In recent years, the use of care management services to provide better patient outcomes has gained momentum. Contributing to this momentum is a desire to generate greater transparency around patient behaviors in Post-Acute Care settings. This setting was the first focus area for the creation of care management services.
Over the last decade, several modalities of care management services have been established for payment by the Centers for Medicaid and Medicare (CMS), but uptake among all has been lower than expected. In response, CMS has issued recent legislation changes aimed at encouraging higher levels of provider participation.
Transitional Care Management (TCM) is a small but priority subset of managed care that focuses strictly on the 30-day period immediately following Post-Acute Care discharge. CMS’s recent ruling greatly impacted this area of managed care.
Based on provider feedback, billing codes for TCM have been significantly overhauled to remove codes previously restricted as duplicative codes and to improve RVU for certain services.
Here we review the establishment of managed care services, the defining rules of post-acute managed care, as well as the updates to payment methods set forth by CMS’s ruling for 2020.
Transitional Care Management was the first care management service to be set forth by CMS rules in 2013. It was followed by the establishment of Chronic Care Management, Remote Patient Monitoring, and Principal Care Management, the most recent service added January 2020. A succinct timeline of the service offerings is provided below:
Upon release of CPT Codes 99495 (Moderate Medical Decision Making) and 99496 (High Complexity Medical Decision Making) in 2013, CMS set forth general guidelines for what constitutes TCM.
Regardless of complexity, an unequivocal requirement is that Interactive Contact be made within two business days of discharge. All unsuccessful attempts to make contact must be documented. The other guidelines are summarized below by the professional providing the care in a non-face-to-face setting:
Practitioner:
Clinical Staff (under General Supervision):
While the above can be conducted via remote communications, each of the two codes require face to face encounter, the timing of which depends on the level of complexity.
99495 Moderate Complexity
This code requires contact within two business days of discharge and documentation of all unsuccessful attempts, and additionally:
99496 High Complexity
This code requires contact within two business days of discharge and documentation of all unsuccessful attempts, and additionally:
Upon executing the MPFS 2020 Final Rule, CMS set forth changes across the entire spectrum of care management to address provider feedback around low uptake. The following core changes concerning TCM were effective as of 1/1/2020.
Lifting of Restrictions on Duplicative Billing Codes
CMS has removed 14 Codes previously deemed as non-concurrently billable with Codes 99495 and 99496.
At the outset of TCM in the 2013 MPFS Final Rule, 57 CPT/HCPCS codes were written into regulation as having significant “overlap” with TCM services and thus were not allowed to be billed alongside TCM.
Upon inputs from provider commentary and review with the AMA’s Chronic Care Coordination (C3W) Workgroup, 14 of those original 57 codes were carved out of the billing restrictions effective 1/1/2020. The codes which are now allowed to be billed alongside TCM are the following:
Increase in Work RVU for 99495 and 99496
Provider commentary has pointed repeatedly to the low valuation of the TCM Codes as a reason for lower than expected uptake. In the MPFS 2020 Final Rule, CMS addressed these concerns by increasing the Work RVUs for each of the two codes. Assuming a Geographic Practice Cost Index of 1.00, the following are the monthly reimbursement rates effective 1/1/2020:
There are a few additional key criteria to know in order to successfully bill for TCM: