Establishing ‘contact’ under transitional care management codes

Q:I know that the contact for use of Transitional Care Management (TCM) codes needs to be made by a clinical person, but do they have to make the first call / speak to the patient first?

A: There are lots of questions about this part of the TCM code services. People seem to get hung up in a lot of details that were certainly never specified in either the CPT manual description of the codes or in the even more detailed original Federal Register description of all that went into coming up with TCM services by Medicare.

There are lots of ways that these “contacts” and encounters unfold, not all of them foreseen by Medicare or other payers. But in the end, it all leads to patients getting the kind of prompt attention and hospital follow-up that the codes were intended to produce more of. And don’t forget the big picture: that hospital re-admission rates go down.

The “interactive contact” does have to be made by “clinical staff,” but it doesn’t describe any of the circumstances as to how that arises. Often, when outreach staff attempts to reach a patient-and gets a recording and leaves a message-when the patient calls back they get the front desk or clerical staff. It’s hard to get them back to the nursing loop. Has the contact been made?

Some providers find out that their patients are discharged from the hospital, text their MAs with instructions to call the patients as soon as possible to answer questions and set up the appointment. That works when the calls are made on time. The point is that there are lots of ways to get there relative to the contact, even to the point of leaving the message.

And remember, although attempts to have this interaction should continue per Medicare guidance, the contact itself is not an absolute requirement to billing the service. You need to document the attempts and/or the contact. The core service is the face-to-face visit furnished within the timeframe required by the code. Stop sweating the details that are not spelled out anywhere and settle on a course that works for most of your patients.

Q: Are there specific diagnosis codes that are required for the advanced care planning (ACP) codes?

A: No; per Medicare anyway there are not. The guidance that Medicare puts out on the subject says, “No specific diagnosis is required for the ACP codes to be billed. It would be appropriate to report a condition for which you are counseling the beneficiary, an ICD-10-CM code to reflect an administrative examination, or a well exam diagnosis when furnished as part of the Medicare Annual Wellness Visit.”

Sounds good and quite reasonable. Then you look at some of the denials for the ACP codes, and they make sense too. Recently, we saw a trigger finger diagnosis linked to the ACP code. It was denied. Like any other service, ACP is subject to medical necessity criteria, and if a diagnosis that would make sense is reported in conjunction with ACP, it will likely be paid.

Once again, watch your CPT and ICD-10 relationship. What story are you telling?

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Email him your questions at billdacey@msn.com.