In the 2020 Physician Fee Schedule (PFS) Final Rule , CMS emphasized the importance of increasing utilization of Transitional Care Management (TCM) services for Medicare beneficiaries. TCM is a service that provides care management to patients who are discharging from an acute care stay to their home or residence. TCM services include telephonic support from care teams and face-to-face follow-up visits with outpatient providers, as well as ongoing care coordination for 30 days post-discharge. Patients who receive TCM services have shown to experience lower readmissions, lower mortality, and lower health care costs. However, despite the service being available since 2013, utilization remains low.

With the 2020 PFS, CMS sought ways to increase utilization of these services to positively impact patient outcomes and made two significant changes to decrease barriers to use: (1) they increased physician payments for those who provide the service to patients, and (2) they removed administrative barriers to utilization.; CMS has now approved TCM services to be billed in the same month as 14 other services that were previously not allowed. The list of services was published in Table 20 of the PFS.

A notable omission from the list in Table 20 are care management codes for ’non-complex’ Chronic Care Management (CCM, 99490) and Provider-Only CCM (99491), as well as General Care Management (G0511) specific to use in Rural Health Clinics (RHC) and Federally Qualified Health Centers (FQHC). Later in the Final Rule, CMS included 99490 and 99491 in the list of approved services to be billed in the same month as TCM. However, the omission of General Care Management remained confusing. Patients who receive care from RHCs and FQHCs often have lower access to healthcare services and benefit greatly from TCM and other forms of care management.  The omission seemed to directly oppose the expressed intent of the 2020 PFS, to increase TCM utilization by allowing the service to be billed in the same month as other care management services.

The National Correct Coding Initiative (NCCI) is updated quarterly to define the way codes may be combined and billed together on CMS claims. In the most recently updated NCCI edits, effective April 1, 2020, CMS provides guidance that G0511 may be billed with Transitional Care Management (99495, 99496). The effective date of this change is back dated to January 1, 2020. Medicare Administrative Contractors (MAC) have been instructed to approve claims that were previously denied when the codes were billed in the same month.

TCM and Care Management are valuable services for all Medicare beneficiaries and especially for those who reside in underserved areas. We are pleased to see that CMS has taken action to support patients in FFS, RHC, and FQHC settings to receive and benefit from these services.

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