Getting Paid for Care After Your Patient Is Discharged

Betsy Nicoletti, MS

Disclosures

November 11, 2019

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

In this column, Nicoletti explains restrictions on transitional management codes as well as properly billing for remote monitoring services.

Understanding Transitional Care Code Requirements

Question: A patient at our endocrinology practice is already receiving transitional care management (TCM) code 99496 services due to high-complexity medical decision-making from the physician. However, if more time/services are added on, is there a route for billing that?

As an example, can we add and bill for a PharmD medication review/reconciliation prior to the face-to-face office visit with the practitioner to improve the thoroughness of the patient's medical history and better address medication-specific issues?

Answer: Unfortunately, there is no additional payment for this. If an additional face-to-face office visit is done after the first one, it may be billed separately.

Medication reconciliation is a required component of TCM, which must be completed on the day of the face-to-face office visit. Neither Current Procedural Terminology (CPT) nor the Centers for Medicare & Medicaid (CMS) define who must perform this medication reconciliation, but it is typically done by a clinical staff member or the practitioner who is seeing the patient after the hospitalization.

Of course, there is enormous benefit to this complex patient to have a PharmD review the medication. Non–face-to-face service, before or after the face-to-face visit, is included in the payment for the service and can't be billed separately.

TCM requires:

  • Communication (direct contact, telephone, electronic) within two business days of discharge

  • Review of the discharge summary

  • Medication reconciliation

  • Moderate-complexity medical decision-making for 99495 and a visit within 14 calendar days

  • High-complexity medical decision-making for 99486 and a visit within seven calendar days

  • Additional non–face-to-face work done by the clinical staff or practitioner during the 30-day period after discharge

There are two TCM codes, 99495 and 99496. Both have high work Relative Value Units (RVU) and total RVUs.

2019 Values

Code

Description

Work RVU

Practice expense RVU

Malpractice expense RVU

Nonfacility total RVU

99495

Transitional care management, moderate complexity

2.11

2.38

0.13

4.62

99496

Transitional care management, high complexity

3.05

3.27

0.20

6.52

The Medicare conversion factor nationally is about $36, making the payment about $166 for 99495 and $235 for 99496.

Billing for Remote Monitoring Services Correctly

Question: I am an endocrinologist and we frequently look at patient glucose checks. They either call them in, fax, or email them in. It is time-consuming.

For blood sugar readings, we usually get from our patients 2 weeks of readings, although sometimes they come in weekly for pregnant patients or monthly in the form of readings for patients who in general have less variable sugars.

We are allowed to bill for interpreting continuous glucose monitor readings. However, our coders tell us we are not allowed to bill for interpreting sugar readings or for the time we spend looking at them. We also cannot bill for our nurses calling patients back with recommendations on how to adjust their insulin doses. Is this correct?

Answer: There is a code for treatment management services following remote physiologic monitoring. CPT developed a new code in 2019—99457—that you may be able to use for this service.

However, in order to use this code, the data must be collected on an FDA-approved medical device. It is the payment for the management of the patient on the basis of that data.

99457 is used for remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified healthcare professional time in a calendar month, requiring interactive communication with the patient/caregiver during the month.

Some things to know about this code:

  • Medicare reimburses for this service. Check with each commercial payer.

  • The visit requires that 20 minutes or more spent is in a calendar month.

  • The work may be done by clinical staff, physician, or nonphysician practitioner (NPP).

  • The service must be ordered by physicians or NPPs as part of a specific treatment plan.

  • It requires the use of a medical device recognized by the FDA.

  • It requires a live, interactive communication with the patient or caregiver.

  • This service may not be billed on the same date that the physician/NPP performs an evaluation and management service.

  • A group may not double-bill any time. If care management services are being billed, don't use the time spent in remote monitoring as time spent in care management.

The order for the remote monitoring and name of the supervising physician or NPP should be in the note. Document the date and time spent, as well as the interaction with the patient or caregiver describing the management.

In 2020, this code will be revised. You will use 99457 for the first 20 minutes. For each additional 20 minutes, use code 99458.

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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