Can You Bill an E&M With Transitional Care Management?
Navigate the complexities of combining physician encounters with post-discharge care services for accurate medical billing and compliance.
Healthcare providers often encounter questions regarding the appropriate coding and reimbursement for patient services. A common inquiry arises when considering Evaluation and Management (E&M) services alongside Transitional Care Management (TCM) services. Understanding whether these two distinct service types can be billed concurrently is crucial for accurate financial compliance and proper reimbursement. This ensures that providers are appropriately compensated for the care delivered.
Understanding Evaluation and Management Services
Evaluation and Management (E&M) services are a core category in medical billing, covering clinical activities performed by healthcare professionals during patient encounters. These services involve assessing a patient’s health status and developing a plan for their care. They are based on the complexity of the patient’s history, the thoroughness of the physical examination, and the intricacy of medical decision-making.
E&M codes, which are part of Current Procedural Terminology (CPT), report specific services provided during visits. They are essential for providers to receive payment for their expertise, time, and resources. These services are routinely provided in various settings, including office visits, hospital visits, and emergency department encounters. The selection of the correct E&M code depends on factors such as the type and complexity of the service, reflecting the effort required to manage the patient’s condition.
Understanding Transitional Care Management Services
Transitional Care Management (TCM) services support patients transitioning from an inpatient hospital setting back into their community. This 30-day period following discharge aims to prevent readmissions and improve patient outcomes. TCM involves a coordinated approach to care that addresses the patient’s medical and psychosocial needs during this transition.
Key components of TCM services include interactive communication with the patient or caregiver within two business days of discharge, which can be via telephone, email, or direct contact. A face-to-face visit with the healthcare provider is also required within a specific timeframe, either seven or fourteen days post-discharge, depending on the complexity of the patient’s medical decision-making. Additionally, medication reconciliation and management must be completed no later than the date of the face-to-face visit to ensure patient safety and continuity of care. Two CPT codes, 99495 and 99496, are used to report TCM services, with the choice depending on the medical complexity and the required timeframe for the face-to-face visit.
Billing Rules for E&M and TCM Concurrently
The billing of Evaluation and Management (E&M) services concurrently with Transitional Care Management (TCM) services requires careful adherence to specific guidelines to avoid claim denials. The face-to-face visit, a required component of the TCM service, is integral to the TCM code and cannot be billed separately as an E&M service. The work for this initial follow-up visit is encompassed within TCM reimbursement.
However, medically necessary E&M services that are distinct from the work inherent in the TCM service can be billed separately during the 30-day TCM period. This applies if the E&M service addresses a new or unrelated problem arising during the transitional care period, or if it occurs on a different day than the required TCM face-to-face visit. For instance, if a patient receiving TCM develops an acute, unrelated condition requiring an urgent office visit, that E&M service may be separately billable. The E&M must be for a service beyond the scope of the transitional care coordination already being provided.
When billing a separate E&M service on the same day as another service, such as a TCM-related activity, Modifier 25 is appended to the E&M code. This modifier signifies that the E&M service was significant and separately identifiable from the other service performed. The E&M service must demonstrate a clear medical necessity independent of the transitional care management. It is important that documentation clearly supports the distinct nature of the E&M service to justify its separate billing.
Only one healthcare professional can report TCM services for a patient during the 30-day period. If a surgeon provides care within a global surgical period, they cannot bill for TCM as those services are part of the global package. This ensures healthcare services are not duplicated and reimbursement aligns with the specific care provided, preventing unbundling or inappropriate billing.
Essential Documentation for Concurrent Billing
Accurate and comprehensive documentation is essential when billing Evaluation and Management (E&M) services alongside Transitional Care Management (TCM) services. The medical record must clearly differentiate between the two services, providing explicit evidence that any separately billed E&M service addresses a distinct and separately identifiable medical necessity. This detailed record keeping supports the legitimacy of concurrent billing and helps avoid compliance issues.
For the E&M service, documentation should include a clear chief complaint, a relevant history of the present illness, findings from the physical examination, and the medical decision-making related to the specific, distinct issue being addressed. This ensures that the E&M service stands alone as a medically necessary encounter. The notes must demonstrate that the work performed for the E&M was separate from the care coordination inherent to the TCM.
Similarly, thorough documentation is required for the TCM service to substantiate its components. This includes recording the date of patient discharge, evidence of the interactive communication with the patient or caregiver within two business days, and the date of the required face-to-face visit within the specified timeframe. Detailed notes on medication reconciliation and management, along with the overall care coordination activities, must also be present. The documentation must collectively justify the use of any modifiers applied to E&M codes and support the medical necessity of both the TCM and any separately billed E&M services.