Wiki Transitional Care Management - the CPT codes

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Date of service

Can someone please tell me what date of service would be used on day 30 of TCM services? I have not been able to find an answer to this.
Thank you.
 
Pam-

You are a wealth of information! By reading this thread I've learned a few things from you. So glad we are on the same page! Some of the questions I had, you've supplied answers to , so thank you dear.

I do have a call out to the AMA and hopefully they provide the same answers.

Unfortunately we had a provider who billed out these codes ( didn't inform us) in January the date of his F2F so now we are just waiting to see what the carrier does! Really wish he would have let us know this before the claim went out!!!
 
Tcm

Here's my dilemma:

We are an interventional cardiology group. My practice manager has decided that we can bill TCM for post-op patients as long as another provider in our group takes on the TCM. I've tried to no avail to explain that we can't do that because post-operative care is inclusive with the stenting, AICD/Pacemaker procedures, etc., but because the guidelines say "surgeon" and not "group or practice" he thinks we can skirt it.

Am I wrong? Is there something I can present to him that will show we cannot bill TCM for our post-op patients?

Thanks!
 
I've shown him the CPT guidelines, as well as information from a class I attended a few weeks ago. I can't make him understand when it says the surgeon, it means anybody from our practice. He interprets the guidelines as the actual surgeon, which is incorrect. I've printed the section addressing TCM from the final rule, but I think I'll not fare any better. Thank you for the links.
 
It may very well bump up against his global days anyway, and be denied as inclusive. But billing it when you know it is not covered goes against Medicare's Fraud and Abuse guidelines and against the False Claims Act. Not sure it's worth the trouble.
 
Additional E&M services

If provider sees patient more than once in the 30 day period, can that additional E&M visit be billed?
 
So if we bill an additional E&M visit during the 30 day period how will insurance company differentiate from the bundled E&M service for TCM and not deny? Is there a specific modifier we need to utilize?


Pam Brooks said:
The whole point of TCM is to follow the recommendations of the discharging physician to avoid re-admission. Without that summary, it will be difficult for you to create the patient's care plan. If your provider's patient was discharged from a facility, then it's standard practice (not to mention professional courtesy) to forward a copy of the discharge summary to the patient's PCP---if the patient indicated that they would be following up with their PCP post-discharge. Maybe you need to contact the hospital to see why you're not included in the distribution list for those documents.
Click to expand...

Pam Brooks said:
The requirement for the face to face visit is either 1-7 edays or 8-14 days. There is no other face-to-face requirement (just documentation requirements based on your nurse care manager's work). You don't have to drop the code on a day when there's been a visit....in fact, we have set up a schedule to drop codes exactly on day 30. So if you met the 2-day contact and medication reconciliation, the 14 day face to face requirement, the patient was discharged from an inpatient setting, the MDM is moderate or high, and the nurse care managers have documented the patient-specific criteria as outlined in CPT, then you can drop the code on day 30. In fact, any additional face-to-face provider visits can be billed additionally. Does this help?
Click to expand...
 
They can't, technically, and I'm not aware of any modifier. I guess providers are expected to be prudent and not unbundle that first E&M...but the guidelines are very clear that additional E&M services may be billed during that post-discharge time frame.
 
Tcm

Thanks, Pam, for these links. I have one more question to add...If the PCP has spoken with the patient and arranged therapy with follow-up in office in fourteen days, but the patient cancels all appointments, is the code still billable since the face to face did not occur?
 
I would say that you cannot. The face to face is clearly a requirement to bill the code. Just as you cannot bill Medicare for a no-show appointment, you cannot bill for the care management without the physician face-to-face to support the MDM that you will eventually choose to report the code on day 30. I would definitely document the no-show, in case the patient changes their mind and shows up after the 14 days and then engages in the appropriate post-discharge care. But if the patient refuses treatment, you can't bill the code if they're not coming in to see you. The other option is for the provider to go see the patient at their home.
 
Pam,
Thank you so much for all this information.

My management is asking, Does the ICD-9 code that was used for the discharge have to be the same ICD-9 code that is billed out with 99495 or 99496?

Thank you
Amanda
 
Since the care managment is directly related to the discharge, I would imagine that the diagnosis codes would be the same. Nothing in the guidance I've read says the codes have to mirror each other, but we planned to drop the diagnosis codes reported based on the first face-to-face following the discharge, which of course would be based on the final discharge diagnosis. There's nothing that says the provider can't also address other conditions that arise since discharge that could put the patient at risk for re-admission.
 
I took a class on the new codes for 2013 and the Trans Care Codes were prominent in the discussion.
The instructor said there were criteria for the phone call
Included in the call and documented
1. Medication reconciliation
2. Discharge Summary
3. Nutritional needs/Diet
4. Sleep
5. Elimination
6. Wounds/wound care
7. Home health needs.


Has anyone else heard this specific documentation?
Thanks
 
I think that's an over-interpretation, and if you read the code description in CPT, you'll see what I mean. CPT discusses the non-face to face services, by stating they "MAY" be included in the patient's care, and those that you mentioned are in that list. There is no guideline for the content of the communication other than to make it within the 48 hour time frame. Per CPT: "TCM requires an interactive contact with the patient or caregiver, as appropriate, within two business days of discharge. The contact may be direct, face to face, telephonic or by electronc means". It does not go on to say what must be addressed. That's why they say "as appropriate".

I'm not sure where your information came from, unless your local carrier has come out with more definitive requirements. Ours has not.
 
Diane Zucker taught the class to our local AAPC group. I believe she is well known and respected in her field.
I find this topic quite interesting and and am curious to see what the audits of these claims will show.
Thanks for your expertise.
 
sawhitt said:
Diane Zucker taught the class to our local AAPC group. I believe she is well known and respected in her field.
I find this topic quite interesting and and am curious to see what the audits of these claims will show.
Thanks for your expertise.
Click to expand...


I agree, but I was wondering where she got that specific detail....it hasn't been release from CMS as far as I know, and CPT does not indicate this information as specifically as your explanation read. I would be interested to see those references, particularly for my own group, to make sure we're capturing the data in the way we're expected to. Obviously, the 48-hour contact will be much more than a "Hi how are ya" conversation, and should be relevant to the patient's discharge plan, but I have not read anywhere that certain elements MUST be discussed at that time. I'm not sure I have Diane's contact information, but feel free to give her mine.
 
Date of service to use

I have a question concerning what date of service to use when billing for the TCM service. We have billed one and it came back and denied. As far as the from date we used the discharge date and the to date on the claim we listed as the 30th day after discharge. Can anyone assist me on what we use as the from and to date on the claim.

Thanks
 
Pam,
I have not heard from Diane, but she does answer her emails so I am hoping to hear soon.
I did sit in conference last week with the Ohio MGMA and this subject did come up.
Here is the email from Jeb Shepard
Government Affairs Representative
Midwestern and Southern Sections
Medical Group Management Association
Washington, DC, 20006


Hello Susan,
Thanks again for your questions regarding the new Transitional Care Management CPT codes. Sorry for the delay here, I had to get colleagues in the office involved! I'm following-up from my voicemail with this email.

We were unable to find a specific list of items that must be included in the communication within 2 business days. In the proposed rule, CMS does provide a list for their proposed G codes (in the final rule they adopted CPT codes instead), however they were not finalized. As I mentioned at the conference, CMS has states in the final rule and in our communications with them that more guidance on how to bill these new codes will be forthcoming. Since it is mid March, we hope to see something soon.

I wish I had a better answer for you, but we're just going to have to wait until CMS provides more information. I will make sure to follow-up with you when they do. I'm curious as to what list Diane Zucker is referencing. Do you happen to know?

Please let me know if you have any other questions.

My best,
Jeb


He then sent this to me a few hours ago.

Frequently Asked Questions about Billing Medicare for Transitional Care Management Services
Effective January 1, 2013, Medicare pays for two CPT codes (99495 and 99496) that are used to report physician or qualifying nonphysician practitioner care management services for a patient following a discharge from a hospital, SNF, or CMHC stay, outpatient observation, or partial hospitalization. This policy is discussed in the CY 2013 Physician Fee Schedule final rule published on November 16, 2012 (77 FR 68978 through 68994). The following are some frequently asked questions that we have received about billing Medicare for transitional care management services.
• What date of service should be used on the claim?
The 30-day period for the TCM service begins on the day of discharge and continues for
the next 29 days. The reported date of service should be the 30th day.
• What place of service should be used on the claim?
The place of service reported on the claim should correspond to the place of service of
the required face-to-face visit.
• If the codes became effective on Jan. 1 and, in general, cannot be billed until 29 days past discharge, will claims submitted before Jan. 29 with the TCM codes be denied?
Because the TCM codes describe 30 days of services and because the TCM codes are new codes beginning on January 1, 2013, only 30-day periods beginning on or after January 1, 2013 are payable. Thus, the first payable date of service for TCM services is January 30, 2013.
• The CPT book describes services by the physician's staff as "and/or licensed clinical staff under his or her direction." Does this mean only RNs and LPNs or may medical assistants also provide some parts of the TCM services?
Medicare encourages practitioners to follow CPT guidance in reporting TCM services. Medicare requires that when a practitioner bills Medicare for services and supplies commonly furnished in physician offices, the practitioner must meet the “incident to� requirements described in Chapter 15 Section 60 of the Benefit Policy Manual 100-02.
• Can the services be provided in an FQHC or RHC?
While FQHCs and RHCs are not paid separately by Medicare under the PFS, the face-to- face visit component of TCM services could qualify as a billable visit in an FQHC or RHC. Additionally, physicians or other qualified providers who have a separate fee-for-
Page 1 TCM FAQs
March 12, 2013
service practice when not working at the RHC or FQHC may bill the CPT TCM codes, subject to the other existing requirements for billing under the MPFS.
• If the patient is readmitted in the 30-day period, can TCM still be reported?
Yes, TCM services can still be reported as long as the services described by the code are furnished by the practitioner during the 30-day period, including the time following the second discharge. Alternatively, the practitioner can bill for TCM services following the second discharge for a full 30-day period as long as no other provider bills the service for the first discharge. CPT guidance for TCM services states that only one individual may report TCM services and only once per patient within 30 days of discharge. Another TCM may not be reported by the same individual or group for any subsequent discharge(s) within 30 days.
• Can TCM services be reported if the beneficiary dies prior the 30th day following discharge?
Because the TCM codes describe 30 days of care, in cases when the beneficiary dies prior to the 30th day, practitioners should not report TCM services but may report any face-to- face visits that occurred under the appropriate evaluation and management (E/M) code.
• Medicare will only pay one physician or qualified practitioner for TCM services per beneficiary per 30 day period following a discharge. If more than one practitioner reports TCM services for a beneficiary, how will Medicare determine which practitioner to pay?
Medicare will only pay the first eligible claim submitted during the 30 day period that commences with the day of discharge. Other practitioners may continue to report other reasonable and necessary services, including other E/M services, to beneficiaries during those 30 days.
• Can TCM services be reported under the primary care exception?
TCM services are not on the primary care exception list, so the general teaching
physician policy applies as it would for E/M services not on the list.
• Can practitioners under contract to the physician billing for the TCM service furnish the non- face to face component of the TCM?
Physician offices should follow “incident to� requirements for Medicare billing. “Incident to� recognizes numerous employment arrangements, including contractual arrangements, when there is direct physician supervision of auxiliary personnel.
This issue is addressed in greater detail in the Internet-only Benefit Policy Manual, Chapter 15, Section 60 available at: http://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS012673.html
Page 2 TCM FAQs

When I hear from Diane, I will forward it on. I do feel better that we are doing this correctly in our practice.


Susan Whitt, PA-C, Practice Manager
Diley Medical Group
 
Thanks very much, Susan. We also had the question about what to do if the patient dies shortly after d/c, and of course if the 30-days of TCM doesn't take place, we've not met the criteria to bill the code. It's nice to have a precise explanation here. I'm still waiting to hear from CMS directly with clarification and communication....I honestly think the coders on this board have more information than they do!
 
Pam,
That is how I feel too. I keep these emails so if we have an audit or we get final rules in the next year we can show we correctly coded these after codes were put out and before final rulings.
Susan
 
There are no limitations on specialties that I am aware of. Any qualified provider can bill these codes but only if they are providing the post-discharge care of the patient's condition and co-morbidities in order to prevent re-admission. That's the key to these visits, and why most of the billing providers will be primary care physicians. If a specialist is the overall post-discharge medical provider for the patient and as long as the specialist isn't still within a global surgical period, they can bill if they meet the criteria.

I still think there's some misconceptions about this code. These services are Medicare's solution to provide reimbursement for those entities who provide chronic care management services utilizing care manager RNs who follow patients as they manage multiple conditions, medications, need for resources, etc. Up until now, this work was largely unreimbursed, but in order to prevent readmissions, this code was approved by CMS.

This service is not a one-shot deal, follow-up-after-discharge-and-bill out the code scenario. The expectation is that we follow up with the patient and keep tabs on them for that month to make sure they're staying out of the inpatient setting.
 
Transition of Care coding question

I am confused on when to bill Medicare for cpt code 99495. Our physician is the pt's PCP. The pt was discharged on 2/7/2013, we contacted the pt on 2/8/2013, and the pt was seen with our pcp on 2/11/2013. Our office billed Medicare on 2/21/2013 and the claim was denied due to the time frame was too early? We are really confused with this transition of care coding. THanks for your help. Sherry Webb
 
The date of service needs to be day 30 post discharge. 2/21 would have only been 14 days. You have to complete the 29 days required services to bill.
 
Hi, Cheermom68!
I am still confused with the date of service. For example, the patient is seen on 2/11/2013. we wait until 30 days post discharged and send the bill to madicare on 3/11/2013. So, what date of service we have to use on CMS-1500 form? The 2/11/2013 or 3/11/2013? Thanks
 
The DOS you use is like she said. It's 30 days after the date of the discharge from the hospital. The DOS the provider saw the patient does not come into play for the billing date.
 
Hello everyone!
is anyone knows how much medicare pays for TCM?. Raemarie Jimenez, from AAPC in her article said, it is 163.99 for Moderate complexity and 231.36 for high complexity but she did not clarified that if these prices for facility or non-facility. Today, I read on AAFP website that 231.12$ and 164$ is for non facility and 135$ and 197.76$ is for facility. which one is correct?
 
99495 163.99 non facility, 134.73 facility
99496 231.36 non facility, 197.97 facility

I encourage you to become familiar with the Physician's Fee Schedule.

http://www.cms.gov/apps/physician-fee-schedule/license-agreement.aspx

Both Raemarie and the AAFP were correct, you've just misunderstood the concept. The two codes have two prices each...one for Office based and one for facility based.
 
Dos

Does anyone have anymore specific guidance other than the FAQ that clearly explains how the bill these codes?
Our interpretation was that if patient was discharged on 4/1/13 and then seen in the office on 4/5/13 (face-to-face) as well as other telephone communication etc... that needs to happen within this 30 day period and then the charge will drop with 4/30/13 as the DOS as opposed to the actual face-to-face visit of 4/5/13. Is that how you understand?
Thanks
 
Tcm

Thank you for all the great information on the TCM codes. I have a couple questions
1. To decide if the care is moderate or high, do we base this on MDM from the hospital setting?
2. I understand you can not bill the 99495 or 99496 until 30 days from the date of discharge but have to see the patient 7 or 14 days from date of discharge, so are you setting the electronic health record up to hold the claim until day 30 or do you have a better way for processing the bill on day 30. My concern is if the patient comes back within the 30 days related to the discharge after the vist, then what is a good tracking protocol so it does not hang out there or cause an error. Sorry if my question is confusing. I know this can only be charges once related to the discharge.

Sheila
 
I was wondering if anyone has billed out for the TCM codes and actually got them paid? My co-worker and I have been going over the guidelines for these codes and are actually a little concerned about the DOS needing to be the 30th day post discharge. How is this not inaccurate billing if we are actually changing the dos to the 30th day, when the patient has to be seen within 7 to 14 days?
Thanks
Brittany Merritt, CPC
 
Brittany, TCM is not a single DOS...it's a month-long period of post-discharge care. As such, you cannot bill for the supposed month of work prior to that 30th day after discharge. I think you misunderstand the purpose of this code: it's for a 30-day range of chronic care managment and post-discharge support provided by the patients physician and his ancillary staff to prevent readmission.
 
We're keeping track of phone calls, etc. that is the nurse care manager work within our EHR as communication documents. These remain part of the patient's medical record.
 
Tmc date of service

Hello everyone!!!

I copeid the DATE OF SERVICE answer from another website. It's explain it with an example. I hope this will help.

[COLOR="Lime"] You are using the date of the 30th day of the TCM period for your date of service. Here's an example:

Mrs. Jones was discharged from the hospital on March 3, 2013. You contacted her on March 5th (within 2 days of discharge) to make sure things were going well with her transition and that she was following the discharge instructions given to her at the hospital. You scheduled her appointment with the physician at the practice for March 12th (within 14 days of discharge.) On April 1st, you process the claim for TCM services provided between March 3rd and April 1st, using the CPT code 99495 and date of service 4/1/2013. You do not use the E/M code for the visit during the 14 days, as that is included as part of the 99495.[/COLOR]
 
Tmc date of service

Hello everyone!!!
I copeid the DATE OF SERVICE answer from another website. It's explain it with an example. I hope this will help.

You are using the date of the 30th day of the TCM period for your date of service. Here's an example:

Mrs. Jones was discharged from the hospital on March 3, 2013. You contacted her on March 5th (within 2 days of discharge) to make sure things were going well with her transition and that she was following the discharge instructions given to her at the hospital. You scheduled her appointment with the physician at the practice for March 12th (within 14 days of discharge.) On April 1st, you process the claim for TCM services provided between March 3rd and April 1st, using the CPT code 99495 and date of service 4/1/2013. You do not use the E/M code for the visit during the 14 days, as that is included as part of the 99495[/COLOR][/SIZE]
 
Janet53

Question? If we currently have and EMR system with no established template for TCM when the face to face visit occurs that date will appear on the progress note of the physician. What I seem to be reading is that our billing service would have to put a "hold" on that claim and not bill out until the 29-30th day after discharge, correct? Because the date of service would be the later date not the actual date of the face to face, correct? Then with providers that do have EMR what do they do?
 
I think what a lot of people are misunderstanding, as were some of my Doctors, is that these codes are not for a specific visit or service. They are for an entire 30 day period of care following discharge that must include, but are not limited to contact within 2 days, the face-to-face visit, etc. That is why the date of service is day 30 after discharge, because you can't bill saying you cared for the patient for 30 days following discharge when it hasn't been 30 days since the patient was discharged.
 
Which insurance company is paying for TCM codes?

We send a claim to BCBS with Tcm codes and they denied. I talked to BCBS representative. They said, we do not pay for TCM codes. Then I called Humana and United health care. Both of them are paying for TCM codes. The United health care representative was very nice. She said, we follow all the medicare guidelines.
 
Thank you for the your .PDF related to TCM - I found it very helpful! Appreciate you sharing it with all!
Kathy Fitzpatrick, CPC
Santa Rosa Cardiology
Santa Rosa CA
 
The AAFP.org site has some great FAQ's regarding TCM and a really nice log to complete all the requirements for documentation.
 
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