Getting Paid for a Patient's Endless Paperwork

Betsy Nicoletti, MS


September 23, 2019

Editor's Note:

Betsy Nicoletti, a nationally recognized coding expert, will take your coding questions via email and provide guidance to code properly to maximize reimbursement. Have a coding question? Submit it here.

In this column, Nicoletti explains how to get reimbursed for patient-related paperwork and who can properly code and bill for transitional care management services.

Compensation for Completing Paperwork

Question: I am an internist and have a 21-year-old patient with short gut syndrome. I've only seen him once, 5 months ago, but have endless paperwork since then, mostly regarding his infusion therapy. Can I bill for this?

Answer: There is a code for completing paperwork, but most insurances don't pay it. Medical practices that use the code set a fee and charge the patient.

The code is 99080, "special reports such as insurance forms, more than the information conveyed in the usual medical communications or standard reporting form." It has a status indicator of bundled in the Medicare Fee Schedule, so if your patient is covered by Medicare (not likely for a 21-year-old, but not impossible) then you cannot bill the patient for the service. Other payer policies will vary, but they will probably consider it bundled or patient due.

There is also a code for non–face-to-face prolonged care: 99358, "prolonged evaluation and management service before and/or after direct patient care; first hour." This code follows the CPT time rule, which states: "A unit of time is attained when the mid-point is passed. For example, an hour is attained when 31 minutes have elapsed (more than midway between zero and sixty minutes)."[1] You can bill this on the day of another professional service, such as an office visit, or on another day, as long as there was or will be a service.

There isn't a provision for adding together time from different days for this service, so you could only use it if you spent 31 minutes in one calendar day performing non–face-to-face activities.

Who Can Bill for Transitional Care Management?

Question: As a cardiologist, I frequently manage patients' multiple cardiac problems after an admission to the hospital. Can I bill for transitional care management (TCM) or can the patient's primary care physician only bill for that?

Answer: Any specialty physician may bill for TCM after a discharge from a facility to home. Only one physician, nurse practitioner, or physician assistant may bill TCM for any one discharge, even if more than one clinician is helping to manage the transition.

TCM is provided to patients whose medical and/or psychosocial problems require moderate- or high-complexity decision-making during a transition from a facility (inpatient, observation, inpatient rehab, or nursing facility) to home. The service consists of a combination of face-to-face and non–face-to-face services. The non–face-to-face service may be performed by the physician or clinical staff.

TCM requires all of these:

  • A phone call from the office to the patient in 2 business days;

  • A face-to-face service, usually an office visit; and

  • Non–face-to-face care coordination provided either by the physician/NP/PA or by the clinical staff.

There are two TCM codes. In order to use 99495, in addition to the phone call and non–face-to-face coordination, the patient must require moderate-complexity medical decision-making and have a face-to-face visit within 14 calendar days. In order to use 99496, in addition to the phone call and non–face-to-face coordination, the patient must require high-complexity medical decision-making and have a face-to-face visit within 7 calendar days.

Bill for the service at the time of the visit, and document what non–face-to-face service has occurred between discharge and the visit or the plan for the continuing coordination and support that will occur during the 30-day discharge visit. Examples of this include phone calls to the patient and caregiver, patient education, coordination with community services, communication with community services, and coordination and communication with other healthcare professionals caring for the patient.

Have a coding question? Send it in and it may be answered in a future column. (Please be sure to note your specialty in the text of the question.)

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