What Happnes If I Dont Have Codes Fopr 2-Step Code 99495-99496: Two New Codes to Report Transitional Care Management (TCM) Services

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99495-99496: Two New Codes to Report Transitional Care Management (TCM) Services

Primary care specialties will receive the largest pay increase due to the new payment for managing a Medicare beneficiary’s care when the beneficiary is discharged from an outpatient hospital observation, inpatient hospital, community mental health center, partial hospital care, or SNF. In announcing the new policy, CMS acknowledged that the coordination of extensive, non-personal care provided by physicians and nurses was not considered in the current payment schedule for E/M (Evaluation & Management) services. The new policy provides payments to physicians and other health care providers for coordinating the care of Medicare beneficiaries after they are discharged from hospitals/skilled nursing facilities to assisted living facilities or their own homes. The new rule is effective from January 1, 2013.

The new codes are: 99495 and 99496

CMS has a clear goal of introducing new codes for transitional care management (TCM) services. They aim to prevent emergency department visits and rehospitalization in the first 30 days after discharge. In addition to primary care physicians, who would bill for most of these services, specialists who provide necessary services may also bill for these new CPT codes.

TCM Code Requirements

  • 99495, TCM: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within two working days after discharge; Medical decision-making of at least moderate complexity during service; personal visit within 14 calendar days after departure.
  • 99496, TCM: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within two working days after discharge; High-complexity medical decision-making during service, personal visit within seven calendar days after discharge.

It should be noted that both codes require communication with the patient and/or nurse within two business days of discharge and a personal visit with the patient within a specified time. A decision about medication and treatment should be made at least until the day of the in-person visit.

Non-personal care coordination services may be performed by the provider and/or licensed clinical staff under your direction. However, the personal visit must be carried out by the service providers themselves with staff assistance.

Tariffs for new TCM codes

The values ​​assigned to the new TCM codes are 4.82 relative value units for code 99495 and 6.79 relative value units for code 99496. Assuming Congress blocks the upcoming 26.5% reduction in physician payments and maintains the current conversion factor of $34.0066, payments for these codes will be:

In non-facility (medical office) settings:

  • Code 99495: $163.91
  • Code 99496: $230.90

Settings in the facility (outpatient hospital):

  • Code 99495: $134.67
  • Code 99496: $197.58

These codes cannot be billed until at least 30 days after the service period ends. Primary Care Incentive Payments do not contribute to these amounts.

do not forget

  • Make sure you only bill for post-discharge patients who require moderate to high complexity medical decision making.
  • The first personal visit does not necessarily have to take place in the office.
  • The first personal visit after discharge is part of the TCM service and cannot be reported separately. Additional E/M services can be reported separately.
  • E/M documentation guidelines do not apply to these codes. Providers should therefore consider how they wish to document the non-personal services required by the codes. The complexity of the medical decision-making, the time of the first communication after discharge and the time of the personal visit should be documented.
  • Providers can use these codes to bill new and established patients.
  • The discharge service and the in-person visit required by the TCM code cannot be provided on the same day. However, the same practitioner who bills for discharge services may also bill for TCM services. Importantly, the same practitioner cannot report TCM services provided in the post-operative period for a global period service, as these services are already included in the payment for the underlying procedure.
  • It is very important to know that only one doctor can bill for TCM services within 30 days of the patient’s discharge. The first physician who bills alone for the service will be reimbursed. Therefore, it is essential for practitioners to communicate with the patient and/or caregiver as well as the referring physician to ensure that they are aware of who will manage the TCM services.
  • Physicians may only bill TCM once within 30 days of discharge, even if the patient is discharged two or more times within the 30-day period.
  • Providers may not bill for other care coordination services provided during the TCM period (for example, care plan supervision codes 99339, 99340, 99374 – 99380).

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