Transitional Care Management

 In Articles, Coding & Documentation

The American Medical Association added Transitional Care Management (TCM) Services (99495-99496) to the 2013 Current Procedural Terminology (CPT). The purpose of these codes is to provide payment to providers for transitioning the patient from the hospital, SNF, outpatient observation, or partial hospitalization discharge to their home, rest home or assisted living. The TCM codes should be used for established patients when the medical and/or physchosocial problems require moderate or high complexity medical decision making. The codes will largely be utilized by primary care providers but any provider who manages and coordinates care following hospitalizations can bill these codes.

99495 – Transitional Care Management Services with the following required elements:

  • Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge
  • Medical decision making of at least moderate complexity during the service period
  • Face to face visit within 14 calendar days of discharge

99496 – Transitional Care Management Services with the following requirements:

  • Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge
  • Medical decision making of high complexity during the service period
  • Face to face visit within 7 calendar days of discharge

Communication with the patient and/or caregiver regarding aspects of care, education to support self management, independent living, and activities of daily living, medication adherence and resource assistance can be made by the physician’s staff as long as the practitioner meets the “incident to” requirements as described in Chapter 15 Section 60 of the Benefit Policy Manual 100-02. The contact can be direct, via telephone or electronic and must be made within two business days of discharge. The short timeframe will require close coordination with the discharging provider.

The physician (or other qualified health care professional) is responsible for reviewing the discharge information, reviewing the need for or follow up on pending diagnostic tests/treatments, interaction with other health care professionals who will assume or reassume care of the patient’s problems, and education of patient, family, and/or caregiver as part of the non-face-to-face services. The first face-to-face visit is included in the TCM service, but additional E&M services after the first visit may be reported separately. The first face-to-face visit will be used to determine medical decision making and the appropriate TCM code.

The date of service on the claim should be the 30th day after the day of discharge. For example, if a patient was discharged on June 10, the TCM service period would be the next 29 days. The date of service on the claim should be July 10. The place of service should correspond to the place of service for the face-to-face visit.

If the patient is readmitted during the TCM period, the TCM services can still be submitted for reimbursement as long as the services for the code are provided by the practice during the 30-day period. However, the provider may wish to bill for TCM services after the second discharge. CPT guidance states that only one individual may report TCM services and only once per patient within 30 days of discharge. Another TCM may not be reported by the same practice for any subsequent discharges within 30 days.

The Medicare allowables for TCM as compared to the corresponding medical complexity office visits are provided below:

2013 Medicare Allowable (non-facility):

99495 – $156.16

99214 – $101.97       (53% increase over E&M alone)

99496 – $220.46

99215 – $136.60       (61.4% increase over E&M alone)

Keys to Success:

In order to appropriately document and bill for transitional care services, you will need to focus on three key areas:

1)    In order to make the initial contact with the patient within 2 business days, you must have timely notification that the patient has been discharged from the hospital.  Explore the following options:

  • Talk with the hospital physician relations department to determine how you can best access a list of your patients that have been admitted and/or discharged on a daily basis and assign a staff member to monitor this list.
  • Talk with your hospital about the process used to fax discharge summaries and explain the need for quick notifications.  Focus on how your work to monitor the patient post-discharge will decrease the likelihood of readmission.  Hospitals are now subject to reduced reimbursement based on their readmission rate.
  • Develop a workflow and train staff so that incoming faxes are reviewed and discharge summaries are flagged immediately for action by the clinical staff member who will make the initial phone contact.

2)    Create forms or templates to document the initial phone contact.  This should include the discharge date, reason for hospitalization, the date of two attempts to contact the patient within the two-day time frame, who you spoke with (patient, caregiver, etc.), patient’s current condition, any labs or tests needed prior to the follow-up visit, and the appointment date.

3)    Develop a tickler system to hold billing until 30 days past the discharge date.  Explore what functions exist in your EHR or PM system for developing a ‘future task’ work queue and train staff in its use if needed.  Be sure to include the patient’s hospital discharge date on the claim form.  CMS will hold the charge until they receive a hospital charge for this patient/discharge date.  If a hospital charge is not received for 28 days, they will deny the service.  It can be resubmitted as a standard office visit code if needed.  Note that existing processes to reconcile appointments or checked-in patients with charge entry may need to be adjusted to account for these held charges.

Once you have made the necessary adjustments to your processes and trained staff appropriately, you’ll likely find that you can improve patient loyalty and bring in additional revenue with minimal additional work.

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