Identify patients based on follow-up care model
Identify available community and health resources
Obtain and review discharge information with patient and/ or caregiver
Communicate with the patient or caregiver (by phone, e-mail, or in person)
Communicate with a home health agency or other community service that the patient needs
Educate the patient and/or caregiver to support self-management and activities of daily living
Provide assessment and support for treatment adherence and medication management
Educate the patient and/or caregiver
Facilitate access to services needed by the patient and/or caregivers
Review need of or follow-up on pending testing or treatment
Interact with other clinicians who will assume or resume care of the patient’s system-specific conditions
Establish or re-establish referrals for specialized care
Assist in scheduling follow-up with other health services
In order to bill for Transitional Care Management TCM a Qualified Professional (“QP”) is a physician, physician assistant, nurse practitioner, clinical nurse specialist or certified nurse midwife. TCM is billed under two separate Transition Care Management CPT codes – 99495 and 99496 – which will be explained below. TCM begins on the day of discharge and continues for 29 days after. The two Transitional Care Management reimbursement codes will be used to pay for all non-face-to-face time services that historically have not been reimbursed.
CPT Code 99495
Transitional Care Management CPT Code 99495 covers communication with the patient or caregiver within two business days of discharge. This can be done by telephonically, e-mail, or face-to-face. It involves medical decision making of at least moderate complexity and a face-to-face visit with a provider within 14 days of discharge. The location of the visit is not specified. The work RVU is 2.11.
CPT Code 99496
Transitional Care Management CPT Code 99496 covers communication with the patient or caregiver within two business days of discharge. This can be done by telephonically, e-mail, or face-to-face. It involves medical decision making of high complexity and a face-to-face visit with a provider within 7 days of discharge. The location of the visit is not specified. The work RVU is 3.05.
Benefits of Transitional Care Management
Healthcare reform has long been the topic for popular debate for decades especially since the Affordable Care Act was introduced in 2010 and one of its major focuses was providing care coordination for Medicare patients. With the onset of the Hospital Readmission Reduction Program HRRP there was also a need to incentivize providers for taking actions to provide the much needed care to at risk and vulnerable Medicare patients upon discharge from an acute setting and to hopefully prevent readmission or re-hospitalization.
Transitional Care Management services can essentially be broken down into 5 components.
Initial Contact with the Patient After Discharge
To begin services the QP must make initial contact with the patient or patient’s caregiver within two business days after the date of discharge from a facility. During this contact the QP will schedule an in-office patient encounter and should take the time or designate another time before the in-office encounter to review the discharge summary and any orders the patient is expected to follow and self-manage.
Medications must be reviewed with the patient and should all be available on the discharge summary, pre-admission and post-discharge medications need to documented and reconciled. The clinical care team member reviewing the medication must be qualified to make the initial contact, although new prescriptions obviously must be made by a practitioner with prescribing authority. Documentation should include both lists of medication above, as well as the qualification of the reviewer and any actions taken, such as new medication orders.
Transitional Care Management Services
Care Management services such assessing the patient’s ability to self-manage his/her health in the home setting and identifying and helping to resolve challenges that the patient may experience while trying to recover would be examples of Transitional Care Management Services. These services would be similar in scope to those provided under the Chronic Care Management Program, however there is no set number of interactions or time quota associated with billing for Transitional Care Management services unlike with Chronic Care Management. Each non-face-to-face service needs to be documented and recorded and the code cannot be billed until the 30th day after discharge.
The face-to-face visit must take place within seven calendar days of discharge for CPT code 99495, or 14 days of discharge for CPT code 99496. This encounter may also be performed at the hospital or other facility post-discharge. Note that the initial contact must come within two business days, but the face-to-face visit must happen with the specified number of calendar days dependent on the decision making complexity. This visit must be documented with the location, date and time of the visit, the services and findings rendered as a result of the visit, the QP’s credentials, and the appropriate findings to support a level of medical decision-making required by the TCM codes.
Level of Decision Making
TCM requires specific levels of complexity of medical decision-making be identified for thirty days after discharge. Code 99495 requires medical decision-making of moderate complexity, while code 99496 requires medical decision-making of high complexity. At risk Medicare patients with multiple chronic conditions would typically fall under high complexity and need to be scheduled for a face-to-face visit within 7 business days.
What are the eligibility requirements to receive Transitional Care Management services?
Medicare Beneficiaries discharged from inpatient acute care hospitals (inpatient, observation, and outpatient partial hospitalization); skilled nursing facilities; and community mental health center partial hospitalization programs.
What are the billing time period requirements for Transitional Care Management?
Reimbursement can only be submitted 30-days after the discharge date.
Who is eligible to bill for TCM and what is a QP?
A Qualified Professional (“QP”) is a physician, physician assistant, nurse practitioner, clinical nurse specialist or certified nurse midwife.
Does the Medicare beneficiary need to be an established patient?
No a previously established relationship with the patient is not required.
What are the required components of Transitional Care Management?
- Communication with patient or caregiver within two business days of discharge (or two separate, unsuccessful attempts at communication).
- Non-face-to-face care management services (see next section for further explanation).
- Medication reconciliation and management performed no later than date of face-to-face visit.
- Face-to-face visit within fourteen days (99495) or seven days (99496) (cannot be performed on day of discharge; not separately billable; may be performed at any appropriate location; elements of visit not specified).
- Medical decision making of moderate complexity (99495) or high complexity (99496) (using E/M code definitions).
What are the non-face-to-face care management services required to bill for Transitional Care Management?
Performed by a qualified professional: obtain and review discharge information; review need for, or follow-up on, pending diagnostic tests and treatments; interact with other providers involved in patient’s care; educate patient, family, guardian, and/or caregiver; establish or re-establish referrals and arrange for needed community resources; assist in scheduling required follow-up with community providers and services.
Performed by clinical staff or case manager under direction of qualified professional: communicate with home health agencies and other community services utilized by patient; educate patient and/or family/caretaker regarding self-management, independent living, and activities of daily living; assess and support treatment regimen adherence and medication management; identify available community and health resources; facilitate access to necessary care and services.
Will CMS reimburse for multiple TCM claims if submitted by multiple providers?
CMS will pay for only one Transitional Care Management (TCM) claim for the 30-day period following discharge. The first claim to be filed will be paid. CMS will not pay a second Transitional Care Management (TCM) claim in connection with a discharge that occurs within 30 days of the original discharge (i.e., if the patient is readmitted and discharged within the 30-day period or TCM services are provided by more than one provider.
Are they any other codes or claims that cannot be submitted during the 30- day Transitional Care Management billing period?
A qualified professional who bills for Transitional Care Management (TCM) services cannot bill for the following services during the 30-day period:
- Chronic Care Management (99490)
- Plan oversight services (99339, 99340, 99374-99380
- Prolonged services without direct patient contact (99358, 99359)
- Anticoagulant management (99363, 99364)
- Medical team conferences (99366-99368)
- Education and training (98960-98962, 99071, 99078)
- Telephone services (98966-98968, 99441-99443)
- End stage renal disease services (90951 – 90970)
- Online medical evaluation services (98969, 99444)
- Preparation of special reports (99080)
- Analysis of data (99090, 99091)
- Complex chronic care coordination services (99481X, 99483X)
- Medication therapy management services (99605-99607)
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