Primary care specialties will receive the largest increase in payment under a new payment for managing the care of a Medicare beneficiary when the beneficiary is discharged from an outpatient hospital observation, inpatient, community mental health center, services partial hospitalization or a SNF. In announcing its new policy, CMS acknowledged that the extensive remote care coordination provided by physicians and nurses was not considered in the existing payment schedule for E/M (Evaluation and Management) services. The new directive will provide payments to physicians and other health care providers to coordinate transitions of care for Medicare beneficiaries after they are discharged from hospitals/skilled nursing facilities to assisted living facilities or to their own homes. The new rule is effective as of January 1, 2013.
The new codes: 99495 and 99496
CMS has a clear goal in introducing these new codes for Transitional Care Management (TCM) services. They are intended to prevent emergency department visits and readmissions during the first 30 days after discharge. In addition to the primary care physicians who would bill for most of these services, specialists providing the necessary services may also bill for these new CPT codes.
TCM Code Requirements
- 99495, MTC: Communication (direct, telephone, electronic contact) with the patient and/or caregiver within two business days after discharge; Making medical decisions of at least moderate complexity during the period of service; In-person visit within 14 calendar days of discharge.
- 99496, TCM: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within two business days after discharge; Highly complex medical decision-making during the service period, face-to-face visit within seven calendar days following discharge.
It should be noted that both codes require communication with the patient and/or care provider within two business days of discharge, in addition to a face-to-face visit with the patient within a fixed time period. The decision on medication and management must be made at least on the day of the face-to-face visit.
Non-face-to-face care coordination services may be performed by the provider and/or authorized clinical staff under their direction. However, the face-to-face visit must be carried out by the providers themselves with the assistance of the staff.
Fee Schedule 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. As long as Congress avoids the impending 26.5% cut in payments to physicians and maintain the current conversion factor of $34.0066, the Payments for these codes will be:
In non-facility settings (doctor’s office):
- Code 99495: $163.91
- Code 99496: $230.90
In facility settings (outpatient hospitals):
- Code 99495: $134.67
- Code 99496: $197.58
These codes can be billed only after at least 30 days after discharge, when the service period is complete. Primary care incentive payments will not be added to these amounts.
Points to consider
- Be sure to only bill post-discharge patients who require moderate to high complexity medical decision making.
- The initial face-to-face visit does not necessarily have to be in the office.
- The first face-to-face visit with the patient after discharge is part of the TCM service and cannot be reported separately. E/M services provided additionally may be reported separately.
- The documentation guidelines for E/M do not apply to these codes. Therefore, providers should consider how they would like to document the non-face-to-face services that are required by the codes. The complexity of medical decision-making, the time of first post-discharge communication, and the date of personal visit should be documented.
- Providers can use these codes to bill new and established patients.
- Discharge services and the face-to-face visit required by the TCM code cannot be provided on the same day. However, the same physician who bills for discharge services may also bill for TCM services. It is important to note that TCM services rendered during a post-surgery period cannot be reported by the same physician for a service with a global period, as these services are understood to already be included in the payment for the underlying procedure.
- One very important point to remember is that only a professional can bill for TCM services for 30 days after a patient is discharged. The first physician to bill for the service alone will be reimbursed. Therefore, professionals must necessarily communicate with the patient and/or caregiver, and with the discharging physician to be clear about who will administer the TCM services.
- Physicians may bill for TCM only once within 30 days of discharge, even if the patient is discharged 2 or more times within the 30-day period.
- Providers may not bill for other care coordination services (such as care plan supervision codes 99339, 99340, 99374 – 99380) provided during the TCM period.
