CMS Stepping Up Transitional Care Management Billing Efforts

We all recognize how hard medical teams work to treat patients during inpatient and outpatient hospital, SNF, CMHC, observation and partial hospital stays.  But the team’s work does not end when the patient is discharged.  Reducing hospital readmissions is critical and vital in today’s healthcare environment and, thus, requires an increased focus on discharge care management.  Effective January 1, 2013, CMS has provided clarification on how to bill for these services.

Long before the Patient Protection and Affordable Care Act (PPACA) was signed into law (March 2010), hospitals and other provider types were required to report certain quality measures to CMS.  If the submitted data fell within certain acceptable ranges, incentive payments may be approved.  Conversely, if the data did not meet acceptable standards, a penalty or fee could be assessed reducing overall payments.  Does this sound familiar?

Enter PPACA.  Applicable healthcare related sections have been leaking out for a few years now focusing on improving quality, reducing cost and enhancing the patient experience.  By now, we have all got it!

Until recently, post-discharge work often had not really seen the light of day.

After discharge, the work continues for the medical team.  Care management is now front and center when speaking about healthcare reform.  Many of the new program demonstrations and pilots coming out of Washington, D.C. are laden with the risk versus reward reimbursement structures.  If you improve patient outcomes, reduce your cost and make the patient happy throughout the experience, you are awarded a CMS bonus payment.  If you do not do those things, your overall payments will be reduced.

Transitional care management works to make certain that the bonus payments keep flowing.  The transitional care team works to keep in touch with and monitor the patient post discharge to find out a number of things such as:  Did the patient and/or accompanying family member understand and remember the discharge plan of care?  Did they fill their prescription(s)?  Are they taking their medication timely and at the proper dosage?  Is the patient feeling well?  Have other symptoms developed?  Is the patient attending follow up appointments and treatments?  And, on and on.

Transitional care management services are not new and have been around for years.  In certain circumstances in the past, CMS would even cover and pay the provider for these services.  However, due to the complexity of the reimbursement and billing regulations in place, many providers did not bother to include those types of services on their billing claims to CMS, leaving money on the table.

To add to the confusion and hassle, Medicare Administrative Contractors were disallowing transitional care management costs during audits of filed Medicare cost reports.  Providers were left not knowing what to bill for and what type of transitional services were allowable and which were not.

A new day has come!  CMS now realizes that transitional care management is vital to achieve its goal to reduce hospital readmissions.  Starting January 1, 2013, CMS has added two new billing codes (99495 and 99496) to facilitate the billing process and also incentivize providers to bill for the good work they are conducting to reduce overall readmission rates.

Billing Code 99495 would be used as follows:  Employee of practice contacts patient within 2 days of discharge from the hospital and face-to-face within 14 days (moderate medical decision making at RVU 2.11).

Billing Code 99496 would be used as follows:  Employee of practice contacts patient within 2 days of discharge from the hospital and face-to-face within 7 days (high medical decision making at RVU 3.05).

Physician and nonphysician practitioner care management services may now be billed for a patient following a discharge from a hospital, SNF or CMHC stay, an outpatient visit, observation stay and a partial hospital stay according to the CMS website.

Dependent upon the care management services, CMS has established an RVU range (relative value units) from 2.11 to 3.05.  Payments vary depending on patient acuity.  With the addition of the new billing codes, it will now be easier to bill for these services and receive a payment conducive to the work being performed on behalf of the post-discharge patient.

While we all know we need to work harder to prevent the readmission, now it is a lot easier to get reimbursed for these transitional care management services.

If you have questions regarding billing or documenting transitional care management services, please contact our healthcare advisory practice.


CMS Brief Dated March 25, 2013

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 non-physician 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-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 to 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?  Can the services be reported with the –GC modifier?
    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.  When a physician (or other appropriate billing provider) places the -GC modifier on the claim, he/she is certifying that the teaching physician has complied with the requirements in the Medicare Claims Processing Manual, Chapter 12, sections 100.1 through 100.1.6.
  • 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 here
  • During the 30 day period of TCM, can other medically necessary billable services be reported?
    Yes, 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.
  • If a patient is discharged on Monday at 4:30, does Monday count as the first business day and then Tuesday as the second business day, meaning that the communication must occur by close of business on Tuesday?  Or, would the provider have until the end of the day on Wednesday?
    In the scenario described, the practitioner must communicate with the patient by the end of the day on Wednesday, the second business day following the day of discharge.
  • Can TCM services be reported when furnished in the outpatient setting?
    Yes.  CMS has established both a facility and non-facility payment for this service.  Practitioners should report TCM services with the place of service appropriate for the face-to-face visit.

If you would like to learn more, please contact your BNN advisor at 1.800.244.7444.

CPT is a registered trademark of the American Medical Association.

Disclaimer of Liability: This publication is intended to provide general information to our clients and friends. It does not constitute accounting, tax, investment, or legal advice; nor is it intended to convey a thorough treatment of the subject matter.

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