The information provided here applies to Medicare coding. Be sure to check with your Medicare Administrative Contractor (MAC) for additional information and clarification on these and other items. You should also contact your local insurance carriers to determine if private insurers follow Medicare's lead on all coding matters.
Transitional Care Management
Transitional Care Management (TCM) is a great opportunity for internal medicine physicians to receive reimbursement for services they are already providing. The Centers for Medicare and Medicaid Services (CMS) has allowed codes 99496 and 99495 since 2013 and has continued to do some tinkering with the details. In March of this year, CMS released a new set of Frequently Asked Questions (https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/FAQ-TCMS.pdf) and a new Medicare Learning Network (MLN) brochure (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Transitional-Care-Management-Services-Fact-Sheet-ICN908628.pdf) addressing TCM. Although CMS stated these materials clarified existing policy, there was one glaring omission that has my email inbox filled with questions on TCM.
The new MLN article addresses the interactive contact that your office must have with the patient within two business days of discharge to the community setting. In this section, there is no indication that this contact must be made by licensed clinical staff, which we have seen in the past. The next section titled, “Certain Non-Face-to-Face Services” indicates services “may be” furnished by “licensed clinical staff” under your supervision. The requirement that it be done within two business days of discharge is omitted. As a result, the question I am being inundated with is can non-licensed staff members perform this service?
This would be a significant change from the original release of requirements, and for some offices that do not have licensed clinical staff, it would allow them to bill for TCM services. The requirement that clinical staff conduct that initial contact had precluded them from billing the TCM codes. The best information that we have received from CMS is that they did not intend to make a change in the requirement for clinical staff to make the initial contact. But this clarification of the clarification has not yet been seen in writing.
So my best advice to you is that only clinical staff may make this initial contact. Remember, not all medical assistants are created equal. Check before you use your medical assistants to make the initial contact calls. Some states require licensure, while others require only certification or registration. Those terms are not interchangeable. Clinical staff for CMS means a licensed individual and nothing less. This information was in the final rule for 2013 services. Nothing has been formally released to indicate differently.