P2 Mobile Logo

Search form


Not Reflecting Medical Necessity; TCM/Home Visits; Split-Bill Encounters

Not Reflecting Medical Necessity; TCM/Home Visits; Split-Bill Encounters

Medical Necessity

Q: I was audited by a payer and their criticism of my medical decision-making documentation was that some notes had lists of diagnoses that did not reflect medical necessity. What do they mean by that?

A: In a perfect world they would tell you. But if they didn't, you have to look to the standard guidelines for this.

What the federal guidelines require is that diagnoses reported have a status of the problem and a plan. This could be as simple as, "HTN stable continue Metoprolol." As may have been the case with you, sometimes there are just lists of diagnoses with no indication of either status or plan — the problems are just listed or named.

When we don't see these same problems listed in the HPI (history of present illness), we wonder whether they are really actively managed that day — or whether they are more being mentioned in the A/P. Sometimes doctors use the A/P area as a running problem list, not always indicative of what was actually managed or assessed that day.

So give them what they want — state the problems to be addressed in the chief complaint, give a brief status of them in the HPI, and give us your assessment and plan in the A/P.

TCM Home Visits

Q: I did a transitional care management (TCM) that was a home visit. Can I charge for both?

A: A TCM code doesn't represent a singular service or visit, it is several things that occur in the 30 days following a patient's discharge from an inpatient stay. This includes the two-day contact, a visit within either of the specified periods, and the overall months' worth of oversight.

So when you ask if you can bill for both, it depends. If you mean can you use the home visit to count as the seven-day or 14-day visit included in the TCM code, then yes, but you wouldn't separately bill for the home visit. If you had another visit, in the office for example, within the seven day to 14-day range, and then did a home visit later in the month, between 15 days and 30 days post-discharge, then you can bill for the home visit in addition to the TCM code.

There is no exclusion for the use of home service codes in the TCM period, once you have done the required evaluation and management (E&M) visit in the 7-day or 14-day period. This is different for Chronic Care Management (CCM) services where there is an exclusion for home services in the same month that you are billing CCM.


Loading comments...

By clicking Accept, you agree to become a member of the UBM Medica Community.