Recently Retired Codes; TCM Inappropriate and Appropriate

May 30, 2013

Coding questions? We've got the answers.

Recently Retired Codes

Q: I have been told not to use G8447 and G8448, the codes that reference the use of an EHR. What should I use in their place?

A: These codes have been retired and there are no replacement codes. You will need to select a new measure to report for 2013.

TCM Inappropriate

Q: Can the new transitional care management (TCM) codes be used for follow up after a patient is seen in the ER?

A: No, these codes are for use after transitioning from an inpatient setting.

TCM Appropriate

Q: I have been reading about the new requirements for the TCM  services. In terms of documentation for these, have you seen any guidelines from Medicare specifically for the communication within two business days requirement? In other words, who can do it, what questions have to be asked, and can requirements be met by simply arranging an in-office follow-up?

A: Good question. Regarding who can do it, the contact can be made by someone other than the physician, but it does need to be a clinical person, not just someone making an appointment. Regarding the questions to ask and how to meet the requirements, you need to:

• Establish how the patient is doing;

• Review the need for, or follow up on pending diagnostic tests and treatments;

• Educate the patient, family, guardian, or caregiver;

• Establish or reestablish referrals and arrange for needed community resources; and

• Assist in scheduling any required follow-up care with community providers and services.

While the physician doesn't personally need to perform all these tasks, he does need to oversee them.

Level 5 Encounter

Q: I make every attempt to look at all of my patients' radiographic images personally, if available to me. I also review my patients' referring providers' outside records. If I document this information correctly, I realize that I will be getting four data points routinely, and I also know I will be getting at least four diagnosis points due to new problems with more work-up required.

As a neurologist, I do comprehensive histories and comprehensive exams. I have been taught by my mentors that anything less is not a complete exam. Can I go ahead and routinely bill a level 5 encounter if I have accumulated all of those points on that cognitive labor?

A: If you indeed do a comprehensive history and exam on all your new patients, and you do the record review and image exam on every one, then you are nearly at a level 5. To meet the threshold, you need either a new problem (a nearly guaranteed new problem) with further work-up planned (not guaranteed), or you need documentation of a problem or problems of high risk/high complexity.

Neurologists often make the case that most of their issues are high risk/high complexity, but that's not always true. The problem is that you have built a substantial amount of supporting documentation, but it also has to support a problem of high complexity/high severity, or it has to support the documentation of the risk of such a problem.

Remember that Medicare is adamant that, "The overarching criterion for all payments made under the Social Security System is medical necessity." Your standard and thorough approach is true to your training, and perhaps necessary, but must be considered in the light of each presentation.

The elements you cite are all the technical elements. In order to truly have a level 5 new visit, further work-up must be justifiable, and more importantly, the morbidity/mortality of the problem or the differential must be documented as high.

The latest profile data for neurology shows 40 percent 99205 on new patients and 16 percent 99215 on established patients. These may be undercoded, but I can assure you that a 100 percent 99205 rate would garner some attention that you don't want, and a technical win on the coding tables may not prevail in a medical necessity determination.

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. He can be reached at or

This article originally appeared in the June 2013 issue of Physicians Practice.