Transitional Care Codes Offer Increased Reimbursement Opportunities
April 5th, 2013
If you have a hospital practice, you probably know about 2013's new Transitional Care Codes. These codes are among the first to pay (in part) for telephone followups to patients. Yes, a face to face is also required, but payment is more than payment for a routine evaluation and management code.
The increased payment is designed to reimburse providers who provide services to transition a patient from inpatent status in a hospital or skilled nursing facility into a non-skilled setting. The reimbursement recognizes the non face-to-face aspects involved in such a transition.
The definitions of the codes are:
99496 - 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 high complexity during the service period Face-to-face visit, within 7 calendar days of discharge. (National Medicare Fee: 231.36)
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. (National Medicare Fee: 163.99)
The "complexity" is based on standard definitions of complexity. Thus, at least moderate complexity decision making is required before one of the codes can be used.
The services should be reported by only one provider within 30 days of discharge. Best practices dictate that the provider using the code be the one charged with followup care of the patient. This will NOT ALWAYS be the primary care or admitting provider. For example, if a patient was admitted with hip pain which was discovered to be malignant; the oncologist, not the admitting doctor would likely be primarily responsible for followup care
If followup is in a global surgery period, and the inpatient stay was related to the surgery, billing for transitional care would not be appropriate during the global surgery period.
If the patient does go back to the hospital, inpatient services may be billed again. If the patient comes to the office for a non related evaluation and management during the transitional period, the evaluation and management may be billed.
The codes should be billed AFTER thirty days of care has been provided.
The American Academy of Family Physicians has published some good guidance and tools on these new codes. You can find the article and associated tools at: http://www.aafp.org/online/en/home/publications/news/news-now/practice-professional-issues/20130305tcmtools.html The AAFP tool includes basic information on what should be documented when using the codes.
Medicare has addressed the new codes with a Frequently Asked Questions article which may be found at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/FAQ-TCMS.pdf These codes appear to be a way of increasing reimbursement for followups after a hospital stay by up to $60. Keep in mind that an evaluation and management and other services NOT associated with the hospital stay may be billed in addition to the Transitional Care codes. If the purpose of the followup visit is strictly to see how a patient is doing after a hospital stay, an evaluation and management should NOT be billed. If, however, the evaluation and management is unrelated to the hospital stay, an evaluation and management code may also be billed.
For those interested in reading about the new codes in the Federal Registry, visit page 90 in the pdf at this link: http://www.gpo.gov/fdsys/pkg/FR-2012-11-16/pdf/2012-26900.pdf. (The page number read 68979). The discussion begins about halfway down the first column.
Per Medicare CCI, a physician or other qualified health care professional who reports codes 99495, 99496 may not also report care plan oversight services (99339, 99340, 99374-99380), prolonged services without direct patient contact (99358, 99359), anticoagulant management (99363, 99364), medical team conferences (99366-99368), education and training (98960-98962, 99071, 99078), telephone services (98966-98968, 99441-99443), end stage renal disease services (90951-90970), online medical evaluation services (98969, 99444), preparation of special reports (99080), analysis of data (99090, 99091), complex chronic care coordination services (99487-99489), medication therapy management services (99605-99607), during the time period covered by the transitional care management services codes.
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