Description
Medicare may cover transitional care services during the 30-day period that begins when a physician discharges a Medicare patient from a healthcare facility and continues for the next 29 days. Only one of the Transitional Care Management (TCM) service CPT codes (99495 or 99496) may be billed once during the transitional care period, and TCM services may be reported by only one physician or non-physician practitioner (NPP)
Affected Code(s)
99495, 99496
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3. 42 CFR §405.929- Post-Payment Review
4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
5. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6. 42 CFR §405.986- Good Cause for Reopening
7. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
8. Federal Register / Vol. 77, No. 222 / Friday, November 16, 2012 / Rules and Regulations, PFS proposed rule (76 FR 42917 through 42920) https://www.federalregister.gov/d/2012-26900/p-1175
9. American Medical Association Current Procedural Terminology (CPT) Codebook