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Medicare will reimburse physicians for managing patient transitions from hospital, SNF to home

From international law firm Arnold & Porter LLP comes a timely column that provides views on current regulatory and legislative topics that weigh on the minds of today’s physicians and health care executives.

From international law firm Arnold & Porter LLP comes a timely column that provides views on current regulatory and legislative topics that weigh on the minds of today’s physicians and health care executives.

CMS announced that on Jan. 1, 2013, it will begin paying physicians and other qualified health care providers for coordinating Medicare beneficiaries’ care transitions following discharge from hospitals or skilled nursing facilities to their homes or assisted living facilities.

In announcing this important policy change, CMS acknowledged that payment for existing Evaluation & Management (E/M) services did not take into account the extensive non-face-to-face care coordination provided by nurses and physicians during these transitions. Payment for these services will be made under two new CPT codes for “Transitional Care Management” (TCM) services and is intended to help prevent re-hospitalizations and emergency department visits during the first 30 days post-discharge.

Catherine Brandon

While CMS expects that most of these services will be billed by primary care providers, specialists who furnish the requisite services also may bill the new TCM codes. Specifically, the 2013 Physician Fee Schedule includes national payment amounts and new payment policies for two new CPT codes: 99495 and 99496. Both codes require communication with the patient and/or caregiver within 2 business days of discharge and a face-to-face visit with the patient within a certain time period. Medication reconciliation and management must occur no later than the date of the face-to-face visit. CPT 99495 requires a face-to-face visit within 14 calendar days of discharge and is designed for patients for whom medical decision making is of at least moderate complexity during the service period. CPT 99496 requires a face-to-face visit within 7 calendar days of discharge and is designed for patients who require medical decision making of high complexity.

The non-face-to-face care management services may be performed by the provider and/or licensed clinical staff under his or her direction, but the provider must perform the face-to-face visit with assistance from staff. Physicians should note that the first post-discharge face-to-face visit with the patient is part of the TCM service and not reported separately. Additional E/M services may be reported separately. The E/M documentation guidelines do not apply to these codes; therefore, practitioners should consider how they wish to document the non-face-to-face services that are required by codes. For example, it will be necessary to document the timing of the initial post-discharge communication, the date of the face-to-face visit, and the complexity of the medical decision making. Physicians and other qualified practitioners may begin billing these codes on Jan. 1, 2013.

If Congress acts to prevent the 26.5% cut to physician payments and maintains the current conversion factor, practitioners will be reimbursed $134.67 and $197.58 for codes 99495 and 99496, respectively, in facility (e.g., outpatient hospital) settings and $163.91 and $230.90, respectively, in nonfacility (e.g., physician office) settings. Primary care incentive payments will not be added to these amounts. The codes may only be billed at the conclusion of the service period (at least 30 days post discharge).

These services can be billed for new or established patients. Although discharge services and the required face-to-face visit furnished under the TCM code may not be provided on the same day, the same practitioner who bills for discharge management services also may bill for TCM services. The same individual, however, should not report transitional care management services provided in a postoperative period for a service with a global period because it is assumed that these services are included in payment for the underlying procedure.

One particularly tricky aspect of the new codes is that only one practitioner may bill for TCM services during the 30 days after a patient’s discharge; thus, only the first practitioner to bill for the TCM service will be reimbursed for it. To avoid a race to bill, practitioners should communicate with the discharging physician, patient, and/or caregiver to coordinate who will be responsible for TCM services. Additionally, health care professionals who intend to use this code should carefully review the CPT instructions.

Catherine Brandon, JD, can be reached at Arnold & Porter LLP, 555 12th St. NW, Washington, DC 20004-1206; 202-942-6823; email: Catherine.Brandon@aporter.com

Paul M. Rudolf, MD, JD, can be reached at Arnold & Porter LLP, 555 12th St. NW, Washington, DC 20004-1206; 202-942-6426; email: Paul.Rudolf@aporter.com

Tips for billing TCM codes

• Bill only for post-discharge patients requiring moderate or high-complexity decision making (per CPT requirements).
• Remember:
• The first post-discharge face-to-face visit and all transition-related non-face-to-face services for 30 days post-discharge are included.
• The face-to-face visit does not need to be in the office.
• Only one practitioner can bill TCM services for a given discharge.
• TCM may only be billed once in the 30 days after a discharge even if the patient is discharged two or more times during that 30-day period.
• The practitioner who billed the facility discharge also can bill for TCM.
• TCM cannot be billed during a surgical global period by the surgeon.
• TCM should be billed at the end of the service period.
• You cannot bill for other care coordination services performed during the TCM service period (eg, care plan oversight 99339, 99340, 99374-99380).
• The E/M documentation guidelines do not apply to TCM codes so you must develop your own.