Primary Care Coding Alert

Question: One of our patients had a planned laparoscopic surgery in which they were admitted and stayed overnight to make sure everything was fine. My question is this: can we bill for transi­tional care management (TCM) when the surgery is planned?

Ohio Subscriber

Answer: Whether the surgery was planned or unplanned doesn’t matter in TCM visits. In order to bill 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) or 99496 (… Medical decision making of high complexity during the service period; Face-to-face visit, within 7 calendar days of discharge), what matters is the following elements of TCM are fulfilled:

• The patient’s condition meets the level of medical decision making (MDM), which should be at least moderate for 99495 or high for 99496 during the service period;
• The patient is transitioning from a hospital setting other than the emergency department (ED) or from a skilled nursing/nursing facility setting to their community setting, such as their home or assisted living;
• A member of the TCM team communicates with the patient and/or caregiver within two business days of discharge; and
• A member of the TCM team meets with the patient within 14 calendar days of discharge (99495) or seven calendar days of discharge (99496).