Payment

Below, you'll find post-acute and long-term care (PALTC) coding information as well as how the Medicare Physician Fee Schedule will affect PALTC providers.

AMDA Resources

New Transitional Care Management Codes

Prolonged Service Codes (99356-99357)
Threshold Times for Prolonged Service Codes

  • Ask the Expert: Do you have a question about post-acute and long-term care? Your question will be forwarded to an AMDA leader or staff person who has the expertise necessary to answer your question. A response to your question will be e-mailed directly to you. This feature is intended solely for use by AMDA members to confer with colleagues and AMDA staff; it is not intended to dispense medical advice to consumers. Consumers who have medical or health-related questions are urged to consult their physicians.
  • AMDA's Guide to Post-Acute and Long Term Care Coding, Reimbursement and Documentation
  • Centers for Medicare & Medicaid Services and Joint Commission Requirement for Physician Visits
  • Centers for Medicare & Medicaid Services (CMS) Resources
  • CMS’ Medicare Claims Processing Manual - CMS’ Medicare Claims Processing Manual Chapter 12 provides claims processing instructions for physician and non-physician practitioners. The manual includes nursing facility service codes (99304-99318), home and domiciliary care (99324-9935), and prolonged service codes (99354-99360).
  • CMS’ Evaluation & Management Services Guide (updated July 2008) - This guide provides a more detailed description of evaluation & management codes including details on the three key elements of service – history, examination, and medical decision making.
  • CMS Transmittal 808/Change Request 4246/Updated Processing Manual - This transmittal revises the Claims Processing Manual, Pub. 100-04, Chapter 12, §30.6.13 with the new code changes by the American Medical Association Current Procedural Terminology (CPT) 2006 for reporting evaluation and management visits in the skilled nursing facility (SNF) or nursing facility (NF) settings (codes 99304 - 99306 for the initial visit; codes 99307 - 99310 for subsequent nursing facility visits and code 99318 for an annual assessment visit) and who may use these codes. This transmittal identifies the federally mandated visits per the Long Term Care regulations and also clarifies the "initial visit" definition, medically necessary visits, "incident to" services, prolonged services, split/shared evaluation and management services, gang visits, and discharge day management in the SNF and NF settings.
  • Medicare & Medicaid Program Memos and Transmittals - Program transmittals are used to communicate new or changed policies, and/or procedures that are being incorporated into a specific (CMS) program manual.
  • CMS Local Coverage Determinations - click here to search for local coverage determinations made by your local contractors.
  • Frequently Asked Questions about billing for transitional care management (TCM) services. These FAQs are designed to address questions CMS received about billing of the TCM codes such as what date of service should be used on the claim and what place of service.
  • The TCM codes (99495 and 99496) became effective January 1, 2013 and can be used to report physician or qualifying nonphysician practitioners care management services for a patient following a discharge from a hospital, SNF, or CMHC stay, outpatient observations, or partial hospitalization.
  • CMS also previously issued a fact sheet to provide further education on the TCM services.
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    Additional Information

     

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    Prolonged Service Codes (99356-99357)
    Threshold Times for Prolonged Service Codes

     

     

     

    Code Typical Time
    for Code    		 Threshold Time
    to Bill Code 99356    		 Threshold Time to Bill
    Codes 99356 & 99357
    99305 35 65 110
    99306 45 75 120
    99307 10 65 85
    99308 15 45 90
    99309 25 55 100
    99310 35 65 110
    99318 30 60 105

     

     

     

    • Change Request 5972 - This transmittal updates Chapter 12, §§30.6.15.1 and 30.6.15.2 and provides guidance on the proper use of prolonged service codes.
    • CMS’ MedLearn Matters MM5972 – This article provides additional clarifications and information on the proper use of prolonged service codes.CMS’ Medicare Learning Network - This provides additional clarification and information on the proper use of prolonged service codes.

     

     

     

    NCCI Edits Issued

     

     

     

    The Centers for Medicare & Medicaid Services (CMS) updates annually its National Correct Coding Initiative (NCCI) Coding Policy Manual for Medicare Services (Coding Policy Manual). The Coding Policy Manual is available on CMS’ NCCI Website and should be utilized by carriers and fiscal intermediaries as a general reference tool that explains the rationale for NCCI edits. The purpose of the NCCI edits is to prevent improper payment when incorrect code combinations are reported. The NCCI contains two tables of edits. The Column One/Column Two Correct Coding Edits table and the Mutually Exclusive Edits table include code pairs that should not be reported together for a number of reasons explained in the Coding Policy Manual.

     

     

     

    CPT codes, descriptions, and material only are Copyright © 2016 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.