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.
The next 4 weeks we will be providing you with a step by step guide to why medical billing is now part of our Dental future.
Dental surgery is performed to treat various conditions of the teeth, jaws, and gums. Surgical procedures that dentists perform include dental implants, treatment for temporomandibular ...
The Medicare Fee for Service (FFS) program (Traditional or Original Medicare) has a timely filing requirement; a clean claim for services rendered must be received within one year of the date of service or risk payment denial.
As any company who has billed Medicare services can attest, the one-year timely filing ...
Understanding how payment works with Medicare payment indicators and the impact a modifier has on payment is vital to pricing. Even if you are not billing Medicare, most carriers follow Medicare's policies for participating and non-participating rules. Here is an article from Regence on their policy statement, describing the rules ...
Medical ID Theft
"So, do you guys think you can do something with that?" John asked angrily at our first meeting with him in August 2017 as he slammed a stack of medical bills, EOBs and collection letters - three inches high - down in front of my partner and I. ...
There are three main code sets and Healthcare Common Procedure Coding System (HCPCS), is the third most common code set used. They are often called Level II codes and are used to report non-physician products supplies and procedures not found in CPT, such as ambulance services, DME, drugs, orthotics, supplies, ...
We billed 2 units of L3020 but were denied for not using the right modifiers. What should we do?
Rather than submitting two units of the L3020 to indicate that the patient one orthotic for each foot, you would need to use modifiers identifying left foot and right foot. Appropriate coding ...
Two separate pieces of legislation introduced in the House of Representatives (H.R. 2883 and H.R. 3654) have the potential to change some of Medicare’s policies regarding doctors of chiropractic. Find out what these two bills are all about and how they could affect Medicare policies.