Oncology & Hematology Coding Alert

But be careful: Your MDM calculations may soon change.

When one of your patients transitions from an inpatient hospital setting to a community setting, such as their home or an assisted living facility, your provider will often offer transitional care management (TCM) services to the patient.

The main purpose of these services is to facilitate the patient’s care plan, but as the descriptors for 99495 (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 at least moderate complexity during the service period; face-to-face visit, within 14 calendar days of discharge) and 99496 (… medical decision making of at least high complexity during the service period; face-to-face visit, within 7 calendar days of discharge) show, TCM has a lot of moving parts.

Here’s what you need to know to make sure your TCM documentation is on point.

Tip 1: Make Sure Your TCM Code Choice Is on the Level

“Patients must meet at least a moderate level of complexity of medical decision making (MDM) to use the codes. Patients with straightforward or low-level complexity MDM do not qualify,” explains Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

This means your patient must meet the moderate level of MDM complexity before you can use 99495 and high MDM complexity before you can use 99496, assuming all other conditions are met.

Heads up! Per CPT^®, “medical decision making is defined by the E/M [evaluation and management] Services Guidelines.” For 2022, that means following the MDM complexity guidelines for all E/M services other than those for the office or other outpatient E/M services. However, the AMA has said it will soon be overhauling the guidelines for the non-office/ outpatient E/M services to bring them into line with those now in use for 99202-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …). So, stay tuned to Oncology & Hematology Coding Alert to find out how and when these guidelines will change.

Tip 2: Make Sure You Know Where Your Patient Is Coming From and Going To

“Patients must be transitioning from a hospital setting other than the emergency department (ED) or from a skilled nursing facility (SNF)/nursing facility setting to a community setting, such as their home or assisted living. Patients going from one facility setting to another, for example from a hospital to a SNF, are not transitioning for purposes of TCM, nor are patients who are going from the ED to a community setting,” explains Moore.

Tip 3: Make Sure Your Documentation Speaks to These Elements

Once you’ve established your patient’s medical complexity and transitional locations qualify them for TCM, you then need to make sure your practice’s initial contact and subsequent required face-to-face contact meet the TCM code requirements.

“The TCM codes require a face-to-face visit and initial patient contact all within a specific timeframe,” according to Sherika Charles, CDIP, CCS, CPC, CPMA, compliance analyst with UT Southwestern Medical Center in Dallas, Texas. “At a minimum, in addition to documenting the complexity of MDM, you will need to document the date of the beneficiary’s discharge; the date your provider, a qualified healthcare professional [QHP], or a member of your clinical staff initiated interactive contact with that beneficiary or the beneficiary’s caretaker; and the date your provider, a QHP, or member of your clinical staff furnished a face-to-face visit,” Charles adds.

For both TCM services, that means documenting your provider, a QHP, or a member of your clinical staff initiated “communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge” per the code descriptors. You’ll also need to document a face-to-face visit “within 14 calendar days of discharge,” per 99495’s descriptor and within seven calendar days for 99496, due to the higher level of MDM required.

Know these communication caveats: If your practice fails to establish the initial contact with the patient after two attempts “made in a timely manner,” you can still bill for TCM providing all the “other transitional care management criteria are met,” according to CPT^®.

Also, for 99496, if the face-to-face visit takes place more than seven calendar days after discharge (i.e., if it takes place between day eight and day 14), you will have to code 99495 instead. And remember, “the first face-to-face visit within the TCM period is included in the TCM codes and cannot be reported separately, but additional face-to-face visits within the TCM period are separately reportable,” Moore notes.

Tip 4: Make Sure Your Documentation Records These Services (and Who Performs Them)

Clinical staff under the physician’s supervision may provide the patient (or the patient’s guardian, family members, caretaker, surrogate decision makers, and/or other professionals) with these non-face-to-face services:

• “Communication … regarding aspects of care;
• “Communication with home health agencies and other community services utilized by the patient;
• “… education to support self-management, independent living, and activities of daily living;
• “Assessment and support for treatment regimen adherence and medication management;
• “Identification of available community and health resources;
• “Facilitating access to care and services needed by the patient and/or family.”

Services offered by the physician or QHP, on the other hand, may include:

• “Obtaining and reviewing the discharge information (eg, discharge summary, as available, or continuity of care documents);
• “Reviewing need for or follow-up on pending diagnostic tests and treatments;
• “Interaction with other qualified health care professionals who will assume or reassume care of the patient’s system-specific problems;
• “Education of patient, family, guardian, and/or caregiver;
• “Establishment or reestablishment of referrals and arranging for needed community resources;
• “Assistance in scheduling any required follow-up with community providers and services.”

But “you can’t report TCM during the same period of time you’re reporting CCM [chronic care management] for the same patient,” Moore notes. Even though there is no National Correct Coding Initiative (NCCI) edit prohibiting you from billing TCM with CCM, elements of each service may conflict or overlap, and you can only capture those elements for one service, not both. In other words, “CCM includes components of 99495 and 99496, so reporting CCM services may double-dipping,” concludes Charles.

It is also important to note that TCM can only be reported by one individual, and only once per patient during the TCM period. In the instance that hospital or observation discharge services and TCM are reported by the same individual, the discharge service does not satisfy the required face-to-face visit. Finally, per CPT^® guidelines “the same individual should not report TCM services provided in the postoperative period of a service that the individual reported.”

Resource: For more information on transitional care services, consult www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Transitional-Care-Management-Services-Fact-Sheet-ICN908628.pdf.