Transitional health services, also known as transitional care management, refer to the care management, care coordination and continuity of healthcare during the transition from one healthcare setting to another. These services can include coordination of care, medication management, follow-up appointments, and patient education. In the case of a practice this would include transitioning from a hospital or qualifying health facility to a home, rest home, domiciliary, or assisted living facility.
Transitional care services benefit patient care, health care providers and your practice in several ways:
- Improved patient outcomes: Transitional health services help ensure that patients receive proper care and follow-up after a hospital stay or other qualifying healthcare event. This reduces the likelihood of ER visits, hospital readmissions and complications, and the need for home health care, resulting in improved patient outcomes.
- Improved patient engagement: By providing continuity of care through the transition this helps the patients to take an active role in managing their health and healthcare by providing them with education and resources to help them make informed decisions about their health care.
- Improve Patient Satisfaction: Patients who receive transitional health services are more likely to feel supported and informed throughout their healthcare journey, resulting in a better patient experience and a more satisfied experience with the health care organizations and their healthcare providers and their care team.
- Enhanced communication, care coordination and collaboration: Transitional health services require coordination, collaboration and communication between healthcare providers, their care teams, patients and caregivers which can ultimately enhance patient care, improve outcomes and streamline care.
- Increased efficiency: By coordinating care and preventing unnecessary readmissions or complications, transitional care services can increase efficiency and reduce healthcare costs.
- Competitive advantage: Offering transitional health services to your patients can set your practice apart from others, improve your MACRA/ MIPS/ APM score, improve provider ratings and attract patients who value comprehensive care, support and higher level of service offered.
Overall, incorporating transitional health services in your practice can benefit both patients and healthcare providers by improving patient health outcomes, increasing patient satisfaction, promoting better communication, coordination and collaboration among health care providers and their care team, reducing healthcare costs, increasing efficiency of health care management, improving patient engagement and providing a competitive advantage for your practice.
Transitional Care Management Services Medicare Requirements
Transitional Care Management (TCM) services are covered by Medicare for beneficiaries for medical services that aim to help patients who are transitioning from a hospital or other health care setting to their home or other care settings. Medicare offers reimbursement for transitional care services provided to eligible beneficiaries, and there are specific requirements that providers must meet to receive reimbursement.
The requirements to bill Medicare for TCM services are as follows:
- The Medicare patient must have been discharged from one of the following settings below and returned to their home, domiciliary, rest home or assisted living facility.
- Inpatient Acute Care Hospital
- Inpatient Psychiatric Hospital
- Long Term Care Hospital
- Skilled Nursing Facility
- Inpatient Rehabilitation Facility
- Hospital outpatient observation or partial hospitalization
- Partial hospitalization at a Community Mental Health Center
- A practice staff member must have completed and documented an initial outreach (via email, telephone, or text) to the patient within 2 business days of discharge to make sure they are scheduled for an office visit within 7 to 14 days based on their medical complexity.If the staff member was not able to connect with the patient within the 2 business days to schedule the appointment, and contact happens after the two (2) days it is ok since at least the initial outreach was done within two (2) business days. It is important to have clear documentation when the initial outreach was done in case a provider is faced with a Medicare audit.
CPT Code 99495
Transitional Care Management CPT Code 99495 involves medical decision making of at least moderate complexity and a face-to-face visit with a provider within 14 days of discharge to qualify for billing along with transitional care non-face-to-face services for 30 days from the date of discharge.
Calculate your medicare reimbursement for transitional care management with CareVitality’s TCM Calculator.CPT Code 99496
Transitional Care Management CPT Code 99496 involves medical decision making of at least high complexity and a face-to-face visit with a provider within 7 days of discharge to qualify for billing along with transitional care non-face-to-face services for 30 days from the date of discharge.
Calculate your medicare reimbursement for transitional care management with CareVitality’s TCM Calculator. - The provider and/or his care team needs to provide non-face-to-face services, such as phone calls or electronic communications, to the patient for up to 30 calendar days after the patient’s discharge, as needed, to ensure that the patient receives the necessary follow-up care services.
Examples of the necessary follow up care are as follows:- Obtain and review hospital discharge information
- Communicate with home health agencies and other community services utilized by patient
- Educate patient, family, or caretakers regarding self-management, independent living, and activities of daily living
- Provide support treatment regimen adherence
- Identify available community, therapy, social service, and health resources
Facilitate access to necessary care and services. - Confirm the patient has all their medications and the patient and/ or caregivers have a clear understanding of dosage, how frequently it should be taken, and side effects.
- Make sure the patient and caregivers understand the early signs that their illness/ condition is worsening
- The patient comes in for their scheduled transitional care office visit where the provider will complete the following:
- Initial transitional care visit summary that includes a medication reconciliation, the patient’s current health status, and a review of the discharge plan.
- Review need for, or follow-up on, pending diagnostic tests and treatments for continuity of care
- Interact with other providers involved in patient’s care and share health plans
- Provide educational information to patient, family, guardian, and/or caregiver
- Establish or re-establish referrals
- Arrange for needed community resources
- The provider must create a written plan of care that includes a comprehensive assessment of the patient’s medical, functional, and psychosocial needs and provides instructions for ongoing care.
- At the end of the 30 days, including day 1 being the date of hospital discharge, the provider can bill for the appropriate billing code for TCM services rendered: CPT Code 99495 or CPT 99496.
It is important for providers to follow these requirements and have proper documentation in the patient’s chart to ensure that they can receive reimbursement for transitional care services provided to eligible beneficiaries or if later faced with a Medicare audit.
Health Care Professionals Who May Furnish and Bill TCM Services
Health care professionals who may furnish and bill transitional care services include physicians, physician assistants, clinical nurse specialists, nurse practitioners, and nurse midwives.
What Is the Purpose of Continuity of Care through Transitional Care Units?
The purpose of continuity of care through transitional care units is to provide patients with a smooth and seamless transition from one health care setting to another. This helps to ensure that patients receive appropriate and continuous care, improves patient outcomes, and reduces the risk of medical errors.
What Are the Benefits of Transitional Care Units to Both Patients and Family?
The benefits of transitional care units to both patients and their family include improving patient outcomes, decreasing health care costs, improving patient satisfaction and decreasing medical errors. Transitional care units provide a coordinated and supportive environment for patients and their families during a challenging time, helping to ensure that patients receive timely health care when needed.
Approaches to transitional health services to Help Your Health Care Practice Get Started
To get started with transitional care management (TCM), health care practices can implement a variety of transitional care approaches, including partnering with other health care providers, working with a technology to support the communication, coordination and can even provide the necessary resources to provide patient education and support if needed to effectively implement TCM services. CareVitality, Inc. can provide the needed technology, information and/or resources to help successfully implement TCM services.
