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FAMILY PRACTICE

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Proven solutions to help you ethically maximize coding, documentation and reimbursement for your family practice

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2013 CPT Update:

February 2013

Who Qualifies?

Even though your practice may have been providing some level of transitional care management (TCM) to its post-discharge patients (i.e., check-in phone calls, medication management, etc.), you certainly havent been getting paid for the majority of it especially for your sickest patients. However, in 2013, with the new TCM codes (99495-99496) this will change. Medicare is expecting to pay $1.1 billion in reimbursements for TCM services in 2013 alone. (See CMS Targets Readmissions at right.) 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:

Summary: In 2013, CMS projects the use of the new transitional care management codes will boost your family practices overall Medicare reimbursements by 5%. Heres the catch you need to understand the nuances of how to use them correctly, and you must be willing to jump through a few hoops.

Boost Your Medicare Payments by 5%: Transitional Care Management is the Answer

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3. New vs. Established: CPTs 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 AMAs 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. continued on next page ...
CMS estimates that in 2013, two-thirds of all traditional Medicare discharges will be eligible for transitional care management. It also assumes that 75% of these claims will use 99495. The TCM price tag will be about $1.34 billion, and with beneficiaries responsible for their 20% co-payment, CMS expects to pay about $1.1 billion this year alone.

CMS Targets Readmissions

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.

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).

References: (1) American Academy of Family Physicians Final 2013 Medicare Fee Schedule, published Nov. 19, 2012. (2) CMS Press Release, Payments to Primary Care Physicians Increase in 2013, published Nov. 1, 2012.

So why is Medicare investing in TCM services? Basically, CMS is betting that by providing added incentives for improving post-hospitalization coordination of care, more practices will provide it. In turn, they are expecting (based on the results of several studies) that this will significantly reduce preventable hospital readmissions (which cost Medicare an estimated $17 billion a year), says Joan Gilhooly, MBA, CPC, PCS, CHCC, president and consultant with Medical Business Resources, LLC, a coding and compliance consulting firm in Lebanon, OH.

In summary, CMS formal statement reads, We do not entirely agree with the AMAs 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 Tip: Even though who would benefit most.

practice directly communicate with the patient or caregiver within two business days after discharge, Hill says. The communication must be interactive and address the patients status and needs beyond just scheduling their upcoming office visit, Ellington adds. For example, the communication may involve an assessment of and support for adherence to a treatment regimen and/or medication management help, etc.

4. Diagnoses: Pretty much its definition of whether a new patient any diagnosis that points to a medqualifies for TCM, ically fragile patient such as other payers may not chronic lung disease, ventilator dehave. Be sure to check pendence, or immune deficiencies with your individual could be coded with TCM payers. 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.

Medicare has changed

What if you cant reach the patient or caregiver for the two-day follow-up? Be sure the patients record reflects at least two separate, unsuccessful contacts that include the date, time, and type of contact, Gilhooly advises. Even if you cant reach the patient within the two-day time frame, as long as your practice has met all of the other guidelines, CMS technically allows you to still use the TCM codes, she adds.

Who Can Bill?

What Is Required?

Any qualified healthcare professional can use TCM codes (i.e., physician, PA, NP, CNS, CNM, etc.). You should note that these services are not exclusive to primary care. Also, only one provider/group can code for them in any given 30-day post-discharge period. Accordingly, coordinating who is providing these services is a must.

These new codes are basically a 30-day bundle of services, says Joan Gilhooly, MBA, CPC, PCS, CHCC, president and consultant with Medical Business Resources, LLC, a coding and compliance consulting firm in Lebanon, OH. Most TCM tasks will occur within the first several days after discharge. However, its imSummary of TCM Code Requirements portant to note that other non-face-toface interactions with the patient or Medical Medication Face-to-Face 1st Follow-Up Decision-Making Reconciliation Patient Visit with Patient caregiver may be needed during the Code Complexity (no later than Max # of Business Days Max # of Calendar Days entire 30-day period. st 1. Two-Day Follow-Up: Both 99495 and 99496 require that your 99495 99496
Post-Discharge

TCM services start on the date of discharge and continue for the next 29 days, says Emily Hill, PA, president of Hill and Associates, a coding and compliance firm in Wilmington, NC.

So, what time frame counts toward two days? CMS states that two business days after discharge is calculated Monday to Friday except holidays without respect to normal office hours or date of notification of discharge. The communication within two days post-discharge can be face-toface, via telephone, or by other electronic means, Hill says. 2. Medication Reconciliation: Both TCM codes also require that medications be reconciled with the patient no later than the date of the first face-to-face visit, Hill says. When your office calls to set the first appointment, its a great time to remind your patient or their caregivers that they should bring all of their medications with them to the appointment.

Note: You can download a free copy of a TCM Documentation Cheat Sheet from our website (www.CodingLeader.com).

However, Gilhooly notes that the November 16, 2012, Federal Register states that if you havent been able to reach the patient during the first two business days, but you meet all other requirements and decide to use the TCM codes anyway, CMS still expect[s] attempts to communicate [with the patient/caregiver] to continue until they are successful. Accordingly, It is essential that you have a process in place that identifies your patients who are being discharged, and can specifically track your attempts to contact them within the allotted time frame, Gilhooly cautions.

2 2

No later than 14 No later than 14 No later than 7 No later than 7

Post-Discharge

1 face-to-face visit)

Moderate High

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Family Practice Coding Advisor, Special Report, February 2013

3. Face-to-Face Deadlines/Medical Decision-Making: In order for post-discharge services to qualify for the use of both 99495 and 99496, and take advantage of the additional reimbursement being offered, BOTHthe first face-to-face visit with the patient and the level of required medical decision-making must fall within specified perimeters. (See Summary of TCM Code Requirements box on page 2.)

Unlike the first communication deadline of two days that is based on business days, the time frame requirements for the first face-to-face visit are based on calendar days. This is important because you need to be sure to count weekends and holidays when calculating which code you qualify for. You should also note that the face-to-face contact deadlines apply to those patients who might not be able to get to your office. This means if youre going to use TCM codes, your physicians or NPPs may have to see patients in their homes, assisted living facilities, rest homes, or other locations within the designated time frame, Gilhooly advises.

For example, if your provider uses high-complexity medical decision-making during the first face-to-face visit, but the appointment takes place on the ninth day post-discharge (instead of the required seven days), you cant use code 99496. In this instance, youd report 99495 instead. This means your reimbursement would be about 40% less just because the first face-to-face visit wasnt done on time to qualify for the higher-level code.

Note:When submitting your claims, dont forget to change the place-of-service code based on where the patient is seen (i.e., home = 12, ALF = 13, rest home = 33, etc.).

An 87-year-old established male patient is discharged from the hospital after being admitted for a stroke. Your office follows up with the patient by phone one day post-discharge and schedules the mans office visit with the physician in three days. During the office visit (four days post-discharge), your doctor documents that he performed a high-complexity level of medical decision-making and that he provided medication reconciliation with the patient.

TCM Coding Case Example

continued on next page ...

Five days later (nine days post-discharge), the patient has a second stroke and is once again hospitalized. The man is released from the hospital for a second time after another seven days (16 days after the first discharge). The practice follows up by phone with the patient the day after his second release date, and your physician sees the man again in his office three days later. All of the services were provided within 20 days of the first date of discharge. Heres how to correctly code this TCM case example:

A. 99496 covers the first office visit, which was within the required seven days of discharge, and had high-complexity medical decision-making, medication reconciliation, and the non-face-to-face interactive services provided by your office.

D. You might think the second E/M visit that occurred within the 30-day bundled period needs a modifier, but it doesnt. This is because the TCM code definitions clearly include only one E/M visit in the 30-day bundled period, which means additional visits are not a modification to the way the codes should be billed, Gilhooly explains. However, until Medicare provides formal billing guidelines for these new codes, there are still many unanswered questions.

C. The second post-discharge office visit can be billed separately (i.e., the 20th day). It can be reported using an E/M established patient office visit code (99211-99215) based on the physicians documentation of history, exam, and medical decision-making.

B. Since the date of the second hospital discharge is still within 30 days of the first discharge, your practice cant use a TCM code again; the second two-day phone follow-up is included in the orignal 99496s 30-day bundle of TCM services after the first discharge.

Tip: The one face-to-face visit thats included in the 30-day bundle period cannot be provided on the same calendar day as the discharge management service code (99238-99239) even if the discharge day management service is provided by a physician outside of your group. The next day, the day after that ... whatever the physician determines is clinically appropriate, as long as it is within the seven- or 14-day time frame, Gilhooly adds. Note: See the list on page 4 of inclusive services to ensure you are not double-dipping when coding for TCM. Also, additional updates to these new codes will be covered in future issues of Family Practice Coding Advisor as they occur.
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5. When to Submit the Claim: CMS states that TCM services should be billed after the conclusion of the service (only at 30 days after post-discharge), Gilhooly says.

4. 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 cant 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 Inclusive-Services List

6. Is It Worth It? The chart below compares E/M office visit codes 99214-99215 with the new TCM codes. Code 99495 is measured against 99214, both of which require moderate-complexity medical decision-making, and 99496 is compared to 99215, both of which require high complexity.
Office Visits vs. TCM National Reimbursements Comparison by Setting
Non-Facility $120.50 $78.25 $42.25

99495 Difference 99496 99214

Facility

$99.00 $56.25 $42.75

As would be expected, TCM codes reimburse at a 99215 $105.00 $79.25 higher rate. This compensates Difference $64.76 $63.00 your office for the extra time Reference: Reimbursements amounts and resources required. For from the AMAs CPT Code/Relative non-facility codes, 99495 reimValue Search engine:https://commerce.ama-assn.org/ocm/index.jsp burses 54% higher than 99214, and 99496 pays 62% more than 99215. So, if you are treating a population like geriatrics, who are typically hospitalized more than younger patients, the care they receive qualifies for the new TCM codes, and your practice will most likely see a significant boost in reimbursements.
$169.76 $142.25

Important: Not every follow-up visit after discharge will require a moderate- or high-complexity level of medical decision-making. TCM codes should only be used when they do.

The following codes cannot be billed in conjunction with TCM codes 99495 or 99496 during the 30-day follow-up period (inclusive means included in the 30-day follow-up period): 90951-90970 - End stage renal disease services 98960-98962 - Education and training for patient self-management 98966-98969 - Non-face-to-face non-physician services 99071 - Educational supplies 99078 - Group education 99080 - Additional information 99090 - Clinical data analysis stored in computers 99091 - Collection and interpretation of physiologic data 99339-99340 - Domiciliary, rest home or home care plan oversight services 99358-99359 - Prolonged services without direct patient contact 99363-99364 - Anticoagulant management 99366-99368 - Medical team conference 99374-99380 - Care plan oversight services 99441-99443 - Telephone services 99444 - On-line medical evaluation 99487-99489 - Complex chronic care coordination services 99605-99607 - Medication therapy management services

Although the TCM codes have been approved for payment by CMS, be sure to check with your carriers on their coverage of these new codes, says Debra Seyfried, MBA, CMPE, CPC, coding and compliance strategist, American Academy of Family Physicians.
Editors Note: CMS has not provided all of the answers related to the use of these new codes. For example: What happens if the patient dies before the end of the 30-day period? Or, what date of service (DOS) should you use the final day of the 30-day period, the day the TCM started, etc.? Family Practice Coding Advisor will bring you the answers to these and other questions.

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Family Practice Coding Advisor is published by Coding Leader, a division of Must Have Info, Inc. (c) 2013 Coding Leader all rights reserved. Reasonable attempts have been made to provide accuracy in the content. However, of necessity, examples cited and advice given in a national periodical such as this must be general in nature and may not apply to any particular case. Thus, neither the publisher, editors, board members, contributors nor consultants warrant or guarantee the information contained herein. For information tailored to your specific circumstances, consult a qualified professional. CPT codes, descriptions, and material only are copyright 2013 American Medical Association. All rights reserved. No fee schedules, basic units, relative value units, or related listings are included in CPT. The AMA assumes no liability for the data contained herein.

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