Wiki Transitional Care Management - the CPT codes

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quick question i didn't see this on the post here is our problem. Does the discharging doc have to decide the level if its modorate or server to know if they need to be seen in 7 or 14 days? or can the physican seeing them just set it up for 7 days and decide then? Hope that makes since but we are having a big argument right now because we just had hospitalist start seeing our patients in the hosptial but the physicians are still wanting to bill TCM charges. Thank you so much for your help.
 
tcm code

We are getting conflicting information from insurance companies. Some are saying that the DOS must be 30 days AFTER the date of discharge. This does not make sense to me. It goes against everything I know. If this is the case, the progress note will not match the claim. I hope someone can clarify. Thanks, Rhonda
 
your DOS will be 29 days after discharge. There are requirements that have to be met to bill TCM code. There is a MLN article on this service if you google it.
 
Tcm

Now i have a question ..what would happen in this particular scenario

" pt see the doctor on 3.27.14 and makes her f/u appt for 4.10.14 whithin this time frame pt gets admitted to the hospital and gets discharge on 3.30.14 no communication was made and pt keeps appt for 4.10.14 "

1.-no attempt for comunication was made since the pt had an appt scheduled , so therefore if i follow the 2 day communication rule ...we cant bill TCM

2.-if we had made comunication with pt 2 days whithin dischage then ..can i still charge TCM even if the appt was made prior to his/her hospital visit and discharge ?
 
JDC said:
Now i have a question ..what would happen in this particular scenario

" pt see the doctor on 3.27.14 and makes her f/u appt for 4.10.14 whithin this time frame pt gets admitted to the hospital and gets discharge on 3.30.14 no communication was made and pt keeps appt for 4.10.14 "

1.-no attempt for comunication was made since the pt had an appt scheduled , so therefore if i follow the 2 day communication rule ...we cant bill TCM

2.-if we had made comunication with pt 2 days whithin dischage then ..can i still charge TCM even if the appt was made prior to his/her hospital visit and discharge ?
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The 3/27 visit is irrelevant, no matter where it was done, because the discharge was on 3/30. That's when your clock starts ticking. You need to have made communication within 2 days of that discharge. It appears you didn't so you can't bill TCM, but you can bill a regular OV for 4/10. If you had made the 2-day communcation, then you could have billed the TCM on 4/28 (day 30), and your 4/10 is the bundled visit. Just be careful when you schedule visits prior to discharge, even if it was previously scheduled as a follow up, because you always must consider medical necessity, and the proximity of the visit to the discharge will drive your level of code. Don't shoot yourself in the foot by scheduling too far out.
 
MDM dilemma

So the type of MDM starts after the day of discharge to day 29. If a patient was admitted for a new condition that posed a threat to life and followed-up with the provider 5 days post discharge, would the provider still consider the patient's condition to fall under high severity? My PCP feels that since the acute allergic reaction could have killed the patient that he considers the TCM follow-up to be of high complexity even though the patient was stable for the face-to-face visit and the management included tapering the steroids and a referral to an allergist. Any opinions?
 
TCM and Cardiology

Anyone working with a cardiology group, are you finding success billing for TCM?
 
Tcm 48 hr contact

Hi,

I was wondering if someone could help me regarding the TCM within 48 hr contact with patient, family member, or caregiver? My question is what is considered a caregiver exactly? Is contact with the VNA considered part of that two-day contact? I always thought that the VNA is an outside home care agency and not considered the patient's original caregiver? or am I not understanding? If you can also provide where I can find that information in writing, that would be great! I have spent a long time trying to get clarification on what a caregiver is exactly, or what qualifies as a caregiver?

Thanks so much!

Maritza Caceres, CPC, PCA
 
Transitional care mangement clarification with gi practice

Hello,

We are needing clarification of Transitional Care Management for a gastroenterologist. After we audit the clinical information when the physician wants to charge TCM we agree on a 99215 not a TMC code. Because, the plan. For example patient seen in the hospital for GI bleed, and Anemia, provider consulted on the case, procedure done finding bleeding ulcer. Met criteria of 14 days after d/c, contact patient within 2 days of d/c. However, the transition was to home, not to another medical facility, ect.. The face to face was established in the correct time frame. However the plan was protonix(medication), Another EGD in 6-8 weeks to monitor ulcer, for the anemia(monitor), and OTC iron, constipation, Metamucil(medication). The only education to the patient got, was written material on Miralax. I am not sure what is being transitioned. Please dummy it down for use. We are all a little confused, on TCM. I think the decision making is were we are confused with. Thanks for your help.









Pam Brooks said:
Transitional Care Management (not transition of care) is not a single-encounter charge.
These two codes (99495 and 99496) are designed to report services provided by RN Care managers, under the supervision of physicians and NPPs who are doing comprehensive post-discharge care for complex chronically ill patients. The reporting period is 30 days post- discharge. If your practice does not already employ nurse care managers who are doing this kind of chronic disease management work, I'd suggest you first attempt to get a program up and running in order to bill these services.

CPT actually does a pretty good job of explaining what is involved to bill these services.

A transfer to another provider is definitely not TCM.
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SNF discharge to Assisted living

Help!! If I have a patient who was discharged from SNF and is admitted into Assisted Living Center, can I bill a new patient? The patient was discharged and admitted by the same Physician Assistant.

Thank You,
Rachel
 
TCM and Readmitting

We need a clear interpretation of the TCM rules regarding the following. Please help! It is regarding the patient being readmitted during the 30 days of the TCM. Our questions are:

1) We know that TCM billing can only occur once within a 30 day time frame.

a) If the pat is readmitted within that time frame (the first 30 days), and the TCM requirements have been met, can you still bill for the TCM?

OR

b) Does the clock "start over" and you bill instead the appropriate E&M levels for the visits prior to the 2nd discharge, and use the 2nd discharge to start the 30 day clock????

2) Also, not to be more confusing, but IF (b) is an option, does it apply ONLY if the pt is readmitted for the SAME dx as the first admission? Or is the dx irrelevant?

Any help is greatly appreciated!!! Thank you in advance!!!

​Kellie Fry, CPC
Billing & Coding Compliance Analyst
HMM-Central Billing Office
P: (908) 284-1125, ext. 7284
F: (908) 284-2016
E: kfry@hhsnj.org
 
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Kelly,

If the patient is re-admitted during the 30 days, then the TCM criteria has not been met; our site will then bill the appropriate E&M. If the patient is re-admitted, a new TCM period/criteria applies and the old dx is completely irrelevant. You have to love TCM!!

Steph
 
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dseyfried said:
TCM requires a couple of things. First: physician or staff must contact the patient within 2 business days of discharge. This can be done by phone, e-mail, or in person. Medication must be reconciled by their first face to face visit. 99495 is to be used for patients with moderate complexity medical decision making, and must be seen face to face in 14 days of discharge. 99496 is to be used for patients with high complexity medical decision making and must be seen face to face within 7 days of discharge. The rule lists several things that physician and or staff can do such as education of the patient and/or caregiver, establishing or re-establishing community and social services, coordinating office appointments with physicians that previously cared for the patient, referrals to social services. They are covering the TCM and it pays about $30 more than a 99214 and requires less physician work.
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Hello, can NP add a new dx as a nurse visit during TCM? Can NP put a referral in a billable nurse visit? Can NP perform the intake visits for new patients for TCM? Can NP bill as telehealth follow up after pt is discharged from hospital or emergency room?
 
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