Pediatric Coding Alert

Question: Can we perform transitional care management (TCM) on newborns leaving the hospital for home and who have no issues?

AAPC Forum Participant

Answer: As the TCM guidelines state, 99495 (Transitional Care Management Services with the following required elements: … Medical decision making of at least moderate complexity during the service period …) and 99496 (Transitional Care Management Services with the following required elements: … Medical decision making of high complexity during the service period …) “are for a new or established patient whose medical and/or psychosocial problems require moderate or high complexity medical decision making during transitions in care from an inpatient hospital setting (including acute hospital, rehabilitation hospital, long-term acute care hospital), partial hospital, observation status in a hospital, or skilled nursing facility/nursing facility to the patient’s community setting (home, domiciliary, rest home, or assisted living).”

So, while the newborn satisfies the criteria of being a new or established patient and of transitioning from an inpatient setting to a community setting, the patient has no medical problems that require any level of medical decision making (MDM). This makes the codes inappropriate for a normal newborn transitioning from hospital to home.

In this instance, any transitional issues that the parent and child may experience should be addressed during a preventive evaluation and management (E/M) service. In this case, the most appropriate service for you to document would be 99381 (Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; infant (age younger than 1 year)), which is not a problem-oriented E/M.