Effective Date: March 1, 2020

Purpose:
This policy provides guidelines for reimbursement and appropriate billing of transitional care planning.

Scope:
Products included:

• NJ FamilyCare/Medicaid Plan
• Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP)

Definitions:

• CPT Code 99495: Transitional Care Management Services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge Medical decision making of at least moderate complexity during the service period Face-to-face visit, within 14 calendar days of discharge
• CPT Code 99496: Transitional Care Management Services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge Medical decision making of high complexity during the service period Face-to-face visit, within 7 calendar days of discharge

Policy:
Transitional care planning services are for an established patient whose medical and/or psychosocial problems require moderate or high complexity medical decision making during transitions in care from an inpatient hospital setting (including acute hospital, rehabilitation hospital, long-term acute care hospital), partial hospital, observation status in a hospital, or skilled nursing facility/nursing facility, to the patient’s community setting (home, domiciliary, rest home, or assisted living).

Transitional care management (TCM) planning is comprised of one (1) face-to-face visit within the specified timeframes, in combination with non- face-to-face services that may be performed by the physician or other qualified health care professional and/or licensed clinical staff under his/her direction. The thirty (30) day transitional care management service period begins on the member’s inpatient discharge date and continues for the next twenty nine (29) days.

At a minimum, the following is required to document in the member’s medical record:

• Member discharge date
• Member/Care Giver interactive contact date
• Face-to-face visit date
• Medical complexity decision making (moderate or high)

Note: You may furnish CPT codes 99495 and 99496 via telehealth

Components of Transitional Care Management:

1. Interactive Contact: Within 2 business days following the member’s discharge, you must make an interactive contact with them and/or their caregiver via telephone, email, or face-to-face. Report the service if you make two or more unsuccessful separate attempts in a timely manner. Document your attempts in the medical record if you meet all other TCM criteria.

2. Certain Non- Face-to-Face Services: You must furnish non-face-to-face services to the member, unless you determine they are not medically indicated or needed. Clinical staff under your direction may provide certain non-face-to-face services.

3. Face-to-Face Visit: You must furnish one face-to-face visit within certain timeframes described by CPT codes 99495 or 99496. The face-to-face visit within the seventh or 14th day, depending on the code being billed, is done by the physician; however, it can be done by licensed clinical staff under the direction of the physician. The face-to-face visit must include:

• Communication with outside agencies and services patient can use
• Education must be provided to patient to support self-management and help get back to activities of daily living
• Assess and support treatment regimen and identify any available community resources the patient can be involved in, and
• Assist patient and family in accessing care and service that might be needed

Note: If during the month, the patient is seen more than once for a follow-up visit, any other visit made during the 30 days can be billed separately using an Evaluation and Management (E/M) code.

Procedure:
Horizon NJ Health shall reimburse physicians and non-physician practitioners for transactional care planning codes (CPT codes 99495 and 99496) once per member per the thirty (30) days following discharge. The date of service and place of service you report on your claim should be the date and place of service of the required face-to-face visit. If the required three (3) components of TCM outlined above are not met, the service shall be denied. In addition, if the level of medical decision making is not met within the documentation, the service shall be denied.

Note: Only one (1) health care professional may report TCM services.

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

• Benefit Limitations
• The terms of any applicable provider participation agreement;
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
• Medical necessity; and
• Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.

References:
CMS MLN Fact sheet, Transitional Care Management Services, January 2019
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Transitional-Care-Management-Services-Fact-Sheet-ICN908628.pdf

CMS Frequently Asked Questions about Billing the Medicare Physician Fee Schedule for Transitional Care Management Services, March 17, 2016
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/FAQ-TCMS.pdf

American Medical Association, Current Procedural Terminology (CPT®) Professional Edition and associated publications and services