How to avoid TCM coding denials

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CMS and most commercial payers began to pay for TCM in 2013, but physicians continue to see denials. Experts believe there could be several reasons why.

• CPT code 99495 (TCM with moderate medical decision complexity and a face-to-face visit within 14 days of discharge)

• CPT code 99496 (TCM with high medical decision complexity and a face-to-face visit within 7 days of discharge)

Payment information: CMS began paying for TCM in 2013, and many commercial payers began doing so shortly thereafter. The 2017 national average Medicare payment for TCM with moderate medical decision making is $165.45. For TCM with high medical decision complexity, Medicare pays a national average of $233.99.

Quiz: Do you know your TCM codes?

Transitional care management (TCM) includes the services that physicians provide to new or established patients whose medical and/or psychosocial problems require moderate- or high-complexity medical decision making during transitions in care. These transitions occur when patients move from an inpatient hospital setting, partial hospital, observation status in a hospital or skilled nursing facility/nursing facility to the patient’s home or another community setting (e.g., rest home, domicile, or assisted living).

Even though CMS and most commercial payers began to pay for TCM in 2013, physicians continue to see denials when billing these services. Experts believe there could be several reasons why.

Physicians shouldn’t report TCM every time a patient is discharged, says Raemarie Jimenez, CPC, CPC-I, vice president of membership and certification solutions at AAPC. The patient’s level of severity must support the code assignment, she adds.

In particular, TCM requires either moderate- or high-complexity medical decision-making. A patient admitted due to a dehydration, for example, wouldn’t require TCM services post-discharge. Patients who are admitted for exacerbation of a chronic illness such as chronic obstructive pulmonary disease, diabetes or congestive heart failure would likely qualify.

Not fully understanding TCM requirements could be another reason why denials occur, says Kim Huey, MJ, CHC, CPC, an independent coding and reimbursement consultant. Many physicians don’t fully understand the breadth of their responsibilities when they bill TCM, she adds. “It’s about managing all of their medical and psychosocial needs for 30 days.”

Next: Other potential billing pitfalls

This includes facilitating access to care, identifying community and health resources, establishing referrals, providing support for medication management and anything else necessary to avoid a readmission, says Huey. Documentation of these non-face-to-face services may not be sufficient to justify reporting the codes.

Further reading: To help physicians, EHRs must adapt to value-based care

Other potential billing pitfalls include a failure to document contact with the patient and/or caregiver within two business days of discharge, says Huey. Per CPT guidelines, ‘within two business days of discharge’ is Monday through Friday except holidays. Acceptable methods include direct contact, via telephone or electronic correspondence. If an insurer requests documentation prior to payment-and sees that the physician didn’t attempt to contact the patient-it will deny the service, she adds.

There are other TCM-related nuances to keep in mind. For example, physicians cannot report TCM and CCM for the same patient during the same calendar month, says Huey. TCM pays more, so if TCM requirements are met, Huey advises physicians to report TCM and skip CCM for that month.

Billing TCM more than once every 30 days for the same patient can also result in a denial, says Kathleen Mueller, RN, CPC, president of AskMueller Consulting LLC, a healthcare consulting company. A single TCM code includes services provided on the date of discharge and continues for the next 29 days.

Physicians also can’t report TCM with certain end-stage renal disease services or prolonged services without direct patient contact. According to its 2017 Work Plan, the Department of Health and Human Services’ Office of the Inspector General (OIG) will investigate whether Medicare payments were in accordance with these requirements.

If a physician bills TCM and the patient is readmitted to the hospital or dies within those 30 days, the physician will see a denial, says Huey. In this scenario, the physician should resubmit a corrected claim that includes an office visit evaluation and management (E/M) code, assuming documentation justifies doing so, she adds.

Huey suggests that physicians hold the claim until the 30-day mark and then verify that the patient has not be readmitted or died during that period.

Experts say physicians can avoid denials simply by knowing what documentation is required for each code and sticking to it. Ultimately, coding should reflect the patient’s clinical picture any work the physician performed.

“You need to code appropriately for the care you provide,” says Mueller.