Many practitioners have difficulty being paid for Transitional Care Management (TCM) services. In many cases, claims submitted for TCM services have not been paid due to several common errors in claim submission.
In particular, the practitioner should ensure that the entire 30-day TCM service was furnished, the service began with a qualified discharge from a facility, and that the appropriate date of service is reported on the claim.
In this article, we covered basic claim details while billing for transitional care management.
Procedure Codes for Transitional Care Management
Effective January 1, 2013, under the Physician Fee Schedule (PFS) 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.
- CPT Code 99495 covers communication with the patient or caregiver within two business days of discharge. This can be done by phone, e-mail, or in person. It involves medical decision-making of at least moderate complexity and a face-to-face visit within 14 days of discharge. The location of the visit is not specified. The work RVU is 2.11.
- CPT Code 99496 covers communication with the patient or caregiver within two business days of discharge. This can be done by phone, e-mail, or in person. It involves medical decision-making of high complexity and a face-to-face visit within seven days of discharge. The location of the visit is not specified. The work RVU is 3.05.
Coding Guidelines
- While using codes procedure codes 99495 and 99496 for Transitional Care Management services consider the following coding guidelines:
- Medication reconciliation and management should happen no later than the face-to-face visit.
- The codes can be used following ‘care from an inpatient hospital setting (including acute hospital, a rehabilitation hospital, long-term acute care hospital), partial hospitalization, observation status in a hospital, or skilled nursing facility/nursing facility.’
- The codes cannot be used with G0181 (home health care plan oversight) or G0182 (hospice care plan oversight) because the services are duplicative.
- Billing should occur at the conclusion of the 30-day post-discharge period.
- They are payable only once per patient in the 30 days following discharge, thus if the patient is readmitted TCM cannot be billed again.
- Only one individual can bill per patient, so it is important to establish the primary physician in charge of the coordination of care during this time period. If there is a question, then it might be important to contact the other physician’s office to clarify. The discharging physician should tell the patient which clinician will be providing and billing for the TCM services.
- The codes apply to both new and established patients.
Billing Guidelines for Transitional Care Management (TCM)
Date of service:
The 30-day period for the TCM service begins on the day of discharge and continues for the next 29 days. The date of service you report should be the date of the required face-to-face visit. You may submit the claim once the face-to-face visit is furnished and need not hold the claim until the end of the service period.
The place of service:
The place of service reported on the claim should correspond to the place of service of the required face-to-face visit. While FQHCs and RHCs are not paid separately by Medicare under the Physician Fee Schedule (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-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 Medicare Physician Fee Schedule (MPFS).
Patient readmission within 30 days:
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.
Billing other services:
Other reasonable and necessary Medicare services may be reported during the 30 day period, with the exception of those services that cannot be reported according to CPT guidance and Medicare HCPCS codes G0181 and G0182.
Chronic Care Management (CCM) could be billed to the MPFS during the same calendar month as TCM only if the TCM service period ends before the end of a given calendar month, at least 20 minutes of qualifying CCM services are subsequently provided during that month, and all other CCM billing requirements are met.
However, the majority of the time, CCM and TCM will not be billed during the same calendar month.
The Role of a Central Billing Office (CBO) in Healthcare
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Our billing services include eligibility verification, medical coding, charge entry, payment posting, denial analysis, account receivables (AR) management, and provider credentialing and enrollment.
With our medical billing services, you can increase your practice collection while staying billing compliant as per payer guidelines.
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FAQs
1. What is Transitional Care Management (TCM)?
Transitional Care Management (TCM) refers to the services provided by physicians or qualified non-physician practitioners to help manage a patient’s care during the 30 days following discharge from a hospital or other facility.
2. What CPT codes are used for billing TCM services?
TCM services are billed using CPT codes 99495 and 99496. These codes cover communication with the patient or caregiver within two business days and a face-to-face visit within 7 to 14 days of discharge.
3. When should TCM services be billed?
TCM services should be billed at the conclusion of the 30-day post-discharge period. The date of service reported should be the date of the required face-to-face visit.
4. Can TCM services be billed more than once for the same patient?
No, TCM services can only be billed once per patient during the 30-day period following discharge. If the patient is readmitted, TCM services may be billed following the second discharge for a new 30-day period.
5. What are the requirements for billing CPT code 99495?
CPT code 99495 requires communication with the patient or caregiver within two business days of discharge, medical decision-making of moderate complexity, and a face-to-face visit within 14 days.
