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    Unlisted diagnosis codes could lead to denials


    It’s important that the physician direct the nurses with medication refills, coordination of community services that the patient may need (prior to and after the visit), and any education that the patient might need.

    Example:  A patient was admitted to the hospital for vertigo. He went through a series of tests that ruled out any cardiac, respiratory or neurologic issues, so he was discharged with the diagnosis of vertigo that is stable. The patient is instructed to follow-up with his primary care physician.  

    Should this patient be considered for TCM services? 

    There are a few things to take into consideration.

    •   The physician/NPP should make this determination, not a licensed practical nurse (LPN).
    •   What qualifies a patient for TCM services is the fact that he/she was in the hospital. So the hospital diagnosis needs to be taken into account when determining if the patient should receive TCM services.  
    •   TCM services follow the evaluation and management (E/M) guidelines for determining medical decision making (MDM). While the level of MDM for the code level billed is determined at the face-to-face visit, MDM needs to also be taken into account when determining whether or not the patient is TCM-eligible. In the example, the patient wouldn’t meet the minimum requirement of moderate MDM, and therefore should not be considered for TCM services. 
    •   If your network has an auditing protocol in place, the E/M guidelines are routinely taught to physicians. So the physician can determine the possible level of MDM and direct the LPN whether the patient should be scheduled for an appointment within seven or 14 days. 


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