Description
A physician or other qualified health care professional who reports Transitional Care Management CPT code 99495 or 99496 may not report telephone Service CPT codes (99441-99443) for the same beneficiary during the timeframe covered by the transitional care management service CPT codes. This is the Unbundling of services, and payments will be recouped.
Affected Code(s)
99441, 99442, 99443
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3. 42 CFR §405.929- Post-Payment Review
4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
5. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6. 42 CFR §405.986- Good Cause for Reopening
7. Medicare Claims Processing Manual, Chapter 12 - §30.A – Correct Coding Policy, Coding Based on Standards of Medical/Surgical Practice
8. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
9. Federal Register / Vol. 77, No. 222 / Friday, November 16, 2012 / Rules and Regulations, PFS proposed rule (76 FR 42917 through 42920) https://www.federalregister.gov/d/2012-26900/p-1176
10. AMA CPT Codebook