A Quick Guide to Transitional Care Codes

This year’s Physician Fee Schedule includes a couple of important changes that will impact your practice—two new billing codes for providing transitional care management (TCM) services. To reduce rehospitalization rates, beginning in January of 2013 Medicare started paying doctors and their staff for 30 days of TCM services.

So what types of care do the new codes include? And how will they benefit both patients and physicians? To answer these questions, here’s a quick overview of the new TCM codes.

What Are the New Codes?

Transitional care management refers to the time spent coordinating a patient’s care during his or her transition from an inpatient setting, such as a hospital or nursing facility, back to the home or community.

In order for a physician to be reimbursed, code 99495 requires:

  • Communication (direct contact, telephone, or electronic) with the patient and/or caregiver within two business days of the patient’s discharge
  • Medical decision making of moderate complexity during the service period
  • A face-to-face visit within 14 calendar days of the patient’s discharge

Code 99496 requires:

  • Communication (direct contact, telephone, or electronic) with the patient and/or caregiver within two business days of the patient’s discharge
  • Medical decision making of high complexity during the service period
  • A face-to-face visit within 7 calendar days of the patient’s discharge

As a primary care physician, either you or a licensed clinical staff member under your direction can perform these services. And the services must be billed 30 days after the patient’s discharge.

Medicare will accept only one billing for TCM services per patient during the 30-day period following discharge. So you should keep in mind that if multiple practitioners report transitional care services for one patient, then Medicare will pay the first eligible claim submitted.

What Are the Benefits?

While these changes mean that the Centers for Medicare and Medicaid Services (CMS) will experience additional costs, the savings from lower rehospitalization rates are expected to more than make up for it. In fact, studies indicate that in the past, the provision of insufficient transitional care has cost Medicare as much as $17 billion a year for unnecessary hospitalizations. With better transitional care, it’s believed that fewer patients will have to return to the hospital—which will translate to overall savings in the long run.

Your practice will directly benefit from the reimbursement of these codes—especially in those instances when this type of care was previously uncompensated, such as when communications about a patient didn’t occur face to face.

Reimbursement for code 99495 is valued at 4.82 total relative value units (RVUs), or about $163; while code 99496 equates to 6.79 RVUs, or about $230. Overall, CMS estimates that “the changes in care coordination payment . . . are expected to to family practitioners by seven percent and other primary care practitioners between three and five percent.”

And of course, an increase in transitional care will also benefit your patients. They will have the opportunity to ask questions and address concerns post-discharge, thereby preventing the need for possible rehospitalization in the future.

What Are Some Possible Challenges?

The biggest challenge for busy physicians will be keeping track of when their patients are discharged. Since both of these codes include specific time frames, it’s a good idea for your office to stay informed of discharge dates so you can time your communications properly and bill Medicare accordingly. A crucial first step is establishing a line of communication with the discharging physician or hospitalist.

Tracking dates and deadlines is also key. To help, the American Academy of Family Physicians (AAFP) has developed a for recording patient discharges and following their transitional care status. You could also consider documenting transitional care within your patients’ electronic medical records.

For answers to other frequently asked questions about billing Medicare for TCM services, take a look at CMS’s FAQ document.

 

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