Health Information Management

Q&A: Reporting transitional care management codes

APCs Insider, January 18, 2013

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Q: Why would a hospital bother to bill the transitional care management (TCM) codes for the visit where the practitioner sees the patient for TCM rather than the E/M codes, particularly when the APC assignment and payment is the same as a level 3 office visit (CPT®  code 99213) or level 4 office visit (code 99214)?

A:  CMS had originally proposed a G-code for the non-face-to-face TCM work associated with post-discharge TCM services, which include all non-face-to-face services related to the TCM, furnished by the community physician or non-physician practitioner within 30 calendar days following the date of discharge from a variety of settings. CMS had proposed to package this service.
Subsequent to the release of the OPPS and Medicare Physician Fee Schedule (MPFS) proposed rules, the AMA CPT Editorial Board finalized new CPT codes for TCM services, which include both the non-face-to-face and the face-to-face work effort involved in TCM.
As a result, in the final MPFS rule, CMS elected to go with the new CPT codes for TCM instead of its originally proposed new G-code. Since the new TCM CPT codes include one face to face E/M visit, it will not be paid for separately in addition to the TCM code. CMS has assigned these codes to mid-level visit APCs for 2013.
CMS' expectation seems to be that hospitals will report these new TCM codes to reflect all of the non-face-to-face work that is provided in addition to the E/M service. Therefore, a hospital clinic with TCM practitioners should carefully develop its dollar charge for the TCM codes and determine what is most appropriate given that a regular face-to-face E/M visit is included as part of the TCM definition.
The visit level included is not specified but provides should keep in mind that the visit along with all the non-face-to-face care coordination within 30 days after discharge are part of the TCM code definition which means the dollar charge set for the TCM service likely needs to be higher than what is being charged for just a mid-level visit such as a 99213 or 99214.
Hospitals need to spend time thinking about what to charge for their TCM services as this is the only way the level of work and effort associated with these codes will be recognized over time with higher payment rates. So hospitals need to be reporting these new codes if appropriate and they need to set appropriate charges for them.
Editor’s note: Valerie Rinkle, MPA, Vice President of Revenue Integrity Informatics for Health Revenue Assurance Associates, Inc., in Plantation, Fla., and Jugna Shah, MPH, president of Nimitt Consulting in Washington, DC, answered this question.

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