Any patient post-discharge whose medical and/or psychosocial problems are complex enough to require TCM services qualifies for these codes. Here are the specifics:
1. Location: “TCM is for higher-risk patients being discharged from an inpatient or observation status to their home, rest home, or assisted living facility,” says Raemarie Jimenez, CPC, CPMA, CPC-I, CANPC, CRHC, director of education for the American Academy of Professional Coders. Basically, this means transitioning from a location where the patient is under the watchful eye of nursing staff 24/7, to a setting where there is less nursing care available (for example, a rest home where the patient is monitored far less frequently).
2. Age: While elderly patients may be more likely to need transitional care management services, “99495 and 99496 can be used for any patient that meets their criteria regardless of age,” Jimenez adds.
3. New vs. Established: CPT’s guidelines clearly state that TCM codes can only be used for established patients. However, CMS disagrees. David A. Ellington, MD, the American Academy of Family Physicians’ AMA CPT® Editorial Panel member, said at AMA’s 2013 CPT® Symposium in mid-November 2012 that “CMS indicated they will modify the prefatory instructions to allow physicians to bill these codes for new patients, not only established patients as specified in CPT®.”
In summary, CMS’ formal statement reads, “We do not entirely agree with the AMA’s recommendation that the physician must have an established relationship prior to the discharge with the patient .... We are concerned that this would make it impossible for those who do not have an established relationship with a primary care physician to receive the benefit of post-discharge TCM services. These patients may well be among those who would benefit most.”
4. Diagnoses: “Pretty much any diagnosis that points to a medically fragile patient — such as chronic lung disease, ventilator dependence, or immune deficiencies — could be coded with TCM codes,” says Suzanne Berman, MD, FAAP, a member of the American Academy of Pediatrics’ Section on Administration & Practice Management and a practicing pediatrician at Plateau Pediatrics in Crossville, TN.
30 Days From Discharge: TCM codes are reported once per patient within 30 days of discharge. So, if your patient is readmitted within the 30-day post-discharge time frame, you can’t bill the TCM codes again. You have to wait until after the current 30-day period is over. Then, if you provide TCM services, you can use the codes again.
Reporting the performance of range of motion testing (95851-95852) at the same encounter of an Evaluation and Management (EM) service, produces an NCCI edit resulting in payment for the EM service and denial of the ROM testing. Read the article to learn what other codes ROM testing is considered incidental to.
In the compliance world, it is important to know when the OIG makes an advisory opinion on a subject. For example, the advisory on Time of Service or Prompt Pay Discounts helps to ensure that providers are creating policies and procedures which will meet the standards of the OIG in the case ...
An Escharotomy is used for "local treatment of burned surface" per the AMA Guidelines, when incisions are performed on the burn site. Notice, when cross-walking 16035 or 16036 to inpatient codes, Find-A-Code crosswalks lead to Body System H, Operation 8 - Division of the skin, and Operation N -...
It’s a season for changes. CMS just finalized four rules which directly impact the following payment systems:
Physician Fee Schedule Final Policy, Payment, and Quality Provisions for CY 2018
Hospital OPPS and ASC Payment System and Quality Reporting Programs Changes for 2018
HHAs: Payment Changes for 2018
Quality Payment Program Rule for Year 2
According to the recently released 2018 Physician Fee Schedule Proposed Rule, published in the Federal Register, dated July 21, 2017, the Centers for Medicare & Medicaid Services (CMS) acknowledges that the current Evaluation and Management (E/M) documentation guidelines create an administrative burden and increased audit risk for providers. In response, ...
The Office of the Inspector General was created to protect the integrity of the U.S. Department of Health and Human Services. They investigate fraud, waste, and abuse in HHS programs and make recommendations to various enforcement agencies. Every few years they investigate chiropractic services. Here is a summary of the reports the ...