Billing for Transitional Care Management Services

RHCs, FQHCs Should Follow Specific Billing Protocol to Avoid Payment Delays

June 03, 2013 04:20 pm News Staff

Looking for some good news on the payment front? Family physicians who see Medicare patients in rural health centers (RHCs) or federally qualified health centers (FQHCs) can get paid in a timely manner for providing transitional care management services to their patients.

But to ensure that happens, physicians would do well to follow specific instructions from CMS until further notice.

Why the need for special treatment? Blame a computer glitch.

CMS recently acknowledged that an error in its claims processing system was effectively keeping RHCs and FQHCs from receiving payment on claims filed when physicians applied two new CPT codes -- 99495 and 99496 -- that were activated by CMS on Jan. 1. As outlined in the 2013 Medicare physician fee schedule, the codes refer specifically to payment for transitional care services provided to patients following discharge from a hospital, skilled nursing facility, community mental health center, outpatient observation or partial hospitalization.

According to CMS, a remedy for the underlying problem is on the way, but until a fix is implemented, RHCs and FQHCs should bill for the services using the line item date-of-service that reflects the date of the required face-to-face component for transitional care management.

In addition, CMS said claims for transitional care management services initiated by physicians working in RHCs and FQHCs shouldn't be held up when physicians precisely follow these CMS billing instructions:

  • RHCs should submit claims to their Medicare administrative contractor with a service line that contains the revenue code 052X and no CPT code.
  • FQHCs should submit claims with a service line with the revenue code 052X and a valid evaluation and management code. In addition, include a service line with revenue code 052X and CPT code 99495 or 99496.

For more information regarding billing for transitional care management services, check out a list of frequently asked questions(www.cms.gov) CMS recently posted on its website.


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