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Medical Coding News Archives

New CPT Codes for Transitional Care Management Services

 
December 21, 2012:

Jill Harrington, Manager, Clinical/Technical Editor

New in the CPT manual for 2013 are codes for transitional care management (TCM) services. Medicare will also be paying for these services based on information provided in the Medicare physician fee schedule in the 2013 final rule. These are services for patients transitioning from inpatient hospital, observation, skilled nursing/nursing facility, or rehabilitation to the patients’ normal community settings such as their homes. These services consist of a face-to face visit within the time frame the specific code requires, as well as non-face-to-face services as appropriate for the patient’s condition.

99495 Transitional care management services with the following required elements:

  • Communication (direct contact, telephone, electronic) with the patient and/or care giver within 2 business days of discharge
  • Medical decision making of at least moderate complexity during the service period
  • Face-to-face visit, within 14 calendar days of discharge

99496 Transitional care management services with the following required elements:

  • Communication (direct contact, telephone, electronic) with the patient and/or care giver within 2 business days of discharge
  • Medical decision making of high complexity during the service period
  • Face-to-face visit, within 7 calendar days of discharge

Non-face-to-face services are provided by clinical staff, under the direction of the physician or other qualified health care professional, and may include the following.

  • Communication by direct contact, telephone, or electronic methods with the patient and/or care giver within 2 business days of discharge
  • Communication with home health agencies and other types of community services as utilized by the patient
  • Patient and/or family and caretaker education to support self-management, independent living, and activities of daily living (ADLs)
  • Assessment and support for adherence to treatment regimen and management of medications
  • Identification of health and community resources available to the patient and family
  • Facilitating needed access to care and services as needed by the patient and family

Non-face-to-face services provided by the physician or other qualified health care provider may include the following:

  • Obtaining and reviewing discharge information from facilities such as discharge summaries or continuity of care documents
  • Reviewing or following up on pending diagnostic tests and treatments for the patient and family
  • Interacting with other qualified health care professionals also caring for this patient
  • Providing patient or care giver education
  • Providing referrals for resources
  • Assistance in scheduling for community providers and services

Transitional care management begins on the date of discharge and continues for the next 29 days. Only one provider can report these services per patient within 30 days of discharge. The same individual or group may not report another TCM for any subsequent discharge within that same 30-day period. Also, a physician or other qualified health care professional reporting code 99495 or 99496 may not report a series of other codes during that time frame.

  • Care plan oversight services—99339, 99340, 99374–99380
  • Prolonged services without direct patient contact—99358, 99359
  • Anticoagulant management—99363, 99364
  • Medical team conference—99366- 99368
  • Education and training—98960–98962, 99071, 99078
  • Telephone services—98966-98968, 99441–99443
  • End-stage renal disease services—90951–90970
  • Online medical evaluation services—98969, 99444
  • Preparation of special reports—99080
  • Analysis of data—99090, 99091
  • Complex chronic care coordination services—99487–99489
  • Medical therapy management services—99605–99607

Medical decision making is truly the deciding factor in code selection in these cases, so it is vital that provider documentation be clear and strong, supporting all services provided to the patient in these instances.

 

 

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