Around 14% of patients discharged from hospitals are readmitted within 30 days, and it costs U.S. taxpayers more than $52.4 billion per year to care for the readmitted patients. The U.S. Centers for Medicare and Medicaid Service (CMS) has implemented several programs to reduce the readmission rate of Medicare beneficiaries. Transitional Care Management (TCM) is one such initiative.
Originally reserved for Medicare beneficiaries, TCM is the comprehensive support offered to patients transferred from an in-patient setting to their homes or an assisted living facility. The thorough evaluation, consultation, and management period lasts 29 days, during which the physician ensures continuity of the same level of care rendered in an in-patient setting.
Medicare Part B covers TCM services. However, billing for transitional care management requires accurate CPT coding. Knowing the common TCM CPT Codes will help you submit error-free claims and secure timely reimbursements from government and private payers.
Common Transitional Care Management CPT Codes
Physicians are required to use only two transitional care management CPT codes – 99495 and 99496. They can only assign one code per patient after the completion of the transitional care period, which is 29-30 days. The CPT codes for transitional care management are reported based on the degree of complexity during medical decision-making, ranging from moderate to high. Let’s take a look.
CPT Code 99495 – Moderate Complexity Decision-Making
A physician reports TCM CPT code 99495 once during the 30-day transitional care management period to notify the insurance payer that a moderate level of decision-making was performed after having several non-face-to-face meetings with the patient and one face-to-face meeting within 14 calendar days of discharge.
It also indicates that the physician resumed communication with the patient/caregiver, either through direct contact or via phone or digital medium, within 2 business days of discharge from an in-patient acute care facility.
CPT Code 99496 – High Complexity Decision-Making
Transitional care management CPT code 99496 is reported when the 30-day care period involves complex medical decision-making. Its reimbursement rate is also higher than the TCM CPT code 99495. The physician is required to make the first face-to-face contact with the patient within 7 calendar days of discharge. Ongoing non-face-to-face services, including medically necessary evaluation and management visits, must be rendered throughout the transitional care period.
Like the TCM CPT code above, 99496 must only be reported if the physician was successful in resuming communication with the patient or caregiver within 2 business days of discharge via direct contact, over the phone, or electronically, e.g., an email.
Transitional Care Management (TCM) Billing Guidelines
Billing for transitional care management can quickly become challenging if you are unfamiliar with the payer rules and requirements. Moreover, confusion about what should be considered a medically complex or straightforward decision, office visits vs. interactive contact vs. non-face-to-face services, and the counting of calendar or business days can make it a hassle for the physician and his billing staff to report the accurate code and justify if all the mandatory components of the transitional care management were ticked off.
You must pay close attention to the following guidelines if you wish to avoid the pitfalls in transitional care management billing and secure accurate and rightful reimbursements for the services provided during the 30 days.
Provide Adequate Documentation
Medicare and a few private insurance payers that cover TCM services ask for complete and accurate documentation. It helps the payer understand the medical necessity for transitional care management services. For example, the documents must include discharge papers clearly stating the patient’s discharge date from an in-patient facility like an acute care hospital or rehabilitation center.
You must also provide the patient’s complete medical records, including the date of the first interactive contact with the patient or caregiver, the date of a face-to-face encounter, and the degree of medical decision-making.
Payers also encourage physicians to report an unsuccessful attempt (after 2 tries) at initiating an interactive contact within 2 business days of discharge. In this case, the insurance payer will still reimburse the physician even though the contact occurred later than the required timeframe because he did what he could to resume communication, but the other side did not respond.
File One Claim Per Patient for Services
Medicare has a strict 1:1:1 rule when it comes to billing for transitional care management services. First, its rulebook states that only one provider or non-physician practitioner (NPP) can bill and seek reimbursements for TCM services. Second, the TCM CPT codes, either 99495 or 99496, can be reported only once for the entire 30-day care period. The third and final rule is that only one patient is covered per code per physician for the transitional care management services.
Therefore, only one physician can file one claim, reporting one transitional care management CPT code for one patient approximately 30 days after discharge.
Report All Reasonable & Necessary E/M Visits
Newly discharged patients may need more consultation and medical attention other than compulsory interactive contacts, non-face-to-face services, and in-person encounters to manage their condition or recover successfully. In such cases, insurance payers advise physicians to perform all the necessary evaluation and management (E/M) visits and report them separately using the appropriate E/M CPT codes (99202-99215).
Please note that E/M visits do not include one compulsory face-to-face visit during TCM. All separately billed E/M visits that the payer finds reasonable and medically necessary will be reimbursed in addition to the TCM services.
Don’t Bill Non-Billable Services During the 30-Day TCM Period
Transitional care management is a comprehensive care package that includes several services and procedures, e.g., the provision of durable medical equipment (DME), home care, and telehealth. Therefore, the services that are already covered in the TCM package should not be billed separately during the 30 days as it will be considered a duplication of services. Insurance payers immediately reject duplicate medical claims.
Physicians should NOT bill the following services during the TCM period.
- Care plan oversight (99339, 99340, 99374-99380)
- Education and training (98960-98962, 99071, 99078)
- Medical team conferences (99366-99368)
- Medication therapy management services (99605-99607)
- Online medical evaluation services (98970-98972)
- Preparation of special reports (99080)
- Telephone services (98966-98968, 99441-99443)
Don’t Bill TCM Services in Post-Operative Global Surgery Period
When billing for transitional care management, you must be mindful that the TCM 30-day period does not overlap with the post-operative global surgery period. The two are distinct, have different purposes, and should be billed one after another (or only one should be reported) if the same physician is in charge of both.
Simply put, Medicare’s global surgery rule covers post-operative care for 0,10, or 90 days, depending on the type of surgery. During this period, physicians cannot render 30-day transitional care to the patients nor bill it.
Outsource TCM Billing to MediBill MD
Navigating the transitional care management billing and coding can feel like being in a labyrinth if you don’t have the insurance payers’ rules and requirements mapped out in front of you. From varying degrees of complex decision-making to the confusion regarding the correct time for scheduling a face-to-face patient encounter and incomplete documentation submissions to not waiting out the global surgery period, several factors can derail the TCM billing process. Such mistakes can be costly, leading to claim denials and loss of revenue, especially when you and your staff worked hard for 30 days to ensure high-quality patient care.
However, all this can be avoided if you outsource medical billing services to a professional company like MediBill MD. Our expert team of AAPC-certified professional coders and industry-trained medical billers effortlessly reports the transitional care management CPT codes to the highest degree of specificity and implements billing best practices to file complete, clean, and compliant claims on time.
