Published in the January 2015 issue of Today’s Hospitalist
WE’RE SALUTING THE NEW YEAR by celebrating an anniversary: Two years ago this month, the Centers for Medicare and Medicaid Services implemented two codes “99495 and 99496 “for transitional care management services.
These (relatively) new codes are designed to improve the coordination of post-discharge care and reduce readmissions. And because these codes may potentially deliver better reimbursement than new or established office visits, they are good financial news for hospitalists involved in post-discharge clinics. They may also present a financial upside for health systems and physician groups engaged in ACOs.
But these codes come with a lot of expectations. Which patients are eligible for transitional care services, which clinicians are best suited to provide these services and what criteria must be met to submit a claim?
Here are some of the ground rules: You or another qualified provider in your group can bill these codes only for patients who need a moderate or high level of post-discharge medical decision-making. If you bill these codes, you are responsible for managing and coordinating all the services that patients need, based on their medical condition(s) and psychosocial status. You’re also responsible for ensuring that patients have continuous access to necessary services.
Physicians of any specialty may provide transitional services, as can nurse practitioners (NPs), physician assistants (PAs), clinical nurse specialists and certified nurse-midwives. Let’s take a closer look at the criteria you must meet for billing these codes.
What, when, where
Transitional care services are typically provided to patients discharged from an inpatient acute care or inpatient psychiatric hospital, skilled nursing facility or long-term care hospital, inpatient rehab facility, outpatient observation stay, or a partial hospitalization at a community mental health center.
To qualify for transitional care services, discharged patients must return to their home (personal place of residence), a rest home, an assisted living facility or a domiciliary care location (a residential facility with no medical care component). Patients discharged to another location “such as to a skilled nursing facility “are not eligible for transitional care services.
Further, these services encompass 30 days; the clock starts ticking on the day of discharge and continues for 29 days. The clinician discharging the patient from the hospital or other qualified setting may be the same person who delivers transitional care services. But providers cannot count the face-to-face contact that is required to bill a discharge as the required face-to-face visit for either a 99495 or 99496. (In addition, if one clinician provides both the inpatient discharge and the transitional care services, he or she cannot bill for both services on the same date.)
A face-to-face encounter is one of three criteria that providers must meet to be reimbursed for transitional care management. Other required criteria include an interactive contact and specific non-face-to-face services.
After discharge, the first transitional care “visit” is typically the interactive contact.
That contact should occur within two business days. As a result, it’s important for inpatient physicians to get discharge material swiftly to outpatient physicians. Telephone calls, e-mail communications and face-to-face encounters all qualify. And if the clinician providing transitional care management contacts the patient’s caregiver, that also qualifies as a transitional care visit.
The interactive contact is intended to be just that: interactive. The expectation is that patients or caregivers and the clinician have a direct exchange. During this contact, patients or caregivers should receive related health care information and any appropriate medical instructions.
As for who can make this interactive contact: Some licensed clinical staff including RNs and LPNs can provide this contact and some transitional care services under “incident to” provisions, meaning that licensed staff are acting under the direct supervision of the provider. In an office setting, the physician or nurse practitioner needs to be present and immediately available to assist clinical staff making the contact.
Services provided “incident to” can include such things as educating the patient (or family, guardian and/or caregiver) in how to live independently and self-manage medical conditions; identifying and communicating with medical and community resources, and linking patients to those resources; assessing patients’ compliance with their treatment plan and medications; and facilitating patients’ or families’ access to care and services.
Physicians of record can also provide certain non-face-to-face services. Those include reviewing discharge information and the need for (or follow-up to) pending tests and treatments; interacting with other qualified professionals, including making referrals; assisting patients and families with scheduled follow-up; and educating patients and their families.
Documentation and billing
Then there’s the face-to-face visit. Each of the two transitional care codes actually defines the period of time after discharge in which that visit must occur.
Clinicians who provide transitional care services must see patients requiring at least a moderately complex level of decision-making face-to-face within 14 days of discharge. Providers can then bill a 99495.
But patients who need a high level of decision-making must be seen within seven days of discharge for providers to bill a 99496. For patients in either group, clinicians must perform medication reconciliation on or before the date of the face-to-face visit. (Only the billing clinician, not support staff, can add or delete medications.)
In your documentation, you must include these three dates: when the patient was discharged, when the interactive contact took place and when the face-to-face visit occurred. (You also need to report where the face-to-face visit took place.) Documentation must support the need for furnishing these services and include clear, concise information about education, referrals and other transitional care management components. Providers who furnish these services often develop a flow sheet or form to streamline documentation and ensure that all transitional care management requirements are met.
In terms of billing, transitional care management services can be reported only once during a 30-day period and by only one provider. You may bill for these services only 29 days after discharge “and if a patient dies before that 30 days is up, transitional services may not be billed.
As of January 2014, clinicians can bill for transitional care management services provided via telemedicine. But if the patient has had surgery, any of the 30 days of transitional services that falls within a global payment period is not separately payable IF the doctor who performed the surgery is also providing the transitional services.
Other caveats: Physicians or other qualified providers billing a transitional care code may not simultaneously bill for oversight services, prolonged services without direct patient contact, anticoagulation management, education and training, complex chronic care coordination services or end-stage renal disease services.
It’s complicated! But at least these codes reward services that facilitate patients’ transition back home and ensure their access to resources that can speed up their recovery.
Sue A. Lewis, RN, CPC, PCS, is a coding manager for a nonproﬁt health plan in the Midwest. Send any billing and coding questions you have to her at firstname.lastname@example.org and we may answer them in a future issue.