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E/M transitional care: Q&A on how to code it and get the payments in

Here is a bit of Q&A on the new E/M transitional care codes 99495 and 99496.

These codes cover care coordination during the 30 days after discharge from a hospital or skilled nursing facility, and they include communicating with the patient or caregiver, reviewing the medication, and coordinating the care with other providers and with community services. They also require a face-to-face visit with the patient.

This is the first time Medicare has paid for that type of service, and the codes pay about $230 for the level 1 service and $150 for level 2.

What date of service should the claim carry?

The 30-day period begins on the day of discharge and continues for the next 29 days. The date of service – and the date the office should report – is the 30th day.

What place of service should the claim show?

Both codes require a face-to-face visit, so the place of service is wherever that visit takes place.

The codes became effective January 1, 2013. Can they include services completed before that date?

No. The 30-day period has to begin no sooner than January 1. So the first payable date of service is January 30.

Can the service be provided in a federally qualified health center or rural health clinic?

Yes. The face-to-face visit can be a billable visit in an FQHC or RHC.

If the patient is readmitted during the 30-day period, can the transitional care codes still be used?

Yes, the 30-day period can include time following the second discharge. Or the doctor can bill instead for the entire 30-day period after the second discharge – but that’s only if no other provider bills for transitional care for the first discharge.

There can’t be any overlap. Within 30 days of discharge, the limit is one provider and one code per patient.

What if the patient dies before the 30 days are up?

The codes can’t be used. There has to be a full 30 days of service. If the patient dies, the doctor uses an E/M code for each service and face-to-face visit that took place during the period.

Medicare will pay only one provider for the care management. What happens if more than one provider bills for the service?

The first claim submitted is the one that gets paid. The other providers then have to bill for whatever other services, including E/M services, they have provided during the 30-day period.

During the 30 day period, can the office bill for other services, including E/M services, they have provided during the 30-day period.

During the 30 day period, can the office bill for other services?


The doctor-patient communication has to take place within two business days of discharge. Suppose discharge is Monday. Does it have to take place by close of business Tuesday or Wednesday?

By close of business Wednesday. It’s the second business day following the day of discharge. So Tuesday is the first business day, and Wednesday is the second business day.









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