American College of Physicians: Internal Medicine — Doctors for Adults ®


Transitional care management services change in 2013

From the January ACP Internist, copyright 2013 by the American College of Physicians

By Debra Lansey

The 2013 Medicare physician fee schedule rule changes increase payments to internists by 4% to 5% over last year, an estimated total payment of more than $11 billion. The bulk of this increase (3%) comes from the new transitional care management codes.

Non-face-to-face transitional care management services are now being covered and reimbursed in certain circumstances. New Current Procedural Terminology (CPT) codes allow physicians to report their transitional care management services, including the non-face-to-face time they and their clinical staff spend on patient cases. Prior to Jan. 1, only the face-to-face portion of care was considered for reimbursement. (See this chart to compare differences in transition management codes between CPT coding and Medicare coding.)

Transitional care management services change in 2013

Several codes were under consideration for the 2013 Medicare fee schedule. Two of the codes, CPT codes 99495 and 99496, appear in the 2013 CPT book. These were described in detail in the November/December 2012 ACP Internist.

ACP and other specialty societies had long advocated this coding and payment enhancement. The result is a revolutionary acceptance of the continuum of care that exists for patients who were recently discharged from inpatient facilities. Adding these services to the Medicare fee schedule is a critical move forward in the reimbursement of the cognitive services provided in primary care.

The 2013 fee schedule relative values for the new codes are:

  • 99495, transitional care management services with face-to-face visit within 14 days of discharge: 2.11 work Relative Value Units (RVUs)
  • 99496, transitional care management services with face-to-face visit within 7 days of discharge: 3.05 work RVUs

In the final rule, CMS adopted the CPT codes but implemented some modifications for use in the Medicare program. This means that physicians may have two sets of coding rules for the transition care management codes: the CPT rules and the CMS rules.

CMS officials believe that the adopted CPT transitional care management codes are defined broadly enough to incorporate treatment of chronic conditions, such as Alzheimer’s disease, diabetes and HIV, and the planning services involved in cancer survival after discharge.

However, CMS will consider adoption of the complex care coordination codes (99487-99489) developed by the CPT Editorial Board as it continues to explore payment for primary care services in future rulemaking. ACP will continue to advocate for coverage of these important services and will inform its members of any changes to related Medicare or other payer policies.


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