How to get paid for care coordination

Medicare now covers codes 99495 and 99496 for transitional care
Tools

Thanks to a series of new codes created by the American Medical Association's CPT Editorial Panel, physicians now have the opportunity to bill for much of the previously unreimbursed care-coordination work they've done.

A year ago, the AMA called on the Centers for Medicare & Medicaid Services to adopt and pay for care-coordination codes to "support physicians participating in emerging models of care, such as patient-centered medical homes, accountable care organizations and other novel integrated delivery systems," noted an AMA press release.

Practices do not have to transition to a medical home or ACO to use the codes, however. According to American Medical News, Medicare estimates it will pay $600 million to practices handling patients' transitions from hospitals or skilled nursing facilities in 2013. Eventually, Medicare expects to add funds for reimbursing complex care coordination. Meanwhile, commercial insurers will likely determine whether and how they will accept such codes in the near future.

The new Current Procedural Terminology codes for care coordination include the following:

  • 99495: A physician must have and document some kind of medical discussion with a patient or caregiver, not necessarily in person, about care transitions within two days of discharge from a facility. An additional face-to-face visit must take place within two weeks.
  • 99496: A physician must have and document some kind of medical discussion with a patient or caregiver, not necessarily in person, about care transitions within two days of discharge from a facility. An additional face-to-face visit must take place within one week.
  • 99487: To be used if a nonphysician staff member spends more than an hour over a 30-day period on care coordination involving the patient.
  • 99488: Includes an hour of care coordination time with a nonphysican and a face-to-face visit.
  • 99489: To be used for 30-minute increments over the initial hour of care coordination.

Medicare considers the latter three codes as bundled with other services, but commercial payers may cover them, amednews reported.

The key to managing the new codes, according to coding professionals, is finding a method to track and document the time practices spend on care coordination.

"Because it's accumulated time over a month, it can be much harder to track," Raemarie Jimenez, director of education with the American Academy of Professional Coders, told amednews.

To learn more:
- see the statement from the AMA
- read the article from American Medical News

Related Articles:
WellPoint-owned clinics can help reduce hospital readmissions
Follow-up service helps patients and hospitals
ACOs cover 10% of Americans, report shows
Maintain a master grid of CPT rules by payer

Filed Under