Part B Insider (Multispecialty) Coding Alert

Question: I think the transitional care management codes only apply to established patients, but my physician keeps reporting them for new patients, and he did get paid for one of these claims. Is this accurate or should we pay that money back for the TCM billed for a new patient?

Answer: Your physician is right, but it’s no surprised that you’re confused about this. CPT^® 2013—which debuted the TCM codes—was unclear. However, CPT^® 2014 promises to work some of the kinks out of codes 99495 (Transitional care management services with the following required elements: 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, and face-to-face visit within 14 calendar days of discharge) and 99496 (…within seven calendar days of discharge).

The Editorial Panel’s accepted guideline revisions will indicate that TCM services can now also apply to new patients. The 2013 guidelines limited the codes to established patients, but payers such as Medicare already allow the use of the codes for new patients, too. You’ll also get clarifications about reporting discharge services and other E/M services in addition to TCM when CPT^® 2014 debuts this January.