Transitional Care is Now Billable to Medicare

by Howard Gerber on February 14, 2013

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Beginning in January, Medicare now covers Transitional Care Management (TCM), the services necessary to move patients from inpatient care to home care or other healthcare environments. While some will surely question the cost of administrative services not directly involved in patient care, RNs and APRNs charged with making arrangements know how crucial transitional care is to patient outcomes.


The theory behind this initiative is that, by improving follow-up patient care after a hospital stay, they can improve patient health while saving money by avoiding re-admission, a win-win scenario for the patient, the hospital, and Medicare. It’s an unusually long-view preventative solution for an overburdened system, but the payoff for the billion dollar investment could be big. With a re-admission rate of 20% within 30 days of discharge, it’s speculatively far more expensive to wave patients out the door without a second thought than to ensure they have proper care after they walk out the door.

In the past, the Center for Medicare and Medicaid Services (CMS) has routinely denied such fees for service in attempts to control costs. This initiative follows a 2012 public discussion that explored ways to improve post-discharge care management outcomes for Medicare beneficiaries. As a result of the information gathered, the American Academy of Family Physicians and the AMA formed committees to find answers. The recommendation was to create two new codes to cover TCM.

The Fine Print

• Who can bill for TCM? Physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse midwives are defined as qualified medical professionals. Rural health clinics and federally qualified health centers do not qualify and can’t bill for TCM.
• What’s the time frame? You’ve got 30 days from the discharge date, but you must contact the patient within 2 days and have a face-to-face within one week for code 99496 and two weeks for code 99495.
• What services are required? Medical reconciliation and management services must be performed no later than the face-to-face meeting deadline. Non-face-to-face services are also required for billing.

Here are some of the specific requirements:

◦ Review of discharge information
◦ Follow up on needed tests, diagnostics, and treatments
◦ Coordination with other medical providers
◦ Patient and caregiver training/information about self-care, daily living, treatment and medical regimen
◦ Exploration of community resources

The Bottom Line

Even with a billion dollars on the table, CMS will only pay one claim per qualified stay, and if the patient winds up back in the hospital within 30 days, they won’t pay at all. The amounts will average $142.96 for 99495 claims and $231.11 for 99496 claims. Some claims will undoubtedly take far longer than the payment will warrant, but it’s a big step in the right direction.

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