EM Coding Alert

Question: An 84-year-old female patient of ours who experienced congestive heart failure was released from the hospital after one week. The hospital service included a nurse care manager speaking with the patient’s family by phone the day after discharge to review medications and CHF self-management, and to make the follow-up appointment. The original billing physician reviewed the discharge summary and talked to consultants who treated the patient in the hospital. Four days later, the patient presented for a face-to-face visit that included prescription drug management, recommendations for diagnostic tests, and a home-health referral. The billing physician and clinical staff continue to monitor the patient’s weight during the 30-day transitional care management period via phone calls and home-health data feeds. How should this be submitted?

Wisconsin Subscriber

Answer: Because the services are provided during the 30-day period, you need to use 99496 (Transitional care management services with the following required elements: communication [direct contact, telephone, electronic] with the patient and/or caregiver within 2 business days of discharge, medical decision making of high complexity during the service period, and face-to-face visit, within 7 calendar days of discharge), says Sandra Nyman, professional coding educator at Allegheny Clinic in Pittsburgh, Pa. You also need to include the place of service (POS) code of the location that “required the face-to-face visit.” You would code 99496, POS 11 (Office).

There are restrictions around the 30-day transitional care management (TCM) period. According to CMS during the March 12, 2014 CMS forum:

• “When determining which place of service (POS) code to use on your TCM claim, you should use the location that required the face-to-face visit.

• “The 30-day TCM period begins on the date of discharge and continues for the next 29 days. Your date of service should be the thirtieth day of care — not the first.

• “CMS will reject any claims with dates of service prior to Jan. 30, 2013, because the codes became effective on Jan. 1 and only cover 30-day periods.

• “You can report TCM codes for both new and established patients, which is a departure from CPT® rules. 

• “If 30 days pass between discharge and the initial communication with the TCM practitioner, you cannot report TCM codes.

• “Medicare will pay only the first TCM claim received per beneficiary in one 30-day period beginning on the date of discharge, so if more than one practitioner reports the code for the same patient, only the doctor whose claim is received first will get paid.

• “If the patient dies before the thirtieth day of TCM, you cannot report the TCM codes because they cover a full 30 days. Instead, you’d report the appropriate E/M code.”

If the patient is re-admitted within the 30-day TCM period, an E/M should be billed on the day of the face-to-face encounter and the TCM process will start over again after the second admission date, added Nyman.