Transitional Care Management (TCM) Services

Don't forget to utilize the current Transitional Care Management codes - CPT Codes 99495 and 99496. You may already be performing these services for your patients.

CMS provided an update in January through its Medicare Learning Network, which gives direction as to the necessary elements for using these codes.

Transitional Care Management codes provide reimbursement to support the extra effort needed to facilitate transition from a hospitalization or nursing facility stay back to the community. These services should be provided by the health care providers responsible for the patient’s ongoing care. The management period begins the day of discharge and continues for the next 29 days.

The requirement to qualify for these services begins with an inpatient hospital stay, in which the patient is discharged back to a community setting. The inpatient hospital settings include inpatient acute care hospital or psychiatric hospital, long-term care hospital, skilled nursing facility, inpatient rehabilitation facility, hospital outpatient observation or partial hospitalization. The community settings include home, domiciliary, rest home or assisted living.

These services can be provided by a physician of any specialty and non-physician practitioners such as certified nurse midwives, clinical nurse specialists, nurse practitioners or physician assistants.

There are 3 components required to be reimbursed for these services:

  1. Interactive contact
    You are required to reach out and make contact with the patient within two business days of discharge, or you can also qualify by making two good faith attempts to contact the patient in a timely manner. The interaction can be with the patient or caregiver via telephone, email or face-to-face communication.  During that contact you should address the patient's status, any needs and arrange for follow up care.
  2. Provide non-face-to-face services during the transitional care management period
    You must provide non-face-to-face services, furnished by the provider or clinical staff that you determine to be medically indicated or needed. These would include things such as reviewing discharge information, communicating with other providers, reestablishing or arranging community services, providing education, offering self-management options and supporting adherence to treatment and medication recommendations.
  3. Face-to-face visit within the proper amount of time from discharge
    You must complete a face-to-face encounter with the patient to evaluate the patient’s status and provide medication reconciliation and management within 14 calendar days from discharge. Eligible telehealth services can substitute for an in-person encounter (See MLN Fact Sheet ICN 901705 January 2019 for details of Medicare Telehealth service requirements for Medicare Fee-For-Service and Policy MP.065.PH – Telemedicine Policy for Premier Employee Health Plan coverage details).   

Finally, getting the proper reimbursement requires that you perform a face-to-face visit and document the complexity of medical decision making.  CPT code 99496 is used when the face-to-face visit is completed within seven calendar days and requires high complexity medical decision making. CPT code 99495 is used when the face-to-face visit occurs after day seven, but within 14 calendar days and requires only moderate complexity medical decision making. 

Once you establish a work flow to capture your patients transitioning to home, from the inpatient care setting you will find a significant opportunity to reduce the patient’s chance of readmission and improve their compliance with their treatment plan.

For more information on the transitional care management services, review the MLN Fact Sheet ICN 908628 January 2019.

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