Transitional Care Management Administrative Policy Update

Audience: Physicians, Dentists, Nurse Practitioners, Durable Medical Equipment Providers and Hospitals

Excellus BlueCross BlueShield advises you of an update to Administrative Policy 23, Transitional Care Management, effective January 15, 2023, regarding the payment review process.

Effective January 15, review will change from a post-payment to both pre-payment AND post-payment review for Commercial, Medicare Advantage and Special programs (Healthy NY and Essential Plan) lines of business. The policy defines the coverage and billing guidelines for transitional care services billed by providers contracted to provide this service, and aligns with Centers for Medicare & Medicaid Services, Current Procedural Terminology (CPT®), and Healthcare Common Procedure Coding System (HCPCS®) guidelines.

Administrative Policy 23 – Transitional Care Management (TCM):

• The Health Plan will reimburse code 99495 when billed with a face-to-face visit delivered within 14 days post-discharge.
• The Health Plan will reimburse code 99496 when billed with a face-to-face visit delivered within seven days post-discharge.
• The Health Plan will not reimburse TCM services if they are billed on the same date of service as a facility discharge service.
• The Health Plan will reimburse one TCM service delivered by one provider during the TCM service period despite any subsequent readmissions/discharges within the same TCM period.
• If a provider performs a 10- or 90-day global surgical service that results in a TCM post-discharge, the Health Plan will not reimburse the TCM service reported by that provider.
• The Health Plan will not reimburse the specific services if billed by the same physician or other qualified health care professional who reports codes 99495 or 99496 during the 30-day post-discharge period.

Pre-payment review means claims are reviewed prior to payment. A pre-payment review results in an initial determination. Post-payment review means that claims are reviewed after adjudication. A post-payment review may result in either no change to the initial determination or a revised determination.

This policy is a billing and reimbursement requirements and information policy. These services are subject to audit and policy updates at the discretion of Excellus BCBS. Members are held harmless for all denials resulting from this administrative policy.  You can access the individual policies here.

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