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Primary care specialties receive the largest increase in payment due to a new payment for a Medicare beneficiary’s care administration when the beneficiary is discharged from an outpatient hospital observation, inpatient hospital, community psychiatric center, partial hospital services, or from an SNF. In announcing its new policy, CMS acknowledged that the existing payment schedule for E/M (Evaluation & Management) services did not account for the extensive non-face-to-face care coordination by physicians and nurses. The new policy will provide payments to physicians and other healthcare providers to coordinate care transitions of Medicare beneficiaries after they are discharged from hospitals/nursing facilities to assisted living facilities or at home. The new regulation applies from January 1st, 2013.
The new codes: 99495 & 99496
CMS has a clear goal in introducing these new codes for Transitional Care Management (TCM) services. They are designed to prevent emergency room visits and re-hospitalizations for the first 30 days after discharge. Aside from GPs, who would charge for most of these services, specialists who provide the required services can also charge 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; Physician decision-making of at least medium complexity while on duty; personal visit within 14 calendar days after discharge.
- 99496, TCM: communication (direct contact, telephone, electronic) with the patient and/or caregiver within two working days after discharge; Highly complex medical decision-making during office hours, personal visit within seven calendar days of discharge.
It should be noted that both of these codes require communication with the patient and/or provider within two working days of discharge and a personal visit to the patient within a specified time period. The decision regarding medication and management must be made at least on the day of the in-person visit.
Non-face-to-face care coordination services may be performed by the provider and/or licensed clinical staff under his/her direction. However, the personal visit should be carried out by the providers themselves with personal support.
Schedule of fees for the new TCM codes
The values assigned to the new TCM codes are 4.82 relative denomination units for code 99495 and 6.79 relative denomination units for code 99496. Assuming Congress avoids the forthcoming 26.5% reduction in payments for physicians and retains the current conversion factor of At $34,0066, payments for these codes will be:
In settings outside the institution (doctor’s office):
- Code 99495: $163.91
- Code 99496: $230.90
In the facility (outpatient hospital) Settings:
- Code 99495: $134.67
- Code 99496: $197.58
These codes cannot be billed until at least 30 days after discharge, when the service period has expired. The basic service premiums are not added to these amounts.
Points to note
- Make sure you only bill post-discharge patients who require moderate or highly complex medical decision-making.
- The first personal visit does not necessarily have to take place in the office.
- The first personal conversation with the patient after discharge is part of the TCM service and cannot be shown separately. Additional E/M services provided can be shown separately.
- Documentation guidelines for E/M do not apply to these codes. Providers must therefore consider how they wish to document the non-face-to-face services required by codes. The complexity of the medical decision-making, the timing of the first post-discharge communication, and the date of the in-person visit must be documented.
- Providers can use these codes to bill both new and established patients.
- Discharge services and the in-person visit required by the TCM code cannot be provided on the same day. However, the same doctor who charges for discharge services may also charge for TCM services. Importantly, the same physician cannot report TCM services performed during a postoperative period for a service with a global period, as these services are presumed to be already included in the payment for the underlying procedure .
- A very important point to remember is that only a doctor can bill for TCM services during the 30 days following a patient’s discharge. The first doctor who only charges for the service will receive a refund. Therefore, it is important for physicians to communicate with the patient and/or caregiver and the discharge physician to be clear about who will be administering the TCM services.
- Physicians can only bill TCM once within 30 days of discharge, even if the patient is discharged twice or more within 30 days.
- Providers cannot bill for other care coordination services (e.g., care plan supervisor codes 99339, 99340, 99374 – 99380) provided during the TCM period.
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