Who Qualifies for TCM Services?

April 22nd, 2013 - Lacy Gaskins
Categories:   Billing   Coding   CPT® Coding   Medicare   Reimbursement   Transitional Care Management (TCM)  
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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.

TCM Documentation & Flow Sheet available complimentary at: https://codingleader.com/family-practice/tcm-cheat-sheet

*Excerpt from Family Practice Coding Advisor
 

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