Transitional Care Management (TCM)

The Transitional Care Management (TCM) concept is for the physician, which includes an MD, DO, and non-physician practitioners like a Nurse Practitioners (NP), Physician Assistant (PA), Clinical Nurse Specialist (CNS) or a Clinical Nurse Midwife (CNM), to oversee:

  • Management and coordination of services as needed for all medical conditions,
  • Psychosocial needs, and
  • Activity of daily living support for the full 30-day post discharge as patient transitions back into community setting

The goal of TCM is to avoid the patient being readmitted to a hospital and the components include an interactive contact, certain non-face-to-face services and a face-to-face visit.

CPT Codes

  • 99495: TCM with moderate medical decision complexity with a face-to-face visit within 14 calendar days of discharge
  • 99496: TCM with high medical decision complexity with a face-to-face visit within seven calendar days of discharge

Places of Service

TCM is reportable when the patient is discharged from an inpatient acute care hospital, inpatient psychiatric hospital, long term care hospital, skilled nursing facility, inpatient rehabilitation facility, hospital outpatient observation or partial hospitalization and partial hospitalization at a community mental health center.

The discharge must be to the patient's home, a domiciliary center, rest home or nursing home or an assisted living facility. Skilled nursing facilities do not apply.

Interactive Contact within Two Business Days Following Discharge

Communication with the patient or caregiver must be completed within two business days after discharge, with the first business day after discharge being day one. This can be direct, over the phone or electronically. Document all unsuccessful attempts until reaching the patient or caregiver is successful. Merely leaving a voicemail or email without a response is not a direct exchange of information. Also, this communication cannot take place on the day of discharge.

Interaction with the patient or caregiver must include:

  • Obtaining and reviewing any discharge information given to patient
  • Review the need for any follow-up diagnostic tests or treatment
  • Interact with other healthcare professionals involved in patient's after care
  • Provide education to patient, family members or caregivers
  • Establish referrals and arrange community resources that patient can be involved in to regain activities of daily living; and
  • Assist in scheduling the follow-up visit to physician

This interaction does not need to be completed by the physician; however, the items listed here must be within the person's scope of work and he/she must have the ability to perform each item.

Face-to-Face Visit

The face-to-face visit within the seventh or 14th day, depending on the code being billed, is done by the physician; however, it can be done by licensed clinical staff under the direction of the physician. The face-to-face visit must include:

  • Communication with outside agencies and services patient can use
  • Education must be provided to patient to support self-management and help get back to activities of daily living
  • Assess and support treatment regimen and identify any available community resources the patient can be involved in, and
  • Assist patient and family in accessing care and service that might be needed

The counting of seven and 14 days begins on the day of discharge.

Frequency

If during the month, the patient is seen more than once for a follow-up visit, any other visit made during the 30 days can be billed separately using an Evaluation and Management (E/M) code. The TCM codes are used when the provider wants to assume responsibility for the patient's post discharge services to try to prevent the patient from getting readmitted to the hospital.

The codes must be billed using the seventh or 14th day as the date of service and only one healthcare professional may report this service. If more than one physician assumes care and a claim is denied, the provider can bill the visit using an E/M code. The TCM service may be reported once during the entire 30-day period.

If a surgeon is caring for the patient in the hospital after surgery, TCM cannot be billed for upon discharge as those services are part of the global period of the surgical procedure.

If billing for TCM, the following cannot also be billed:

  • Care plan oversight
  • Home health or hospice supervision: HCPCS codes G0181 and G0182
  • End Stage Renal Disease (ESRD) services: CPT codes 90951-90970
  • Chronic Care Management (CCM) services (CCM and TCM service periods cannot overlap)
  • Prolonged E/M services without direct patient contact codes: CPT codes 99358 and 99359

Documentation

At a minimum, the following information must be in the beneficiary's medical record:

  • Date of discharge
  • Date interactive contact was made with patient and/or caregiver
  • Date of face-to-face visit
  • Complexity of medical decision making (moderate or complex)

Scenarios

Scenario 1

The patient is discharged from the hospital but within the 30-day period, the patient is readmitted to an acute care hospital. Providers can bill TCM if the second day and the seventh or 14th day visit is done, or, start the TCM with the second discharge. If the face-to-face wasn't done before the readmission, the requirements were not met. Hospital visits cannot count as the face-to-face visit.

Scenario 2

The patient was discharged on December 1 but passes away on December 20, within the 30-day period. TCM cannot be billed for; however, any face-to-face visits can be billed using the appropriate E/M code.

Resources

Last Updated Fri, 14 Feb 2020 12:21:51 +0000