Medicare Compliance & Reimbursement

Some MACs seem to be in the dark regarding whether subsequent E/M visits are separately payable.

The Centers for Medicare & Medicaid Services announced new transitional care management codes but have yet to issue in-depth instructions on how to use them. If you think that your local MAC will be able to clarify the process, you might be in for a shock.

That’s the takeaway from a Feb. 7 “Ask the Contractor” conference call held by NGS Medicare, the Part B MAC for New York and Connecticut.

“As of yet, we have not received complete direction from CMS on how to use these, but codes 99495 and 99496 have been established,” said NGS’s Jim Bavoso during the call. “These are services for established patients whose medical care requires high or complex medical decision-making during the transition period when they come out of an inpatient hospital setting.”

The TCM codes commence on the date of discharge and continue for the next 29 days, Bavoso said. “The codes require a face-to-face visit, initial patient contact, medication reconciliation and so forth. The first face-to-face visit that is part of the TCM service is not reported separately. Additional E/M services after the first face-to-face visit may be separately payable.”

At this point, Bavoso added, NGS does not have any built-in restrictions on these codes, “but we only pay it for one provider,” he said. “Also, some codes are mutually exclusive with the transitional care management codes, so you’ll have to look at CCI to look at additional services that may be bundled. We’re waiting for additional information from CMS on this issue.”

July 1 Is Go Time for New Therapy Codes

As most therapy coders are aware, CMS introduced several new G codes and severity/complexity modifiers to convey information about a patient’s functional status to Medicare. Although the codes went into effect on Jan. 1, your claims have still been paid correctly without them, but that won’t be the case for long.

“Approximately 42 functional G codes are now going to be used for physical and occupational therapy for data reporting effective Jan. 1, 2013,” Bavoso said. “However, we are in a testing period through June 30 to allow providers to use the new coding requirements and ensure that the new codes work. During this time period, claims without the G codes and modifiers will still be processed, but as of July 1, if a claim comes in without these codes, the claim will be denied,” he added.

Examples of the new codes include G8978 (Mobility: Walking and moving around functional imitation, current status, at therapy outset and at reporting intervals) and Modifier CJ (At least 20 percent but less than 40 percent impairment limitation restriction).

For more about the functional G codes, visit the CMS Web site at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8005.pdf.