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Coding Q&A: Problem areas with 99495 and 99496


There are two principal criteria that need to direct physicians’ code assignment once they have decided to use a TCM code.

Q1: Several of our primary care providers are billing transitional care management codes 99495 and 99496. One of our coders tells us we aren’t doing these correctly, and sometimes we shouldn’t bill them. Can you give us a heads up on the problem areas here?

A1: Certainly, there are very definite areas where providers go astray with these. For both the 99495 and the 99496, the first thing providers need to remember is that there are two principal criteria that need to direct their code assignment once they have decided to use a TCM code. These are the time window of 7 or 14 days after discharge applying to the 99496 and 99495 respectively, and the level of decision-making.

We see many providers bill a 99496 when they see a patient within 7 days, but that patient is nowhere near high level decision-making, or it isn't documented. Even if it's within the seven days, if the decision-making is only moderate, it becomes a 99495.

Providers also sometimes code 99496 based in part on the severity or acuity of the event or circumstances causing the hospitalization, (i.e., stroke, MI etc.), versus the status of the patient the day they are seen. We see the hospital history in the HPI, but the A/P describes f/u by Neuro or Cards, the problems are resolved or stable, and they don't say much about the status of relevant chronic conditions in the A/P. Sometimes these cases fall right out of the range of TCM codes altogether.

Which points to another issue - not all hospital follow-up encounters qualify for a TCM. In the case above, where the provider might describe a single issue followed by another specialty, you'd only get a 99213 out of the visit unless it was based on time. Ideally, since the intent of these codes is to prevent re-hospitalization within 30 days, and they are intended to cover all issues relevant to the patient's safe return to the community, the A/P should include the Dx, status and Tx/Rx for the significant co-morbid or chronic conditions to make sure the bases are covered to promote a strong recovery. And you know that sometimes certain drug regimens are altered by hospitalists and need to be re-configured. The medication reconciliation is a required component of the TCM codes, and it must be documented. But you should also show those problems that are specifically addressed, considered, or assessed.

Some hospital follow ups just shouldn't be assigned a TCM. Healthy young adult spends a day or two in house, short course of something, goes home. Comes to see you a week or two later for f/u - nothing going on, resolved or stable, no other problems - it's a 99213.

Remember to:

  • Document the discharge date
  • Document the medication reconciliation
  • And always clearly document the medical decision-making that represents your work the day of the encounter

That covers most of what causes problems with these codes. I'm sure there are some minor variations or permutations of the above - but if they get all that right then you'll likely be at 95% correct on these.

The issue of 'do you qualify for' a TCM re the patient contact piece is much more of an operational issue, with many pitfalls, and isn't as much of a coding issue. We’ll leave that to a later time.

About the Author
Bill Dacey, MHA, MBA, CPC-I is principal in The Dacey Group, Inc., a consulting firm dedicated to coding, documentation and compliance concerns for physicians. Bill is an evaluation and management (E/M) coding expert and has been active in physician training for more than 25 years. He can be reached at billdacey@msn.com.
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