CMS has approved paying two new codes for care
management of patients transitioning from an inpatient hospital setting
(including acuity, rehabilitation, or long-term acute care), partial hospitalization,
or observation status in a hospital, skilled nursing facility, or other nursing
facility to the patient’s community setting (home, domiciliary, rest home, or
These new codes are based on the complexity of
medical decision-making and the amount of time between discharge and the
patient’s first face-to-face visit with the physician or other qualified health
care provider. Code 99495 requires moderately complex medical decision-making
and a face-to-face visit within 14 days. Code 99496 requires highly complex medical
decision-making and a face-to-face visit within seven days.
Transitional care management (TCM) is based on the CMS Evaluation and Management Guidelines. Medical decision-making consists of three components: (1) Diagnosis and Management, (2) Data Reviewed, and (3) Table of Risk. Ideally the first place to look is the table of risk. If the patient falls under the minimal or low section of the table of risk it is highly unlikely they will qualify for either of these codes. However, you need to review all three components to determine the appropriate level.
Both codes require communication with the patient or caregiver within two business days of discharge by telephone, direct contact, or electronic means, and that, by the first face-to-face visit following discharge, the patient’s medications be reconciled with the medications listed on the patient’s chart.
The physician or other qualified health care provider may provide the following non-face-to-face services:
• Obtaining and reviewing the discharge information (e.g., discharge summary or continuity of care documents).
• Reviewing and follow-up of pending diagnostic tests and treatments.
• Interaction with other qualified health care professionals who will assume or re-assume care of the patient’s system-specific problem.
• Education of patient, family, guardian, and/or caregiver.
• Establishment or re-establishment of referrals, and arranging community services, if needed.
• Assistance in scheduling any required follow-up with community providers and services.
Clinical staff under direction from a physician or
other provider can provide such non-face-to-face services as communicating
aspects of care, self-management and treatnment regimen adherence with the
patient, caregiver, or other decision maker, as well as communicating with home
health agencies or other community services the patient is using. They can also help identify available
community resources for the patient and help get them access.
You cannot charge an office visit on the same day as your face-to-face visit for TCM. However, you can be the discharging physician and bill the discharge and then the TCM. Only one physician may bill the TCM and it can only be billed once per 30 days, even if the patient has another hospitalization and discharge.
CMS has valued Code 99495 at 4.82 total RVUs, or
about $163. Code 99496 is valued at 6.79 RVUs, or approximately $230.
These codes are ideal for a strong team approach, covering services many family physicians are providing on a regular basis, and recognizing that primary care physicians take care of many time-consuming issues of care coordination for patients.This is a start in the right direction. Happy Transitioning!
–Debra Seyfried, MBA, CMPE, CPC, Coding and Compliance Strategist for the American Academy of Family Physicians
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