7 Services PCPs Forget to Bill For

Betsy Nicoletti, MS


June 12, 2018

In This Article

The Physician Did the Work but Didn't Get Paid

There are times when medical practices perform a service, the physician documented the service, the service is readily reimbursable, but the practice fails to bill for it.

Why? There are many reasons: Perhaps the practice doesn't realize they can get reimbursed; their workflow flows to provide for capturing the service into the EHR; or the service is lumped in with another service, rather than being billed separately, which would provide more reimbursement.

Here are some of those services that often do not get billed for, even though they should be.

1. Transitional Care Management (TCM)

Two codes, 99495 and 99496, are used to describe the work of caring for a patient who is transitioning from a facility (inpatient or observation status, nursing facility, or partial hospitalization) to a nonfacility setting (home, domiciliary care).

The work includes direct contact, such as a phone call, with the patient or caregiver within 2 calendar days of discharge, an evaluation and management (E/M) service, medication reconciliation, review of the discharge documents, and other non-face-to-face service provided by the clinician or the clinical staff to support the patient's transition of care.

Both the work relative value units (wRVUs) and the payment to the practice are considerably higher than for an established patient visit.

Why is it overlooked? Some practices haven't set up a workflow and are not able to document the service in their electronic health record (EHR). This is unfortunate, given the difference in payment between office visits and these TCM services. It's worth taking the time with your EHR to set up a workflow that captures this activity. If you are unable to make this change within your own office staff, it's worth it to call the vendor and get some help with this.

Code Description wRVUs National Non-facility Payment
99495 TCM, 14-day visit, moderate medical decision-making (MDM) 2.11 166.99
99496 TCM, 7-day visit, high MDM 3.05 236.45
99214 Office/outpatient visit, established, level four 1.5 109.41
99215 Office/outpatient visit, established, level five 2.11 147.56


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