Jump to content

billng code 99496

Recommended Posts

  • Moderator

TCM codes are a PIA to bill


pay good but have to be billed on the 30th day of DC and they had to be actually admitted and not on observation status (which many times is the real admission)


here is a summary


you can bill now


A Comprehensive Look at the New Transitional Management Codes

In the CY 2013 Physician Fee Schedule (PFS) proposed rule, the Centers for Medicare & Medicaid Services (CMS) proposed to address the significant non-face-to-face work involved in coordinating services for a beneficiary after discharge from a hospital or SNF. Specifically, CMS proposed to create a HCPCS G-code to describe care management involving the transition of a beneficiary from care furnished by a treating physician during a hospital stay (inpatient, outpatient observation services, or outpatient partial hospitalization), a SNF stay, or community mental health center (CMHC) partial hospitalization program to care furnished by the beneficiary's primary physician in the community within 30 calendar days following the date of discharge. In response to comments, the final rule adopts two new CPT transitional care management codes, 99495 and 99496, which distinguish between moderate and high complexity services, instead of the single proposed G-code. The nomenclature for CPT 99495 and 99496 is given below.

  • 99495 Transitional Care Management Services with the following required elements: 
    • Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge.
    • Medical decision making of at least moderate complexity during the service period.
    • Face-to-face visit, within 14 calendar days of discharge.
  • 99496 Transitional Care Management Services with the following required elements: 
    • Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge.
    • Medical decision making of high complexity during the service period.
    • Face-to-face visit, within 7 calendar days of discharge.

CMS says it considers the requirement for a face-to-face visit in association with the non-face-to-face tasks of TCM to be a short-term, transitional strategy while CMS further explores further improvements to advanced primary care payment. CMS also emphasizes that the above new CPT codes do not specify the location/setting for the required face-to-face visit. CMS also notes that incorporating such a visit into the TCM codes will help beneficiaries understand their coinsurance liability better.

In the PFS proposed rule, CMS invited comment on whether it should require a face-to-face visit on the same day as a patient's discharge from hospital, SNF or other settings (in relation to TCM services). CMS says that commenters were almost uniformly opposed to a requirement for a same day visit and does not adopt such a requirement. However, CMS emphasizes that physicians should conduct the face-to-face visit as quickly as medically necessary after discharge in order to address patient care needs.

With respect to the required post-discharge communication with patients (now incorporated into CPT 99495 and 99496), commenters recommended that CMS change "business days" to "calendar days." CMS refuses to do this, but notes that the CPTTCM codes specify that business days are Monday through Friday, except holidays, without respect to normal practice hours or date of notification of discharge. Also, if two or more separate attempts are made in a timely manner, but are unsuccessful and other TCM criteria are met, the service may be reported. CMS emphasizes, however, that it expects attempts to communicate to continue until they are successful.

Despite its decision to adopt CPT 99495 and 99496, CMS says it does not agree with the American Medical Association's recommendation that the physician must have an established relationship with the patient prior to the discharge to report the CPTTCM codes.CMS is concerned that such a requirement would prevent some vulnerable patients from benefiting from TCM services. CMS says it will develop additional Medicare-specific guidance for the use of the TCM codes to allow a physician to bill the codes for new patients (although payment for the codes will be the same for both new and established patients). CMS adds that it believes the typical case will involve provision of TCM services to an established patient, and relative values for codes are established on the basis of the typical patient. CMS also notes that physicians may choose to bill other appropriate codes (for example, new patient E/M codes) that better describe the services furnished.

The final rule states that TCM services are for a patient whose medical and/or psychosocial problems require moderate or high complexity medical decision making during transitions in care from an inpatient hospital setting (including acute hospital, rehabilitation hospital, long-term acute care hospital), partial hospitalization, observation status in a hospital, or skilled nursing facility/nursing facility, to the patient's community setting (home, domiciliary, rest home, or assisted living). It adds that TCM commences upon the date of discharge and continues for the next 29 days. The final rule also provides two lists of non-face-to-face services (repeated below), which CMS expects will be routinely provided as part of TCM services "unless the practitioner's reasonable assessment of the patient indicates that a particular service is not medically indicated or needed."

The first list of non-face-to-face services, which CMS says would be provided by clinical staff, under the direction of the physician or other qualified health care professional, includes the following:

  • Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge.
  • Communication with home health agencies and other community services utilized by the patient.
  • Patient and/or family/caretaker education to support self-management, independent living, and activities of daily living.
  • Assessment and support for treatment regimen adherence and medication management.
  • Identification of available community and health resources.
  • Facilitation access to care and services needed by the patient and/or family.

The second list of non-face-to-face services, which CMS says would be provided by the physician or other qualified health care provider, includes the following:

  • Obtaining and reviewing the discharge information (for example, discharge summary, as available, or continuity of care documents).
  • Reviewing need for or follow-up on pending diagnostic tests and treatments.
  • Interaction with other qualified health care professionals who will assume or reassume care of the patient's system-specific problems.
  • Education of patient, family, guardian, and/or caregiver.
  • Establishment or reestablishment of referrals and arranging for needed community resources.
  • Assistance in scheduling any required follow-up with community providers and services.

The final rule also says that TCM requires a face-to-face visit, initial patient contact, and medication reconciliation within specified time frames (for medication reconciliation, this is said to be no later than the date of the face-to-face visit). The final rule also notes that the first face-to-face visit is part of the TCM service but that additional E/M services may be reported separately. In addition, for purposes of the medical decision making incorporated into the TCM codes, the final rule refers readers to definitions in the E/M Services Guidelines. Required documentation for the TCM codes includes the timing of the initial post discharge communication with the patient or caregivers, the date of the face-to-face visit, and the complexity of medical decision making.

In the proposed rule, CMS proposed to preclude a physician to report both a discharge management code and a TCM code but now accepts the AMA/RUC recommendation (as supported by a number of commenters) to allow this. However, CMS says it continues to be concerned that there could be some overlap in the actual work involved in providing the two services, and will monitor claims data to ascertain the extent to which the same physician bills for both the discharge day management and TCM services. CMS adds that it will analyze whether it may be appropriate to develop a payment adjustment that recognizes overlap in resources in the future. CMS also emphasizes that the E/M service required for the CPTTCM codes cannot be furnished by the same physician or nonphysician practitioner on the same day as the discharge management service; in other words, the E/M services furnished on the day of discharge as part of the discharge management service cannot simultaneously be counted as satisfying the TCM face-to-face visit requirement.

In response to comments, CMS agrees to allow reporting of emergency department visits when also billing the CPTTCM codes. On the other hand, the final rule states that a physician or other qualified health care professional who reports the TCM codes may not report any of the following during the time period covered by the TCM codes:

  • Care plan oversight services (99339, 99340, 99374-99380);
  • Prolonged services without direct patient contact (99358, 99359);
  • Anticoagulant management (99363, 99364);
  • Medical team conferences (99366-99368);
  • Education and training (98960-98962, 99071, 99078);
  • Telephone services (98966-98968, 99441-99443);
  • End stage renal disease services (90951-90970);
  • Online medical evaluation services (98969, 99444);
  • Preparation of special reports (99080);
  • Analysis of data (99090, 99091);
  • Complex chronic care coordination services (99481X-99483X); and
  • Medication therapy management services (99605-99607).

In the proposed rule, CMS indicated that a physician or qualified nonphysician practitioner billing for a procedure with a 10- or 90-day global period would not be allowed to bill for post-discharge transitional care management because CMS considers such management included in the post-operative portion of the global period. CMS now finalizes this policy. CMS acknowledges that the AMA RUC recommends that specialists work with the CPT Editorial Panel to develop a new code for those cases in which comprehensive TCM services are furnished along with the services already bundled into global surgical services, but does not comment on this recommendation.

In the proposed rule, CMS had indicated that the TCM codes could be billed only once per patient within 30 days of discharge and only by a single physician. CMS now finalizes these policies. CMS also notes that billing of the TCM codes will occur at the conclusion of the period for providing TCM services, 30 days post discharge. CMS adds that it expects most community physicians who furnish TCM services will be primary care physicians and practitioners but notes that there will be circumstances in which cardiologists, oncologists, or other specialists will be in the best position to furnish TCM services. CMS also says that among nonphysician qualified health care professionals, only nurse practitioners, physician assistants, clinical nurse specialists and certified nurse midwives could bill for TCM services. In response to comments, CMS explicitly says that psychologists are not licensed to perform TCM services and declines to create a special TCM G-code for them.

Further, CMS notes that "limited-license practitioners" (optometrists, podiatrists, and doctors of dental surgery or dental medicine), by virtue of their scope of practice, would also not be able to furnish the comprehensive medical evaluation and management services described by the TCM codes.In addition, since rural health clinics are not paid under the PFS, CMS says that physicians and other rural health clinic providers whose services are paid within the rural health clinic all-inclusive rate cannot bill using the CPTTCM codes for services furnished in the rural health clinic.

In response to comments, CMS notes that the TCM codes may not be billed when patients are discharged to a SNF; however, when SNF patients are discharged from the SNF to the community or to a nursing facility (even when the SNF and nursing facility are part of the same entity or located in the same building), the physician or practitioner who furnishes TCM services can use the TCM codes to bill for those services.

CMS acknowledges comments recommending that it monitor readmissions for patients receiving TCM services to determine if these services positively impact beneficiary outcomes, and says it will consider how to incorporate such monitoring into its existing initiatives.

In response to MedPAC and other comments expressing concern about potential confusion over which physician or practitioner is providing the bulk of TCM services (and therefore should be the one billing for a TCM code), CMS provides a lengthy discussion about the role of the discharging physician, which CMS believes would include the following:

  • Informing beneficiaries that they should receive TCM services from their doctor or other practitioner after their discharge, and that Medicare will pay for those services;
  • Asking the beneficiary to identify the practitioner whom he or she wishes to furnish these TCM services;
  • If the beneficiary does not have a preference for the physician who would furnish these services, suggesting a specific physician who might be in the best position to furnish them; and
  • Recording the community physician who will be providing TCM services in the discharge medical record and the discharge instructions for patients (which CMS says "could be helpful").

In the CY 2013 PFS proposed rule, the CMS-proposed payment for the proposed TCM G-code involved the following:

  • A work RVU identical to that for CPT 99238 (Hospital discharge day management; 30 minutes or less; work RVU = 1.28).
  • Physician times of 8 minutes pre-evaluation, 20 minutes intra-service, and 10 minutes immediate post-service.
  • Clinical labor inputs cross-walked from CPT 99214 (Level 4 established patient office or other outpatient visit).
  • Malpractice expense crosswalked from CPT code 99214.

The final rule instead accepts AMA RUC recommendations for the CPT 99495, a work RVU of 2.11 with 40 minutes of intra-service time. CMS also accepts the AMA RUC-recommended work value of 3.05 for CPT 99496 but reduces the intra-service time to 50 minutes (from the recommended 60 minutes). The RUC recommendations were based on a multi-specialty survey of 110 physicians. CMS also accepts the RUC's recommended malpractice crosswalks for CPT 99495 and 99496, and most of the RUC's recommended PE inputs for them. The sole exception is that CMS increases the clinical labor time for a RN/LPN nurse blend dedicated to non-face-to-face care management activities from 60 minutes to 70 minutes.

In terms of the required budget neutrality adjustment, the proposed rule had estimated that the new TCM G-code would be billed 10 million times in CY 2013. The AMA RUC commented that 2 million would be a more reasonable assumption. In the final rule, CMS assumes 5.7 million claims after adjusting its earlier estimate for readmissions. CMS also disagrees with the RUC's assumption that 60 percent of the TCM claims would be for CPT 99495 and 40 percent for CPT 99496, saying that a 75/25 split would be a more reasonable assumption. CMS notes that it partially offset the cost of the TCM services with the cost of the existing visits assumed to be billed as part of the CPTTCM codes (in other words, CMS acknowledges that many of the these visits would have been separately billed under current policy). CMS rejects comments urging it to assume that some of the costs would be offset by reduced readmissions, saying that the statute does not permit costs or savings from outside of the PFS to be used in the PFS budget neutrality calculation. CMS also argues that it lacks the authority to add the new TCM codes to the list of primary care services eligible for incentive payments under the Primary Care Incentive Payment Program (PCIP). However, CMS says that the allowed charges for the TCM services will not be included in the denominator when calculating a physician's or practitioner's percent of allowed charges that were primary care services for purposes of PCIP eligibility; this removes the risk that the TCM payments could make some practitioners ineligible for the PCIP.

Commenters requested that CMS waive beneficiary cost-sharing for the TCM services but CMS says it does not believe it has the authority to do so.

CMS Issues Physician Fee Schedule Final Rule

On November 1, 2012, the Centers for Medicare & Medicaid Services (CMS) released the 2013 Medicare physician fee schedule (MPFS) final rule with comment period. The rule will take effect January 1, 2013 with a comment period that closes on December 31, 2012.

The rule includes new payments for care-coordination services in the month following patient discharges. As a result of this proposal payments to family physicians would get an approximately 7 percent pay increase and other practitioners practicing primary care services between a 3 and 5 percent increase. AMDA will provide more detailed information on how long-term care practitioners can take advantage of these codes in future issues of Health Policy Advisor.

In responding to the proposed rule on this measure, Charles Crecelius, MD, PhD, CMD, AMDA Past President and Chair of the AMDA Public Policy Committee stated "Acknowledging and paying for transitions of care is an important step to improving patient care and safety. AMDA will continue to support CMS and RUC efforts to improve reimbursement for undervalued and underappreciated services."

These increases would however be offset by a statutorily required 26.5 percent across-the-board reduction to Medicare payment rates as a result of the sustainable growth rate (SGR). Congress has acted in the past to avert such cuts and AMDA will continue to work with Congress to repeal and replace this flawed formula. If Congress does avert the cut, nursing homes codes will get a 1-2 percent increase in payment due to an increase in practice expense (PE) relative value unit (RVU) as detailed in the following tables.

Table 1: Proposed CY2013 Payments With $25.0008 Conversion Factor Reflecting the 26.5% Cut



Total 2013 RVUs 2013 Payment Rate
Total 2012 RVUs 2012 Payment Rate
Percentage Change


99304 2.69 $67.25 2.64 $89.86 -25.16% 99305 3.82 $95.50 3.73 $126.96 -24.78% 99306 4.82 $120.50 4.73 $161.00 -25.15% 99307 1.28 $32.00 1.25 $42.54 -24.77% 99308 1.99 $49.75 1.94 $66.03 -24.65% 99309 2.61 $65.25 2.55 $86.80 -25% 99310 3.88 $97.00 3.79 $129.00 -24.80% 99315 2.1 $52.50 2.05 $69.78 -24.76% 99316 3.01 $75.25 2.94 $100.07 -24.80% 99318 2.75 $68.75 2.7 $91.90 -25.19% %= (new-old)/old


Table 2: Potential Payments With $34.0066 Conversion Factor Reflecting the Averted Cut



Total 2013 RVUs 2013 Payment Rate
Total 2012 RVUs 2012 Payment Rate
Percentage Change


99304 2.69 $91.48 2.64 $89.86 1.80% 99305 3.82 $129.91 3.73 $126.96 2.32% 99306 4.82 $163.91 4.73 $161.00 1.81% 99307 1.28 $43.53 1.25 $42.54 2.32% 99308 1.99 $67.67 1.94 $66.03 2.49% 99309 2.61 $88.76 2.55 $86.80 2% 99310 3.88 $131.95 3.79 $129.00 2.28% 99315 2.1 $71.41 2.05 $69.78 2.34% 99316 3.01 $102.36 2.94 $100.07 2.29% 99318 2.75 $93.52 2.7 $91.90 1.76% *this conversion factor is estimated by AMDA policy experts


The final rule also includes the following provisions:

  • Implementation of the physician value-based payment modifier
  • Changes to the PQRS and the Electronic Prescribing (eRx) Incentive Program – as well as the Medicare Electronic Health Records (EHR) Incentive Pilot Program which promotes the use of health information technology;
  • Durable medical equipment (DME) face-to-face requirement as a condition of payment for certain high-cost Medicare DME items;
  • Next steps to enhance the Physician Compare website, including posting names of practitioners who, as part of the Million Hearts campaign, successfully report measures to prevent heart disease;
  • Expands access to services that can be provided by non-physicians practitioners. The rule allows Certified Registered Nurse Anesthetists (CRNAs) to be paid by Medicare for providing all services that they are permitted to furnish under state law;
  • Allows Medicare to pay for portable x-rays ordered by nurse practitioners, physician assistants and other non-physician practitioners.


The final rule with comment period will appear in the November 16 Federal Register. AMDA will post more detailed summaries of various provisions in the rule in future editions of the Health Policy Advisor.


Update on 2012 Medicare Physician Payment Rates

The payroll tax extension legislation that was passed by Congress and signed by the President on December 23, 2011, delayed the 27.4 percent Medicare physician payment cut for two months.  It also extended the floor on the work geographic practice cost index (GPCI), and extended the therapy caps exception process.

The two-month extension provided for a zero percent update to the Medicare conversion factor. However, the final rule indicated that there would be a 0.18% increase in the conversion factor for budget neutrality. This change was effective January 1, 2012.  The budget neutrality increase is due to the Centers for Medicare & Medicaid Services (CMS) adoption of the RVS Update Committee recommendations for mis-valued codes.  The 2011 conversion factor was $33.9764.  The 2012 conversion factor will now be $34.0376.

Because Congress acted so late in 2011 to prevent the payment cut, claims must still be held for a period of time to allow CMS time to develop the new payment rate files and the Medicare claims administration contractors time to install and test the files. CMS expects that most, if not all contractors will be ready to process claims under the revised rates on or before January 18, 2012. 

The table below lists the physician fee schedule update for the nursing facility codes with the new updates reflected. The figures do not include any geographic adjustments. 


2011 Pay 
(CF =33.9764)

2012 Pay 
(CF =34.0376)

Change in Pay

% Change in Pay



















































Source:Medicare Program; Payment Policies under the Physician Fee Schedule, Five-Year Review of Work Relative Value Units, Clinical Laboratory Fee Schedule: Signature on Requisition, and Other Revisions to Part B for CY 2012, Addendum B


If Congress fails to pass a new extension or address the SGR after the two-month extension, the 27.4 percent cuts could be implemented. See article below with table showing new rates if a cut occurs.

Link to comment
Share on other sites

  • Moderator

make sure you follow your billing company to make sure you're getting paid.  In a house call business the reimbursement is not worth it.  Over a traditional house call reimbursement but an office-based practice it would be worth it as long as you get paid.



Key things are a true admission and billing on or after the 30th day after discharge

Link to comment
Share on other sites


This topic is now archived and is closed to further replies.

  • Create New...

Important Information

Welcome to the Physician Assistant Forum! This website uses cookies to ensure you get the best experience on our website. Learn More