How to bill and code transitional care management the right way

Q: Our office is having a difficult time reaching patients within the required two business days from discharge for transitional care management (TCM) codes. Will this preclude us from billing the codes when all of the other criteria are met?

A: TCM services require that you make direct contact with the patient or the patient’s caregiver within two business days of their discharge from the hospital or other facility. However, as long as you attempt to make contact, that counts for Current Procedure Terminology (CPT) billing purposes, and you’re eligible to submit the claim.

This information is included in the “Coding Tip” directly following the TCM codes (99495 and 99496) in the CPT codebook.  It explains what to do if you aren’t able to fulfill the codes’ direct-contact requirement.  Specifically, it reads:

“If two or more separate attempts are made in a timely manner but are unsuccessful and other transitional care management criteria are met, the service may be reported.” 

Since the coding tip seems to only be focused on the use of modifier 54 in a post-op period, it’s easy to miss this piece of information. However, it can be very helpful when trying to bill these codes.  

However, make sure you check with your local Medicare Administrative Contractor (MAC) to see whether they adhere to the CPT policy.  While this rule covers you for commercial payers, it’s important to remember that Medicare Learning Network fact sheet 908628 states,  “For Medicare purposes, attempts to communicate should continue after the first two attempts in the required two business days until they are successful.”

Q: Can TCM services be reported if the patient dies prior to the 30th day following discharge?

A: Because the TCM codes describe 30 days of care, in cases when the patient dies prior to the 30th day, you should not report TCM services.  However, you can report any face-to-face visits that occurred under the appropriate evaluation and management (EM) code.  

Since all EM codes after the first required visit can be billed separately, you should only have to worry about billing the first office.

Q: Can TCM services be reported under the primary care exception? Can the services be reported with the GC modifier?

A: TCM services are not on the primary care exception list, so the general teaching physician policy would not apply.  

Therefore, do not use modifier GC (Service has been performed in part by a Resident under the direction of a teaching physician).  When a physician places the GC modifier on the claim, he/she is certifying that the teaching physician has complied with the Teaching Physician requirements.