Published in the May 2013 issue of Today’s Hospitalist
ON JAN. 1 THIS YEAR, Medicare began to recognize the growing importance of transitional care. By introducing two new transitional care codes, Medicare now allows providers to be paid to manage the transitional care of patients who have been recently discharged and have medical and/or psychosocial problems. The new codes were designed to help improve overall quality of care and reduce readmissions.
Clinicians can use these codes only for patients who require at least moderate medical decision-making, as spelled out by evaluation and management (E/M) guidelines. The two codes have different requirements in terms of how soon patients must be seen post-discharge and the level of decision-making involved. But both codes require a face-to-face visit with a qualified provider.
The good news is that these new codes allow you to be reimbursed for the non-face-to-face services that you, another physician or a midlevel provider may already be delivering but haven’t been able to bill for. Such services include arranging follow-up care and referrals, and identifying community resources that patients need.
The bad news? Hospitalists who see only inpatients will not be able to bill these codes, and the codes don’t apply to patients discharged to a skilled nursing facility. But hospitalists who also practice as “transitionalists,” staff post-discharge clinics or otherwise see patients in an outpatient setting should all be able to use these codes and receive higher compensation than they may now be getting.
And the new codes may end up affecting every hospitalist in the sense that they could encourage more outpatient offices to beef up transitional care services. That could reduce hospitals’ readmission rates and the financial penalties now associated with them.
Who can bill the codes?
Here are the two new CPT transitional care management codes and the required elements for each:
- 99495 requires that all of the following elements be met:
- communication (either direct or electronic contact or via telephone) with the patient and/or caregiver within two business days of discharge;
- medical decision-making of at least moderate complexity during the service period; and
- a face-to-face visit within 14 calendar days of discharge.
- 99496 is similar to 99495, but it is geared to more complex patients. This code requires that all of the following elements be met:
- communication (direct or electronic contact or via telephone) with the patient and/or caregiver within two business days of discharge;
- high-complexity medical decision-making during the service period; and
- a face-to-face visit within seven calendar days of discharge.
The relative value units (RVUs) associated with these codes are 2.11 for 99495 and 3.05 for 99496.
Because Medicare and CPT reporting guidelines differ slightly, let’s take a look at what Medicare requires for billing these codes. Only one provider may bill for transitional care management, and only once per patient within 30 days of discharge. As for which providers can bill these codes, Medicare lists these specific credentials: MD, DO, NP, PA, CNS and CNM, unless otherwise limited by scope of practice restrictions within a state.
According to Medicare, the clinician providing these services does not have to have an established relationship with a patient. However, physicians cannot bill a transitional care code within the same time frame as other services they may be billing for that fall within a 10- or 90-day global period. That would cover some minor procedures and surgeries.
Discharge services don’t count
You can report transitional care management services for a patient after discharge from an inpatient setting (including acute or rehab hospitals or long-term acute care facilities), partial hospital, skilled nursing or nursing facility, or observation status in a hospital. You can use these codes when helping a patient transition to a variety of community settings, including home or assisted living.
You must communicate with the patient or caregiver, as appropriate, within two business days of discharge, and you can satisfy that requirement either face to face or via telephone or electronically. Medication reconciliation and management must occur no later than the date of the face-to-face visit.
Keep in mind that your hospital discharge services cannot count as the face-to-face encounter for either of these codes. However, if you perform both the discharge and the transitional care services, you may bill each separately “only not on the same day.
And you cannot bill your initial face-to-face visit separately from the other elements included in the transitional care code. You may, however, separately bill for additional visits beyond that first transitional face-to-face.
Then there’s the question of which non-face-to-face elements of transitional care can be performed by clinical staff and don’t need to be done by a clinician with one of the credentials listed above. Those services include:
- In addition to communicating with patients or families within two business days, clinical staff may also communicate with home health agencies and other community services that a patient needs.
- Clinical staff can perform and bill for educational activities with the patient, family or caregiver to support independent living and self-management.
- Assessment and support:
- Clinical staff can provide these services for regimen adherence and medication management.
- Resource identification:
- Clinical staff can help find available community and health resources.
- Service facilitation:
- Clinical staff may facilitate access to care and to services that a patient and/or family needs.However, there are some non-face-to-face services that Medicare states can be provided only by a clinician with qualified credentials. (Not all these services would be appropriate for every patient.) Those include:
- obtaining and reviewing information related to discharge, including the discharge summary or continuity of care plan;
- following up (or reviewing the need for follow-up) on pending treatments or diagnostic tests;
- interacting with other qualified providers who will assume (or re-assume) care for a patient’s system-specific issues;
- establishing (or re-establishing) referrals or arrangements for necessary community resources; and
- helping schedule required follow-up with community providers and services.You can bill one transitional care code only after services are concluded. (The date of service should be the 30th day after discharge, even if you see the patient two weeks after discharge, and the bill should reflect the place where the face-to-face encounter occurred.) And finally, Medicare placed no diagnosis restrictions on billing these codes.Kristy Welker is an independent medical coding consultant based in San Diego. E-mail your documentation and coding questions to her at her firstname.lastname@example.org. We’ll try to answer your questions in a future issue of Today’s Hospitalist.
Transitional care codes: what’s covered
By introducing two new transitional care codes, the Centers for Medicare and Medicaid Services is making it possible for clinicians to be reimbursed for providing transitional care. But Medicare has also noted services that cannot be billed in addition to either code. Here’s a list of services that are considered “bundled” into a transitional care code:
- 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)
Source: Federal Registry