to-face requirement (just documentation requirements based on your nurse care manager's work).  You don't have to drop the code on a day when there's been a visit....in fact, we have set up a schedule to drop codes exactly on day 30.  So if you met the 2-day contact and medication reconciliation,  the 14 day face to face requirement, the patient was discharged from an inpatient setting, the MDM is moderate or high, and the nurse care managers have documented the patient-specific criteria as outlined in CPT, then you can drop the code on day 30.  In fact, any additional face-to-face provider visits can be billed additionally.  Does this help?


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## Pam Brooks (Feb 12, 2013)

maddismom said:


> Hi Pam:
> 
> I had another quick question for you. I'm trying to explain to the providers that they have to obtain the discharge summary and I'm having trouble justifying why that would be (they understand why they would have to review it, but the "obtaining" is causing issues). What is your take on this?
> 
> Thanks!


 
The whole point of TCM is to follow the recommendations of the discharging physician to avoid re-admission. Without that summary, it will be difficult for you to create the patient's care plan.  If your provider's patient was discharged from a facility, then it's standard   practice (not to mention professional courtesy) to forward a copy of the discharge summary to the patient's PCP---if the patient indicated that they would be following up with their PCP post-discharge.  Maybe you need to contact the hospital to see why you're not included in the distribution list for those documents.


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## maddismom (Feb 13, 2013)

Hi...apparently my question was not worded correctly.  In a perfect world, we DO get the discharge summaries sent to us and of course we DO understand the whole point of TCM.  I was wondering about the cases where the discharge summary does not get delivered and if you knew why it would have to be the provider who contacted medical records to request a copy as opposed to clinical staff was all.


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## akmorgan (Feb 13, 2013)

*Date of service*

Can someone please tell me what date of service would be used on day 30 of TCM services?  I have not been able to find an answer to this.
Thank you.


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## Pam Brooks (Feb 14, 2013)

Day 30 following the date of discharge.


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## rthames052006 (Feb 16, 2013)

Pam-

You are a wealth of information! By reading this thread I've learned a few things from you. So glad we are on the same page! Some of the questions I had, you've supplied answers to , so thank you dear. 

I do have a call out to the AMA and hopefully they provide the same answers.

Unfortunately we had a provider who billed out these codes ( didn't inform us) in January the date of his F2F so now we are just waiting to see what the carrier does! Really wish he would have let us know this before the claim went out!!!


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## Pam Brooks (Feb 18, 2013)

Roxie...it's like herding cats, sometimes, isn't it??


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## jstubbs (Feb 19, 2013)

*Tcm*

Here's my dilemma:

We are an interventional cardiology group. My practice manager has decided that we can bill TCM for post-op patients as long as another provider in our group takes on the TCM. I've tried to no avail to explain that we can't do that because post-operative care is inclusive with the stenting, AICD/Pacemaker procedures, etc., but because the guidelines say "surgeon" and not "group or practice" he thinks we can skirt it. 

Am I wrong? Is there something I can present to him that will show we cannot bill TCM for our post-op patients?

Thanks!


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## Pam Brooks (Feb 19, 2013)

This is clarified in the Final Rule, and is also outlined in CPT.  

From the CMS Final Rule:  http://www.cms.gov/Medicare/Medicar...ral-Regulation-Notices-Items/CMS-1590-FC.html
 
We agree with the
commenters that the physician who
reports a global procedure should not be
permitted to also report the TCM
service, and we are adopting that policy​in this final rule.


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## jstubbs (Feb 19, 2013)

I've shown him the CPT guidelines, as well as information from a class I attended a few weeks ago.  I can't make him understand when it says the surgeon, it means anybody from our practice. He interprets the guidelines as the actual surgeon, which is incorrect. I've printed the section addressing TCM from the final rule, but I think I'll not fare any better. Thank you for the links.


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## Pam Brooks (Feb 20, 2013)

It may very well bump up against his global days anyway, and be denied as inclusive. But billing it when you know it is not covered goes against Medicare's Fraud and Abuse guidelines and against the False Claims Act.  Not sure it's worth the trouble.


----------



## chrisrjjj (Feb 21, 2013)

*Additional E&M services*

If provider sees patient more than once in the 30 day period, can that additional E&M visit be billed?


----------



## chrisrjjj (Feb 22, 2013)

So if we bill an additional E&M visit during the 30 day period how will insurance company differentiate from the bundled E&M service for TCM and not deny?  Is there a specific modifier we need to utilize?




Pam Brooks said:


> The whole point of TCM is to follow the recommendations of the discharging physician to avoid re-admission. Without that summary, it will be difficult for you to create the patient's care plan.  If your provider's patient was discharged from a facility, then it's standard   practice (not to mention professional courtesy) to forward a copy of the discharge summary to the patient's PCP---if the patient indicated that they would be following up with their PCP post-discharge.  Maybe you need to contact the hospital to see why you're not included in the distribution list for those documents.





Pam Brooks said:


> The requirement for the face to face visit is either 1-7 edays or 8-14 days.  There is no other face-to-face requirement (just documentation requirements based on your nurse care manager's work).  You don't have to drop the code on a day when there's been a visit....in fact, we have set up a schedule to drop codes exactly on day 30.  So if you met the 2-day contact and medication reconciliation,  the 14 day face to face requirement, the patient was discharged from an inpatient setting, the MDM is moderate or high, and the nurse care managers have documented the patient-specific criteria as outlined in CPT, then you can drop the code on day 30.  In fact, any additional face-to-face provider visits can be billed additionally.  Does this help?


----------



## Pam Brooks (Feb 22, 2013)

They can't, technically, and I'm not aware of any modifier.  I guess providers are expected to be prudent and not unbundle that first E&M...but the guidelines are very clear that additional E&M services may be billed during that post-discharge time frame.


----------



## tdeas (Feb 22, 2013)

*Tcm*

Thanks, Pam, for these links.  I have one more question to add...If the PCP has spoken with the patient and arranged therapy with follow-up in office in fourteen days, but the patient cancels all appointments, is the code still billable since the face to face did not occur?


----------



## Pam Brooks (Feb 25, 2013)

I would say that you cannot.  The face to face is clearly a requirement to bill the code.  Just as you cannot bill Medicare for a no-show appointment, you cannot bill for the care management without the physician face-to-face to support the MDM that you will eventually choose to report the code on day 30.  I would definitely document the no-show, in case the patient changes their mind and shows up after the 14 days and then engages in the appropriate post-discharge care.  But if the patient refuses treatment, you can't bill the code if they're not coming in to see you.   The other option is for the provider to go see the patient at their home.


----------



## asteele813 (Feb 26, 2013)

Pam,
Thank you so much for all this information.

My management is asking, Does the ICD-9 code that was used for the discharge have to be the same ICD-9 code that is billed out with 99495 or 99496?

Thank you
Amanda


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## Pam Brooks (Feb 26, 2013)

Since the care managment is directly related to the discharge, I would imagine that the diagnosis codes would be the same.  Nothing in the guidance I've read says the codes have to mirror each other, but we planned to drop the diagnosis codes reported based on the first face-to-face following the discharge, which of course would be based on the final discharge diagnosis.  There's nothing that says the provider can't also address other conditions that arise since discharge that could put the patient at risk for re-admission.


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## sawhitt (Feb 27, 2013)

I took a class on the new codes for 2013 and the Trans Care Codes were prominent in the discussion.
The instructor said there were criteria for the phone call
Included in the call and documented
1. Medication reconciliation
2. Discharge Summary
3. Nutritional needs/Diet
4. Sleep
5. Elimination
6. Wounds/wound care
7. Home health needs.


Has anyone else heard this specific documentation?
Thanks


----------



## Pam Brooks (Feb 28, 2013)

I think that's an over-interpretation, and if you read the code description in CPT,  you'll see what I mean.  CPT discusses the non-face to face services, by stating they "MAY" be included in the patient's care, and those that you mentioned are in that list.  There is no guideline for the content of the communication  other than to make it within the 48 hour time frame.  Per CPT: "TCM requires an interactive contact with the patient or caregiver, as appropriate, within two business days of discharge.  The contact may be direct, face to face, telephonic or by electronc means".   It does not go on to say what must be addressed. That's why they say "as appropriate".  

I'm not sure where your information came from, unless your local carrier has come out with more definitive requirements.  Ours has not.


----------



## sawhitt (Feb 28, 2013)

Diane Zucker taught the class to our local AAPC group.    I believe she is well known and respected in her field.     
I find this topic quite interesting  and and am curious to see what the audits of these claims will show. 
Thanks for your expertise.


----------



## Pam Brooks (Mar 1, 2013)

sawhitt said:


> Diane Zucker taught the class to our local AAPC group. I believe she is well known and respected in her field.
> I find this topic quite interesting and and am curious to see what the audits of these claims will show.
> Thanks for your expertise.


 

I agree, but I was wondering where she got that specific detail....it hasn't been release from CMS as far as I know, and CPT does not indicate this information as specifically as your explanation read.   I would be interested to see those references, particularly for my own group, to make sure we're capturing the data in the way we're expected to.  Obviously, the 48-hour contact will be much more than a "Hi how are ya" conversation, and should be relevant to the patient's discharge plan, but I have not read anywhere that certain elements MUST be discussed at that time.  I'm not sure I have Diane's contact information, but feel free to give her mine.


----------



## meleahjacobson@yahoo.com (Mar 13, 2013)

*Date of service to use*

I have a question concerning what date of service to use when billing for the TCM service.  We have billed one and it came back and denied.  As far as the from date we used the discharge date and the to date on the claim we listed as the 30th day after discharge.  Can anyone assist me on what we use as the from and to date on the claim.

Thanks


----------



## Pam Brooks (Mar 13, 2013)

Everything I've read (and we're doing this) is billing on day 30.


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## meleahjacobson@yahoo.com (Mar 13, 2013)

*Tcm*

So we use the date of the 30th day as our to and from date?


----------



## Pam Brooks (Mar 14, 2013)

Yes, day 30 as your single date of service.


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## sawhitt (Mar 14, 2013)

Pam,
I have not heard from Diane, but she does answer her emails so I am hoping to hear soon.
I did sit in conference last week with the Ohio MGMA and this subject did come up.
Here is the email from Jeb Shepard
Government Affairs Representative
Midwestern and Southern Sections
Medical Group Management Association
Washington, DC, 20006


Hello Susan,
Thanks again for your questions regarding the new Transitional Care Management CPT codes. Sorry for the delay here, I had to get colleagues in the office involved! I'm following-up from my voicemail with this email.

We were unable to find a specific list of items that must be included in the communication within 2 business days. In the proposed rule, CMS does provide a list for their proposed G codes (in the final rule they adopted CPT codes instead), however they were not finalized. As I mentioned at the conference, CMS has states in the final rule and in our communications with them that more guidance on how to bill these new codes will be forthcoming. Since it is mid March, we hope to see something soon.

I wish I had a better answer for you, but we're just going to have to wait until CMS provides more information. I will make sure to follow-up with you when they do. I'm curious as to what list Diane Zucker is referencing. Do you happen to know?

Please let me know if you have any other questions.

My best,
Jeb


He then sent this to me a few hours ago.

Frequently Asked Questions about Billing Medicare for Transitional Care Management Services
Effective January 1, 2013, Medicare pays for two CPT codes (99495 and 99496) that are used to report physician or qualifying nonphysician practitioner care management services for a patient following a discharge from a hospital, SNF, or CMHC stay, outpatient observation, or partial hospitalization. This policy is discussed in the CY 2013 Physician Fee Schedule final rule published on November 16, 2012 (77 FR 68978 through 68994). The following are some frequently asked questions that we have received about billing Medicare for transitional care management services.
• What date of service should be used on the claim?
The 30-day period for the TCM service begins on the day of discharge and continues for
the next 29 days. The reported date of service should be the 30th day.
• What place of service should be used on the claim?
The place of service reported on the claim should correspond to the place of service of
the required face-to-face visit.
• If the codes became effective on Jan. 1 and, in general, cannot be billed until 29 days past discharge, will claims submitted before Jan. 29 with the TCM codes be denied?
Because the TCM codes describe 30 days of services and because the TCM codes are new codes beginning on January 1, 2013, only 30-day periods beginning on or after January 1, 2013 are payable. Thus, the first payable date of service for TCM services is January 30, 2013.
• The CPT book describes services by the physician's staff as "and/or licensed clinical staff under his or her direction." Does this mean only RNs and LPNs or may medical assistants also provide some parts of the TCM services?
Medicare encourages practitioners to follow CPT guidance in reporting TCM services. Medicare requires that when a practitioner bills Medicare for services and supplies commonly furnished in physician offices, the practitioner must meet the â€œincident toâ€� requirements described in Chapter 15 Section 60 of the Benefit Policy Manual 100-02.
• Can the services be provided in an FQHC or RHC?
While FQHCs and RHCs are not paid separately by Medicare under the PFS, the face-to- face visit component of TCM services could qualify as a billable visit in an FQHC or RHC. Additionally, physicians or other qualified providers who have a separate fee-for-
Page 1 TCM FAQs
March 12, 2013
service practice when not working at the RHC or FQHC may bill the CPT TCM codes, subject to the other existing requirements for billing under the MPFS.
• If the patient is readmitted in the 30-day period, can TCM still be reported?
Yes, TCM services can still be reported as long as the services described by the code are furnished by the practitioner during the 30-day period, including the time following the second discharge. Alternatively, the practitioner can bill for TCM services following the second discharge for a full 30-day period as long as no other provider bills the service for the first discharge. CPT guidance for TCM services states that only one individual may report TCM services and only once per patient within 30 days of discharge. Another TCM may not be reported by the same individual or group for any subsequent discharge(s) within 30 days.
• Can TCM services be reported if the beneficiary dies prior the 30th day following discharge?
Because the TCM codes describe 30 days of care, in cases when the beneficiary dies prior to the 30th day, practitioners should not report TCM services but may report any face-to- face visits that occurred under the appropriate evaluation and management (E/M) code.
• Medicare will only pay one physician or qualified practitioner for TCM services per beneficiary per 30 day period following a discharge. If more than one practitioner reports TCM services for a beneficiary, how will Medicare determine which practitioner to pay?
Medicare will only pay the first eligible claim submitted during the 30 day period that commences with the day of discharge. Other practitioners may continue to report other reasonable and necessary services, including other E/M services, to beneficiaries during those 30 days.
• Can TCM services be reported under the primary care exception?
TCM services are not on the primary care exception list, so the general teaching
physician policy applies as it would for E/M services not on the list.
• Can practitioners under contract to the physician billing for the TCM service furnish the non- face to face component of the TCM?
Physician offices should follow â€œincident toâ€� requirements for Medicare billing. â€œIncident toâ€� recognizes numerous employment arrangements, including contractual arrangements, when there is direct physician supervision of auxiliary personnel.
This issue is addressed in greater detail in the Internet-only Benefit Policy Manual, Chapter 15, Section 60 available at: http://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS012673.html
Page 2 TCM FAQs

When I hear from Diane, I will forward it on.  I do feel better that we are doing this correctly in our practice.


Susan Whitt, PA-C, Practice Manager
Diley Medical Group


----------



## Pam Brooks (Mar 15, 2013)

Thanks very much, Susan.  We also had the question about what to do if the patient dies shortly after d/c, and of course if the 30-days of TCM doesn't take place, we've not met the criteria to bill the code.  It's nice to have a precise explanation here.  I'm still waiting to hear from CMS directly with clarification and communication....I honestly think the coders on this board have more information than they do!


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## sawhitt (Mar 15, 2013)

Pam,
That is how I feel too.    I keep these emails so if we have an audit or we get final rules in the next year we can show we correctly coded these after codes were put out and before final rulings.    
Susan


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## edelyslpz@gmail.com (Mar 26, 2013)

*TMC question*

Good morning

What specialty physicians can bill these codes?


----------



## cardiology (Apr 2, 2013)

My question is this only apply to a PCP not the specialist??
Please help me to clarify.

Thank you,
jnninso@yahoo.com
Cardiology


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## Pam Brooks (Apr 2, 2013)

There are no limitations on specialties that I am aware of.  Any qualified provider can bill these codes but only if they are providing the post-discharge care of the patient's condition and co-morbidities in order to prevent re-admission.  That's the key to these visits, and why most of the billing providers will be primary care physicians.  If a specialist is the overall post-discharge medical provider for the patient and as long as the specialist isn't still within a global surgical period, they can bill if they meet the criteria. 

I still think there's some misconceptions about this code.  These services are Medicare's solution to provide reimbursement for those entities who provide chronic care management services utilizing care manager RNs who follow patients as they manage multiple conditions, medications, need for resources, etc.  Up until now, this work was largely unreimbursed, but in order to prevent readmissions, this code was approved by CMS.

This service is not a one-shot deal, follow-up-after-discharge-and-bill out the code scenario.  The expectation is that we follow up with the patient and keep tabs on them for that month to make sure they're staying out of the inpatient setting.


----------



## webbsherrybond007 (Apr 2, 2013)

*Transition of Care coding question*

I am confused on when to bill Medicare for cpt code 99495.  Our physician is the pt's PCP. The pt was discharged on 2/7/2013, we contacted the pt on 2/8/2013, and the pt was seen with our pcp on 2/11/2013.  Our office billed Medicare on 2/21/2013 and the claim was denied due to the time frame was too early?  We are really confused with this transition of care coding. THanks for your help.  Sherry Webb


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## cheermom68 (Apr 2, 2013)

The date of service needs to be day 30 post discharge.  2/21 would have only been 14 days.  You have to complete the 29 days required services to bill.


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## second to none  (Apr 4, 2013)

Hi, Cheermom68!
I am still confused with the date of service. For example, the patient is seen on 2/11/2013. we  wait until 30 days post discharged and send the bill to madicare on 3/11/2013. So, what date of service we have to use on CMS-1500 form? The 2/11/2013 or 3/11/2013? Thanks


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## maddismom (Apr 4, 2013)

The DOS you use is like she said.  *It's 30 days after the date of the discharge from the hospital*.  The DOS the provider saw the patient does not come into play for the billing date.


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## second to none  (Apr 4, 2013)

Hello everyone!
is anyone knows how much medicare pays for TCM?.  Raemarie Jimenez, from AAPC in her article said, it is 163.99 for Moderate complexity and 231.36 for high complexity but she did not clarified that if these prices for facility or non-facility. Today, I read on AAFP website that 231.12$ and 164$ is for non facility and 135$ and 197.76$ is for facility. which one is correct?


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## Pam Brooks (Apr 5, 2013)

99495 163.99 non facility, 134.73 facility
99496 231.36 non facility, 197.97 facility

I encourage you to become familiar with the Physician's Fee Schedule.  

http://www.cms.gov/apps/physician-fee-schedule/license-agreement.aspx

Both Raemarie and the AAFP were correct, you've just misunderstood the concept.  The two codes have two prices each...one for Office based and one for facility based.


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## Tammy69 (Apr 5, 2013)

*Dos*

Does anyone have anymore specific guidance other than the FAQ that clearly explains how the bill these codes?
Our interpretation was that if patient was discharged on 4/1/13 and then seen in the office on 4/5/13 (face-to-face) as well as other telephone communication etc... that needs to happen within this 30 day period and then the charge will drop with 4/30/13 as the DOS as opposed to the actual face-to-face visit of 4/5/13.  Is that how you understand?
Thanks


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## SSweetland (Apr 5, 2013)

*Tcm*

Thank you for all the great information on the TCM codes. I have a couple questions 
1. To decide if the care is moderate or high, do we base this on MDM from the hospital   setting? 
2. I understand you can not bill the 99495 or 99496 until 30 days from the date of discharge but have to see the patient 7 or 14 days from date of discharge, so are you setting the electronic health record up to hold the claim until day 30 or do you have a better way for processing the bill on day 30. My concern is if the patient comes back within the 30 days related to the discharge after the vist, then what is a good tracking protocol so it does not hang out there or cause an error. Sorry if my question is confusing. I know this can only be charges once related to the discharge. 

Sheila


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## maddismom (Apr 5, 2013)

This may help with some of your questions:
http://www.aafp.org/online/etc/medi...resources/tcmfaq.Par.0001.File.dat/TCMFAQ.pdf


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## bnmellon (Apr 5, 2013)

I was wondering if anyone has billed out for the TCM codes and actually got them paid? My co-worker and I have been going over the guidelines for these codes and are actually a little concerned about the DOS needing to be the 30th day post discharge. How is this not inaccurate billing if we are actually changing the dos to the 30th day, when the patient has to be seen within 7 to 14 days? 
Thanks
Brittany Merritt, CPC


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## Pam Brooks (Apr 8, 2013)

Brittany, TCM is not a single DOS...it's a month-long period of post-discharge care.  As such, you cannot bill for the supposed month of work prior to that 30th day after discharge.  I think you misunderstand the purpose of this code: it's for a 30-day range of chronic care managment and post-discharge support provided by the patients physician and his ancillary staff to prevent readmission.


----------



## ked2505 (Apr 9, 2013)

Any suggestions on how you are keeping tract of the patients, phone calls, visit, etc?


----------



## Pam Brooks (Apr 9, 2013)

We're keeping track of phone calls, etc. that is the nurse care manager work within our EHR as communication documents.  These remain part of the patient's medical record.


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## second to none  (Apr 15, 2013)

*Tmc date of service*

Hello everyone!!!

  I copeid the DATE OF SERVICE answer from another website. It's explain it with an example. I hope this will help.

[COLOR="Lime"]   You are using the date of the 30th day of the TCM period for your date of service. Here's an example:

Mrs. Jones was discharged from the hospital on March 3, 2013. You contacted her on March 5th (within 2 days of discharge) to make sure things were going well with her transition and that she was following the discharge instructions given to her at the hospital. You scheduled her appointment with the physician at the practice for March 12th (within 14 days of discharge.) On April 1st, you process the claim for TCM services provided between March 3rd and April 1st, using the CPT code 99495 and date of service 4/1/2013. You do not use the E/M code for the visit during the 14 days, as that is included as part of the 99495.[/COLOR]


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## second to none  (Apr 15, 2013)

*Tmc date of service*

Hello everyone!!!
  I copeid the DATE OF SERVICE answer from another website. It's explain it with an example. I hope this will help.  

You are using the date of the 30th day of the TCM period for your date of service. Here's an example:

Mrs. Jones was discharged from the hospital on March 3, 2013. You contacted her on March 5th (within 2 days of discharge) to make sure things were going well with her transition and that she was following the discharge instructions given to her at the hospital. You scheduled her appointment with the physician at the practice for March 12th (within 14 days of discharge.) On April 1st, you process the claim for TCM services provided between March 3rd and April 1st, using the CPT code 99495 and date of service 4/1/2013. You do not use the E/M code for the visit during the 14 days, as that is included as part of the 99495[/COLOR][/SIZE]


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## jancullum (Apr 16, 2013)

*Janet53*

Question?  If we currently have and EMR system with no established template for TCM  when the face to face visit occurs that date will appear on the progress note of the physician.  What I seem to be reading is that our billing service would have to put a "hold" on that claim and not bill out until the 29-30th day after discharge, correct?  Because the date of service would be the later date not the actual date of the face to face, correct?  Then with providers that do have EMR what do they do?


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## awallace11 (Apr 18, 2013)

I think what a lot of people are misunderstanding, as were some of my Doctors, is that these codes are not for a specific visit or service. They are for an entire 30 day period of care following discharge that _must include_, but are not limited to contact within 2 days, the face-to-face visit, etc. That is why the date of service is day 30 after discharge, because you can't bill saying you cared for the patient for 30 days following discharge when it hasn't been 30 days since the patient was discharged.


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## second to none  (Apr 18, 2013)

*Which insurance company is paying for TCM codes?*

We send a claim to BCBS with Tcm codes and they denied.  I talked to BCBS representative. They said, we do not pay for TCM codes. Then I called Humana and United health care. Both of them are paying for TCM codes. The United health care representative was very nice. She said, we follow all the medicare guidelines.


----------



## meleahjacobson@yahoo.com (Apr 22, 2013)

*TCM/Observation Status*

If a patient was inpatient but only under observation status can our office still bill for TCM service?


----------



## katfitzpat (Apr 22, 2013)

Thank you for the your .PDF related to TCM - I found it very helpful! Appreciate you sharing it with all!
Kathy Fitzpatrick, CPC
Santa Rosa Cardiology
Santa Rosa CA


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## molisa (Apr 23, 2013)

The AAFP.org site has some great FAQ's regarding TCM and a really nice log to complete all the requirements for documentation.


----------



## samsaldukas@aol.com (Apr 25, 2013)

*TCM Flow Sheet*

Here is a link to a free TCM Documentation & Flow Sheet that is helpful: https://codingleader.com/family-practice/tcm-special-report


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## rthames052006 (Apr 25, 2013)

meleahjacobson@yahoo.com said:


> If a patient was inpatient but only under observation status can our office still bill for TCM service?



Yes, you can bill TCM for patients seen in OBS status. Please take a look at your CPT book for details of which POS and patient status qualify.


----------



## sawhitt (Apr 30, 2013)

Does anyone have the fee sched for these codes?  What are you billing and what are you getting paid?


----------



## Tanna717 (May 6, 2013)

*99495 tcm*

So the face to face visit that must be performed with 14 calendar days of discharge can then not be billed for If we bill a 99495?

It almost seems like too much trouble to bill the 99495 if we are not going to get paid for the appointment afterwards. 

Also, is this a FQHC billable encounter or would this be billed FFS?


----------



## Patricia Belew (May 23, 2013)

*Payment*

Has anyone received payment from the TCM charges from Medicare yet?  I recieved a denial on one and they told me I billed it  6 days too late that it has to be billed exactly on the 30th day afer discharge.  What are we supposed to do if that date occurs on the weekend and our clearing house doesnt send claims on the weekend?


----------



## cheermom68 (May 24, 2013)

Yes, the date of service has to be the 30th day.  It doesn't matter what day of the week it is.  You don't have to submit the claim that day, but the date of service on the claim has to be that day.


----------



## susansipe (Jun 6, 2013)

*TCM ER visit?*

Can someone supply documentation where it states that ER does not qualify as TCM?  thanks!  Need to provide it to higher-ups!


----------



## swilliams2 (Jun 7, 2013)

*Tcm*

In the CPT book there is a description and list of requirements just before the two codes are listed. In mine, the first paragraph describes the services as being for a patient transitioning from an Inpatient setting (ER is out pt) to home. That should be enough.


----------



## susansipe (Jun 7, 2013)

*wow...my cpt book*

Wow, my cpt book does not state that before the 2 codes....it lists items it includes, but not that...  which version are you using, who is the manufacturer?  ours is OPTUM


----------



## swilliams2 (Jun 7, 2013)

*Tcm*

We use AMA's Professional Edition. There is about a whole page and a half of info before the actual codes, including coding tips after the codes.


----------



## rthames052006 (Jun 11, 2013)

Patricia Belew said:


> Has anyone received payment from the TCM charges from Medicare yet?  I recieved a denial on one and they told me I billed it  6 days too late that it has to be billed exactly on the 30th day afer discharge.  What are we supposed to do if that date occurs on the weekend and our clearing house doesnt send claims on the weekend?



Have you called Medicare on this yet? I have seen denials for billing the codes prior to the 30th day but not after? The date Medicare is looking at is the dos not the date they received your claim.

I'd call them if I were you to get clarification.


----------



## katymatte (Jun 13, 2013)

*Tcm*

DOES THE DR BILLING THE TCM HAVE TO SEE THE PT IN THE HOSPITAL?
WE HAVE A SITUATION WHERE THE PT WAS IN THE HOSPITAL BUT WE DID NOT SEE HIM AND HE CALLED THE DAY AFTER HE WAS DISCHARGED TO TELL OUR OFFICE HE WAS IN THE HOSPITAL. MY OFFICE WANTS TO BILL A TCM VISIT BECAUSE NO WHERE DOES IT SAY THAT THE DR BILLING THE TCM HAD TO SEE THE PT IN THE HOSPITAL. PLEASE HELP!!!!


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## Pam Brooks (Jun 13, 2013)

The physician billing the TCM does not have to be the physician who attended in the hospital, but has to be the provider who will be overseeing the post-discharge care that is reportable during the 30 days following the discharge.


----------



## 01085585 (Jul 2, 2013)

*correct way to bill?*

I am needing just a clear cut way on the proper way to bill these claims. (probably everyone else too Say the patient is discharged on May 31st they follow up in our office on June 3rd. Do we bill the e/m say 99214 on the June 3rd visit and then bill the transition of care code on the 30th day on June 30th? Or does the June 3rd visit not get billed at all? Or do I hold it and bill everything together? Thank you in advance.


----------



## ajfinn0216 (Jul 10, 2013)

you may find this document helpful in answering your questions


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## ChrisZim (Jul 12, 2013)

Thanks Pam - your summary sheet was extremely helpful!


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## ChrisZim (Jul 12, 2013)

*thanks*



maddismom said:


> This may help with some of your questions:
> http://www.aafp.org/online/etc/medi...resources/tcmfaq.Par.0001.File.dat/TCMFAQ.pdf



very helpful - thanks!


----------



## jnieto625 (Jul 25, 2013)

*Additional office visit during TCM face to face*

My doctor is asking if he can bill an office visit during the TCM face to face if the patient has additional issues unrelated to TCM.  When his patient came in for TCM, he happened to burn himself 3 days prior to coming in.  It was a 2nd degree burn and the physician treated.  Since this has nothing to do with the TCM, I am unsure if I can carve out that part of the visit or if it cannot be billed at all since the first TCM visit cannot be billed separately.  Any suggestions?


----------



## teabowdoe (Aug 7, 2013)

*same question as above, more or less*

I have more or less same concern: has anyone gotten denials on EM codes that fall within that 30 day period range from Medicare? I see in CPT book it says other EM can be billed separately, but my contractor these days (Palmetto) has been doing all kinds of screwy things. Clinically I am not sure why they made this 30 days as opposed to 14 days, since that is when provider is required to see patient, other than the fact the patient is still at high risk of re-admission.


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## Twixle2002 (Aug 15, 2013)

Just for clarification.. Should the actual billing date be 30 days from the date of discharge?  We are having a lot of problems with this code being paid.


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## Pam Brooks (Aug 15, 2013)

jnieto625 said:


> My doctor is asking if he can bill an office visit during the TCM face to face if the patient has additional issues unrelated to TCM. When his patient came in for TCM, he happened to burn himself 3 days prior to coming in. It was a 2nd degree burn and the physician treated. Since this has nothing to do with the TCM, I am unsure if I can carve out that part of the visit or if it cannot be billed at all since the first TCM visit cannot be billed separately. Any suggestions?


 
That F-2-F must be bundled into the TCM code, so billing out a visit at the same time might be a challenge.  I've seen no guidance that says you can't, however.  The trick would be to keep the documentation separate so that you bill the E&M based only on the burn treatment. I'd even go so far as to document two separate notes.  However it might be clearer (and we may get better guidance in 2014) to have the patient come back for his TCM visit.  Good question, for which I've seen no answer!


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## Pam Brooks (Aug 15, 2013)

teabowdoe said:


> I have more or less same concern: has anyone gotten denials on EM codes that fall within that 30 day period range from Medicare? I see in CPT book it says other EM can be billed separately, but my contractor these days (Palmetto) has been doing all kinds of screwy things. Clinically I am not sure why they made this 30 days as opposed to 14 days, since that is when provider is required to see patient, other than the fact the patient is still at high risk of re-admission.


 
So far, no denials that I'm aware of. Our contractor is NHIC, and I've found that they aren't really up to speed on the concept of TCM.  
They made the timeframe 30 days because the facility doesn't get reimbursed for the second admission if the patient is re-admitted for the same condition as the previous admission within 30 days.  This is an attempt to keep that patient out of the hosptial during that 30-day time frame.  It's a win-win, really.


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## Pam Brooks (Aug 15, 2013)

Twixle2002 said:


> Just for clarification.. Should the actual billing date be 30 days from the date of discharge? We are having a lot of problems with this code being paid.


 

Day 30, following discharge.  Many commercial payers are not covering this, we've found.


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## AnnesPics (Oct 8, 2013)

*TCM billing*

While I understand the Transitional Care Management billing; I do have a question when it comes to the balance.  Should we bill the patient the 20% or is the patient not to be billed?

Thank you in advance.

Anne


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## mhartley (Oct 21, 2013)

*TCM - communication within 2 business days*

I don't belive I have seen an answer to this and if it is listed, please forgive me.

What are your offices doing when the initial communication has not been done even when there is adequate documentation on attempts but the patient was in for their initial face-to-face visit by at least day 14?

For example if a patient no longer has a phone or maybe staying with a friend or family member and isn't home to receive messages.

I've seen in a different thread that if by day 4, no contact is made then they do not bill out the TCM.  My concern is having the provider lose out on the service because of something they cannot control.

All thoughts are greatly appreciated!!

Missy


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## drmpurple (Oct 24, 2013)

*Transitional Care Codes*

[I have started to bill the 99495 code and have 2 questions:

1.  Does anyone know if the contact made within the 2 days must have specific information documented?  Or can the office just note they spoke with pt on "that date"

2.  I had Medicare pay for a TCM/99495 code only to have them take the money back because the 30th day patient was back in the hospital.  Has anyone heard of this happening?  If yes, can we appeal? or we would just change to an E&M visit?

thank you! Donna


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## debkidcks (Nov 21, 2013)

I have a question about which billing provider to use.

We have PA's in our practice as well as physicians.  Our physicians rotate schedules and end up seeing each other's patients, or the physicians have a PA see the patient.  Also, one of our physicians works two weeks and then is off two weeks.  The physicians sometimes disagree on who is really "overseeing" the patient's care.

My question is - As a general rule, should the provider who provided the first face-to-face visit (7 or 14 days post-discharge) be the billing provider?  

With all the "sharing" of patient care that goes on in our practice, we have an endless number of possible scenarios.  We usually see TCM patients weekly post-discharge, and I understand that the visits after the initial face-to-face can be billed separately, but the weekly visits, including the initial face-to-face, could be by any of the physicians or it could be a PA.  I also sense trouble if we bill TCM under a physician if the PA does the initial face-to-face.  Additionally, with the physician who works two weeks and then takes two weeks off, can we bill TCM under this doctor at all?

Any suggestions? 

Thanks -


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## bsesender (Jan 28, 2014)

*another e&m within 30 days*



Pam Brooks said:


> They can't, technically, and I'm not aware of any modifier.  I guess providers are expected to be prudent and not unbundle that first E&M...but the guidelines are very clear that additional E&M services may be billed during that post-discharge time frame.




Have you gotten any clarification on this?  we saw patient within 7 days and did not bill to medicare because it is "bundled", saw the patient a few weeks later for unrelated condition so we billed (applied to deductible), now i am ready to bill TCM but won't they deny since i billed an e&m during the 30 days, as they don't know of the face to face that i didn't bill......

also do i put the discharge date somewhere on the claim so they know the tcm is at the 30 day mark?

bridget.brown@casanovamd.com


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## shannon.annapolisinternalmed@gmail.com (Feb 4, 2014)

*99496-99495*

We have a question we have a physician that is billing out 99495 14day after discharge our question is do you count the discharge date as day one or is it the day after discharge to set up appt for a follow up for face to face thank you


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## Kisalyn (Feb 5, 2014)

Discharge day is day one and the date you would bill as the DOS is the 30th day. CPT 99495 is for moderate complexity with a face to face within 14 days.


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## emma021785 (Feb 17, 2014)

*Thank You Pam Brooks*

Your little handout was most helpful.  Thank you so much!


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## emma021785 (Feb 17, 2014)

*Question about TCM*

If a patient is discharged from inpatient to outpatient rehab, do the transitional care rules apply while he is in outpatient rehab (in other words, is outpatient rehab the same as home, domiciliary, rest home or assisted living.  

Or does he actually have to be done with outpatient rehab before that 30 days begins.

thanks to all


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## sawhitt (Feb 19, 2014)

*Transitional care*

We have not received payment for any transitional care claims. 
Can someone post simple exact directions for me?  
Thanks


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## drmpurple (Feb 19, 2014)

*Tcm*



emma021785 said:


> If a patient is discharged from inpatient to outpatient rehab, do the transitional care rules apply while he is in outpatient rehab (in other words, is outpatient rehab the same as home, domiciliary, rest home or assisted living.
> 
> Or does he actually have to be done with outpatient rehab before that 30 days begins.
> 
> thanks to all



From what I have read in the CPT book the pt must be discharged to their community (home) setting.  If the patient is at home and having outpt rehab I would think you could still bill the TCM code and the rules then apply (since the patient is no longer inpt and is in the home setting).   This is just what I am thinking.  Hope it helps.


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## Pam Brooks (Feb 20, 2014)

drmpurple said:


> From what I have read in the CPT book the pt must be discharged to their community (home) setting. If the patient is at home and having outpt rehab I would think you could still bill the TCM code and the rules then apply (since the patient is no longer inpt and is in the home setting). This is just what I am thinking. Hope it helps.


 

I believe that they cannot be in a facility setting...so outpatient rehab would not apply. The TCM codes are to be reported to help manage patients when they are in a post-discharge environment where they do not have any direct medical care and support, thus the care management model that TCM reimburses. If anyone understands this differently, perhaps they could comment. 

Also regarding this post: 
We have not received payment for any transitional care claims. 
Can someone post simple exact directions for me? 
Thanks 


If you read through this entire thread, you will get the answers to most, if not all of your questions about TCM. Also, CMS has several publications that address both FAQs as well as guidelines. Go to you local contractor's site and use the search engine to locate the guidance.


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## bsesender (Feb 20, 2014)

*paid!!! but a different question*

yay, i was paid for our first billed tcm..  communicated and noted, saw pt within 10 day time frame and then billed tcm code counting 30 days from date of discharge and using that as date of service...


now different patient, discharged, phone call made, patient seen, should be billing tcm today (day 30), but patient was readmitted a few weeks ago-- did not do tcm phone call or face to face after second discharge because patient went to a nursing home.  

can i bill tcm for first discharge on day 30 for first discharge?  in the faq on medicare site it says
 If the patient is readmitted in the 30-day period, can TCM still be reported?
*Yes, TCM services can still be reported as long as the services described by the code are furnished by the practitioner during the 30-day period, including the time following the second discharge. Alternatively, the practitioner can bill for TCM services following the second discharge for a full 30-day period as long as no other provider bills the service for the first discharge.* CPT guidance for TCM services states that only one individual may report TCM services and only once per patient within 30 days of discharge. Another TCM may not be reported by the same individual or group for any subsequent discharge(s) within 30 days.

this is a little confusing to me--should i bill 30 days after 2nd discharge even though work was done for first discharge?


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## davidinasheville (Mar 13, 2014)

shannon.annapolisinternalmed@gmail.com said:


> We have a question we have a physician that is billing out 99495 14day after discharge our question is do you count the discharge date as day one or is it the day after discharge to set up appt for a follow up for face to face thank you


I have the same question.

For billing 99495 the date of billing is the 30th day counting the discharge day as day one.  

However, for communicating with the patient "within 2 business days," CMS's FAQ are clear that the day after discharge is counted as day one.  

I suspect that F2F "within 14 calendar days" would count the day after discharge as the first day.  For example, if the patient is discharged on Tuesday a Face to face visit on Tuesday 2 weeks later would count for 99495.  

Does anyone know for sure, especially from any communication from CMS?  

David

See references below

http://www.cms.gov/Outreach-and-Edu...-Management-Services-Fact-Sheet-ICN908628.pdf

If a beneficiary is discharged on Monday at 4:30 p.m., does Monday count as the first business day and	
then Tuesday as the second business day, meaning that the communication must occur by close of 
business on Tuesday? Or, would the provider have until the end of the day on Wednesday?
In the scenario described, the practitioner must communicate with the beneficiary by the end of the day on 
Wednesday, the second business day following the day of discharge.


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## cgneff72 (Mar 13, 2014)

To determine the date you bill the TCm code, you count the discharge day as Day 1.  So a patient discharged on March 13, the TCM would be billed on April 11.  

The FAQ's state:  The 30-day period for the TCM service begins ON the day of discharge and continues for the next 29 days.  The reported date of service should be the 30th day.

The FAQ's also say:
If a patient is discharged on Monday at 4:3opm, does Monday count as the first business day and then Tuesday as the second business day, meaning that the communication must occur be close of business on Tuesday?  Or, would the provider have until the end of the day on Wednesday?
Answer:  In this scenario, the practitioner must cimmunicate with the patient by the end of the day on Wednesday, the second business day following the day of discharge.


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## susila (Mar 20, 2014)

*Can we bill TCM code 99495/99496 instead of Care plan Oversite for home health pts*

Can we bill TCM code 99495/99496 instead of Care plan Oversight services for home health,Assisted living and Hospice patients?






Pam Brooks said:


> The 'service period reporting' is the time following the date of discharge through the next 29 days, according to CPT.  So if the patient has moderate or high MDM for services during those days, they'd qualify.  Follow your MDM grid from your carrier's audit tool to determine if they meet at least the moderate.


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## Pam Brooks (Mar 20, 2014)

No because the purpose of TCM is to manage the patient when they are in their community home settings.  If the patient is in a nursing or assisted living facility, they are not eligible for TCM.


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## debkidcks (Mar 20, 2014)

According to an article in Medicare Learning Network, the patient IS eligible for TCM if discharged to a nursing home (or at least a "rest home") or to assisted living.  Here's the article:

http://www.cms.gov/Outreach-and-Edu...-Management-Services-Fact-Sheet-ICN908628.pdf

We've been billing Medicare for TCM for a few months now and have gotten paid on all of them so far.  We've really had to dot our i's and cross our t's - in other words, document and double-check _everything._  Make sure the follow-up phone call is done within two business days and documented.  And obtain a copy of the hospital discharge summary with the date of discharge.  That is what Medicare will go by and if your records don't match, I guarantee you'll have problems.

We did hit a bump in the road this week.  Medicare requested a refund on a 1/28/14 TCM charge.  The patient was readmitted in 1/20.  Our billing staff didn't know that at the time because the doctors hadn't turned in hospital charges but our doctors billed hospital visit charges for that hospitalization, including a visit on 1/28/14.  If you look on page 6 of the article linked above, Medicare says you CAN bill TCM even if the patient is readmitted before the 30 days are up.  However, when I called Medicare I was told "the patient can't be in two places at once - they can't be both in the hospital and in the office on the same day."  That's actually wrong - we see rehab hospital patients in our office - they are inpatients but they are brought to our office to see the doctor.  But that's another story.  On the TCM, I'm not sure, but it appears that maybe you have to only count out-of-the-hospital days for TCM.  In other words, you can only count up to the readmit, then resume after the patient is again discharged - ?  Does anyone know?  This patient hasn't gotten out of the hospital since the readmit.  Somehow I doubt Medicare will allow us to resume the counting a few months down the road.


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## susila (Mar 21, 2014)

*Tcm*

Can we bill 99495/99496 TCM codes for Care plan oversight services for patient in Home health,Hospice and Assisted living.
Anyone please do reply asap.

Thanks,
Susila


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## Pam Brooks (Mar 21, 2014)

debkidcks said:


> According to an article in Medicare Learning Network, the patient IS eligible for TCM if discharged to a nursing home (or at least a "rest home") or to assisted living. Here's the article:
> 
> http://www.cms.gov/Outreach-and-Edu...-Management-Services-Fact-Sheet-ICN908628.pdf
> 
> ...


 

A nursing home is considered a facility. A rest home is not a facility, (it's a private home where patients live with the family, and receive supportive care).  An assisted living facility is considered a facility when it's part of a nursing home.  So you have to be careful to know how the facility is licensed.


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## debkidcks (Mar 21, 2014)

I've never seen "facility" being a determining factor by Medicare when it comes to what constitutes a community setting.  In the article I referenced, as well as other literature I've seen on TCM billing, the explanation has always been that the patient must be being discharged FROM an inpatient setting (hospital inpatient, rehab hospital inpatient, skilled nursing, etc.) TO a community setting (including assisted living, etc.).  If the facility reference has already been addressed in this thread I apologize for not seeing it, (it's a long thread!), but could you tell me where that is explained by Medicare?


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## Pam Brooks (Mar 24, 2014)

debkidcks said:


> I've never seen "facility" being a determining factor by Medicare when it comes to what constitutes a community setting. In the article I referenced, as well as other literature I've seen on TCM billing, the explanation has always been that the patient must be being discharged FROM an inpatient setting (hospital inpatient, rehab hospital inpatient, skilled nursing, etc.) TO a community setting (including assisted living, etc.). If the facility reference has already been addressed in this thread I apologize for not seeing it, (it's a long thread!), but could you tell me where that is explained by Medicare?


 

I think this  would make more sense to everyone if we consider the point of TCM--that is to keep the patient from being re-admitted into another costly facility setting by managing them through a nurse care manager program while they are in their typical community/home setting.  So if we're discharging them from an inpatient hosptial setting and sending them to another facility----i.e. a nursing home, we've not yet gotten them to their community setting (home, domiciliary home, etc.)    Both the Federal Register and a CMS MLM article discuss that the community setting does not include a nursing home.  Hope this helps.


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## debkidcks (Mar 24, 2014)

Thanks for the response.  I'm still having trouble with this, though.  Medicare doesn't pay for all facility services - they don't pay for most nursing home services.  They just pay for medically necessary skilled nursing services while in a nursing home.  If Medicare's purpose for paying for TCM is cost management by minimizing readmissions to an inpatient setting they have to pay for, why would they care if the patient is released to an expensive nursing home or a less expensive private residence - as long as they aren't paying for it?

I'll admit, I don't usually read the Federal Register, but I've searched the MLN articles for everything I could find on the subject of TCM and have yet to see 
that nursing home patients don't count as patients in a community setting.  I'll keep my eyes open, but if you can find a link and can pass it on I'd sure appreciate it.


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## suzriley (Mar 27, 2014)

*Tcm*

Hello, has anyone had questions regarding contact made before the patient is discharged? some of my providers are being contacted before patient is discharged, appointments are made.  Can this be considered an appropriate contact even though it not done within the 2 day window after discharge? thank you


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## susila (Mar 28, 2014)

*Tcm*

Thank you so much,

Kindly provide me the details as under which settings we could bill TCM codes?
Also how to bill CPO services for HOME HEALTH,Assisted living and Hospice patients.
99374/99375,99380,G0181,G0182-Please help.


Susila


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## rthames052006 (Apr 1, 2014)

suzriley said:


> Hello, has anyone had questions regarding contact made before the patient is discharged? some of my providers are being contacted before patient is discharged, appointments are made.  Can this be considered an appropriate contact even though it not done within the 2 day window after discharge? thank you



The initial contact must be after the patient is discharged from the facility.  CMS has a TCM guide on their website.


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## rthames052006 (Apr 1, 2014)

susila said:


> Thank you so much,
> 
> Kindly provide me the details as under which settings we could bill TCM codes?
> Also how to bill CPO services for HOME HEALTH,Assisted living and Hospice patients.
> ...



Susila-

If you take a look at your CPT book, it gives a listing of the codes that cannot be reported with TCM.  Also there are several MLN Matters documents relating to TCM as well as a guide to TCM on CMS website.


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## tmcquegge (Apr 10, 2014)

quick question i didn't see this on the post here is our problem.  Does the discharging doc have to decide the level if its modorate or server to know if they need to be seen in 7 or 14 days?  or can the physican seeing them just set it up for 7 days and decide then?  Hope that makes since but we are having a big argument right now because we just had hospitalist start seeing our patients in the hosptial but the physicians are still wanting to bill TCM charges.  Thank you so much for your help.


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## synda5989 (Sep 11, 2014)

Pam, I have been unable to open your PDF attachment.  Could you please help me?


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## rhondaturpin (Nov 11, 2014)

*tcm code*

We are getting conflicting information from insurance companies.  Some are saying that the DOS must be 30 days AFTER the date of discharge.  This does not make sense to me.  It goes against everything I know.  If this is the case, the progress note will not match the claim.  I hope someone can clarify.  Thanks, Rhonda


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## teresabug (Nov 12, 2014)

your DOS will be 29 days after discharge. There are requirements that have to be met to bill TCM code. There is a MLN article on this service if you google it.


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## Cortzea (Apr 16, 2015)

*Tcm*

Now i have a question ..what would happen in this particular scenario 

" pt see the doctor on 3.27.14 and makes her f/u appt for 4.10.14 whithin this time frame pt gets admitted to the hospital and gets discharge on 3.30.14 no communication was made and pt keeps appt for 4.10.14 " 

1.-no attempt for comunication was made since the pt had an appt scheduled , so therefore if i follow the 2 day communication rule ...we cant bill TCM 

2.-if we had made comunication with pt 2 days whithin dischage then ..can i still charge TCM even if the appt was made prior to his/her hospital visit and discharge ?


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## Pam Brooks (Apr 16, 2015)

JDC said:


> Now i have a question ..what would happen in this particular scenario
> 
> " pt see the doctor on 3.27.14 and makes her f/u appt for 4.10.14 whithin this time frame pt gets admitted to the hospital and gets discharge on 3.30.14 no communication was made and pt keeps appt for 4.10.14 "
> 
> ...



The 3/27 visit is irrelevant, no matter where it was done, because the discharge was on 3/30.  That's when your clock starts ticking.  You need to have made communication within 2 days of that discharge.  It appears you didn't so you can't bill TCM, but you can bill a regular OV for 4/10.  If you had made the 2-day communcation, then you could have billed the TCM on 4/28 (day 30), and your 4/10 is the bundled visit.  Just be careful when you schedule visits prior to discharge, even if it was previously scheduled as a follow up, because you always must consider medical necessity, and the proximity of the visit to the discharge will drive your level of code.  Don't shoot yourself in the foot by scheduling too far out.


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## Quaker (Sep 3, 2015)

*MDM dilemma*

So the type of MDM starts after the day of discharge to day 29.  If a patient was admitted for a new condition that posed a threat to life and followed-up with the provider 5 days post discharge, would the provider still consider the patient's condition to fall under high severity?  My PCP feels that since the acute allergic reaction could have killed the patient that he considers the TCM follow-up to be of high complexity even though the patient was stable for the face-to-face visit and the management included tapering the steroids and a referral to an allergist.  Any opinions?


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## Phyzit (Sep 14, 2015)

*TCM and Cardiology*

Anyone working with a cardiology group, are you finding success billing for TCM?


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## MACACERES (Apr 26, 2016)

*Tcm 48 hr contact*

Hi,

I was wondering if someone could help me regarding the TCM within 48 hr contact with patient, family member, or caregiver?  My question is what is considered a caregiver exactly?  Is contact with the VNA considered part of that two-day contact?  I always thought that the VNA is an outside home care agency and not considered the patient's original caregiver?  or am I not understanding?  If you can also provide where I can find that information in writing, that would be great!  I have spent a long time trying to get clarification on what a caregiver is exactly, or what qualifies as a caregiver?

Thanks so much!

Maritza Caceres, CPC, PCA


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## renoma1 (Jun 7, 2016)

*Transitional care mangement clarification with  gi practice*

Hello,  

We are needing clarification of Transitional Care Management for a gastroenterologist.  After we audit the clinical information when the physician wants to charge TCM we agree on a 99215 not a TMC code.  Because, the plan.   For example patient seen in the hospital for GI bleed, and Anemia, provider consulted on the case, procedure done finding  bleeding  ulcer.  Met criteria of 14 days after d/c, contact patient within 2 days of d/c.  However, the transition was to home, not to another medical facility, ect..  The face to face was established in the correct time frame.  However the plan was protonix(medication), Another EGD in 6-8 weeks to monitor ulcer, for the anemia(monitor), and OTC iron, constipation, Metamucil(medication).  The only education to the patient got, was written material on Miralax.  I am not sure what is being transitioned.  Please dummy it down for use.  We are all a little confused, on TCM. I think the decision making is were we are confused with.  Thanks for your help.











Pam Brooks said:


> Transitional Care Management (not transition of care) is not a single-encounter charge.
> These two codes (99495 and 99496) are designed to report services provided by RN Care managers, under the supervision of physicians and NPPs who are doing comprehensive post-discharge care for complex chronically ill patients. The reporting period is 30 days post- discharge. If your practice does not already employ nurse care managers who are doing this kind of chronic disease management work, I'd suggest you first attempt to get a program up and running in order to bill these services.
> 
> CPT actually does a pretty good job of explaining what is involved to bill these services.
> ...


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## rachelm1977 (Nov 30, 2016)

*SNF discharge to Assisted living*

Help!! If I have a patient who was discharged from SNF and is admitted into Assisted Living Center, can I bill a new patient? The patient was discharged and admitted by the same Physician Assistant.

Thank You, 
Rachel


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## kfrycpc (Dec 2, 2016)

*TCM and Readmitting*

We need a clear interpretation of the TCM rules regarding the following.  Please help!  It is regarding the patient being readmitted during the 30 days of the TCM.  Our questions are:

1) We know that TCM billing can only occur *once* within a 30 day time frame.  

a) If the pat is readmitted within that time frame (the first 30 days), and the TCM requirements *have been met, can you still bill for the TCM?   

OR 

b)  Does the clock "start over" and you bill instead the appropriate E&M levels for the visits prior to the 2nd discharge, and use the 2nd discharge to start the 30 day clock????

2)  Also, not to be more confusing, but IF (b) is an option, does it apply ONLY if the pt is readmitted for the SAME dx as the first admission?  Or is the dx  irrelevant?

Any help is greatly appreciated!!!  Thank you in advance!!!

​Kellie Fry, CPC 
Billing & Coding Compliance Analyst
 HMM-Central Billing Office
 P: (908) 284-1125, ext. 7284
 F: (908) 284-2016
 E: kfry@hhsnj.org*


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## StephR (Dec 14, 2016)

Kelly,

If the patient is re-admitted during the 30 days, then the TCM criteria has not been met; our site will then bill the appropriate E&M.  If the patient is re-admitted, a new TCM period/criteria applies and the old dx is completely irrelevant.  You have to love TCM!!

Steph


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## thomas7331 (Dec 14, 2016)

Here's a document published by CMS that addresses some of these questions:

https://www.cms.gov/medicare/medica...ment/physicianfeesched/downloads/faq-tcms.pdf

According to this (see page 2), in the case of readmission the TCM can still be billed for either the first or second discharge as long as it is not billed twice within the full 30 day time frame.


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