Wisconsin
Provider Communications
Shared savings and transition care management after inpatient discharges
The goal is to ensure comprehensive physician follow-up and management of patients within seven and/or 14 days of discharge from hospital, skilled nursing facility (SNF), inpatient rehabilitation hospital (IRF), or long-term acute care hospitals (LTAC). And thus, to minimize clinical relapses, that often result in acute hospital readmissions, within 30-days of discharge.
CPT® codes for these visits are:
- 99496 (post-discharge comprehensive follow-up within seven days): pays between $250 to $350, depending on region, and;
- 99495 (post-discharge follow-up within 14 days): pays between $190 to $260, depending on region.
The primary intent for these visits is close post-discharge patient follow up with comprehensive physician/provider management of ongoing chronic comorbidities. So, visits should include:
- Review of the discharge information
- Medication reconciliation
- Treatment of acute exacerbations and/or fluctuations in the physician office as appropriate
- Active management of and attention to chronic renal, lung, cardiac, skeletal, social, caregiver, etc. conditions, and providers should:
- Review the need for pending diagnostics, and/or follow up of said diagnostics.
- Interact with other healthcare professionals who may assume care of any system-specific problems.
- Educate the patient, family, and caregiver.
- Establish referrals, arrange needed community resources, address/assist/advise the member/family with relevant caregiver needs.
- Help schedule required community providers and services follow-up.
- Comprehensively and holistically manage common chronic/acute medical conditions seen after hospital discharge, such as (but not limited to): Heart failure, COPD, DM, AFIB, DVT, cellulitis, pneumonia, dehydration, AMS, encephalopathy, AKI, polypharmacy/medication reconciliation, and even custodial/social needs impacting/resulting in admission(s).
CMS encourages TCM for Medicare members. CMS has detailed fact sheets explaining the program, and billing, see resources below:
- https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/transitional-care-management-services-fact-sheet-icn908628.pdf
- https://edit.cms.gov/files/document/billing-faqs-transitional-care-management-2016.pdf
Appendix
CPT 99496 coding requirements:
- Attestation that the initial communication between patient/practitioner began within two business days of discharge:
- Geared to patients with conditions requiring medium or high-level decision-making
- Direct contact: telephone/electronic
- Face-to-face visit within seven days of DC. Cannot be virtual
- Clinician-patient visit can be done by physician, PA, or nurse practitioner, or other practitioners as authorized by state law
- Includes DC from hospitals, SNFs, IRFs, and LTACs
- Includes time spent coordinating patient services for specific medical care or psychosocial needs and guiding them through activities of daily living
CPT 99495 coding requirements:
- Attestation that the initial communication between patient/practitioner began within two business days of DC:
- Geared to patients with conditions requiring at least moderate complexity decision-making
- Direct contact: telephone/electronic
- Face-to-face visit within 14 days of discharge. Cannot be virtual
- Clinician-patient visit can be done by physician, PA, or nurse practitioner, or other practitioners as authorized by state law
- Includes DC from hospitals, SNFs, IRFs, and LTACs
- Includes time spent coordinating patient services for specific medical care or psychosocial needs and guiding them through activities of daily living
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March 2023 Anthem Provider News - Wisconsin