The document discusses billing for Transitional Care Management (TCM) services, highlighting common errors that lead to claim denials and outlining essential claim submission details. It specifies two CPT codes (99495 and 99496) for TCM services and the requirements for using them, including timing of communication and complexity of medical decision-making. Additionally, it provides guidelines for proper coding and billing practices and emphasizes the importance of following payer regulations.

1. BILLING FOR
TRANSITIONAL CARE
MANAGEMENT
Medical Billers and Coders

2. Many practitioners have difficulty being paid for Transitional
Care Management (TCM) services. In many cases, claims
submitted for TCM services have not been paid due to
several common errors in claim submission. In particular, the
practitioner should ensure that the entire 30-day TCM
service was furnished, the service began with a qualified
discharge from a facility, and that the appropriate date of
service is reported on the claim. In this article, we covered
basic claim details while billing for transitional care
management.

3. Procedure Codes for Transitional Care Management:
Effective January 1, 2013, under the Physician Fee Schedule (PFS) Medicare pays
for two CPT codes (99495 and 99496) that are used to report physician or qualifying
nonphysician practitioner care management services for a patient following a
discharge from a hospital, SNF, or CMHC stay, outpatient observation, or partial
hospitalization.
1. CPT Code 99495 covers communication with the patient or caregiver within two
business days of discharge. This can be done by phone, e-mail, or in person. It
involves medical decision-making of at least moderate complexity and a face-to-
face visit within 14 days of discharge. The location of the visit is not specified.
The work RVU is 2.11.
2. CPT Code 99496 covers communication with the patient or caregiver within two
business days of discharge. This can be done by phone, e-mail, or in person. It
involves medical decision-making of high complexity and a face-to-face visit
within seven days of discharge. The location of the visit is not specified. The
work RVU is 3.05.

4. Coding Guidelines
• While using codes procedure codes 99495 and 99496 for Transitional
Care Management services consider the following coding guidelines:
• Medication reconciliation and management should happen no later
than the face-to-face visit.
• The codes can be used following ‘care from an inpatient hospital
setting (including acute hospital, a rehabilitation hospital, long-term
acute care hospital), partial hospitalization, observation status in a
hospital, or skilled nursing facility/nursing facility.’
• The codes cannot be used with G0181 (home health care plan
oversight) or G0182 (hospice care plan oversight) because the
services are duplicative.
• Billing should occur at the conclusion of the 30-day post-discharge
period.

5. MedicalBillersandCoders (MBC) is a leading medical billing company
providing complete revenue cycle management services. Our billing
services include eligibility verification, medical coding, charge entry,
payment posting, denial analysis, account receivables (AR)
management, and provider credentialing and enrollment. With our billing
services, you can increase your practice collection while staying billing
compliant as per payer guidelines.

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