Primary Care Coding Alert

Question: One of our patients was discharged from a local hospital and enrolled in transitional care management (TCM). We completed the initial phone call within two business days as required by the service and scheduled the patient’s first visit within the 14 days stipulated by 99495. However, when the patient showed up for the appointment, our provider treated him for an acute condition unrelated to the diagnosis associated with the hospital visit and the TCM service. Under these circumstances, should the patient be treated for the acute condition and the TCM visit be rescheduled? Or is it possible to code for both the TCM and a separate evaluation and management (E/M) service?

Michigan Subscriber

Answer: CPT^® guidelines for 99495 (Transitional Care Management Services …) state that “the first face-to-face visit is part of the TCM service and not reported separately. Additional E/M services provided on subsequent dates after the first face-to-face visit may be reported separately.”

This tells you that you should not bill a separate sick visit on the same day of service as the first face-to-face visit component of 99495 because the work of the E/M is folded into the TCM service. Even though your provider treated the patient for a different condition than the one the patient was hospitalized for, TCM services involve moderate- and, in the case of 99496, high-level medical decision making (MDM). This level of care implies providers should attend to all of the patient’s health issues at the time of the initial face-to-face encounter in order to facilitate a smooth transition from the hospital to the patient’s home or domicile.

Lastly, rescheduling the TCM appointment for another day within the 14-day timeframe would be an inconvenience to the patient, which is something your practice should avoid.