For patients with moderate or high complexity medical issues, the first month after being discharged from an inpatient setting (such as a hospital or a skilled nursing facility) is a critical time frame. In this period of adjusting to community settings, the patient faces the highest risk of readmission due to the existing medical condition or the development of a new one. In this period, family physicians can play a critical role in delivering transitional care management (TCM) to help the patient (or the primary caregiver) manage the medical condition.
Transitional care management is a reimbursable, preventative wellness initiative of the CMS to remove the patient care gap post-discharge. According to a 2018 paper shared by PubMed.gov, patients receiving the full complement of TCM had 86.6% decreased odds of readmission compared with patients who did not receive TCM.
TCM services can be provided by physicians (any specialty), clinical nurse specialists (CNS), nurse practitioners (NP), physician assistants (PA), and certified nurse-midwife. TCM can be billed for post-discharge patient care from inpatient settings, including acute care hospitals, psychiatric hospitals, long-term care, nursing homes, and rehabilitation centers.
Essential Components of Transitional Care Management
If your medical practice wishes to offer TCM, you must meet these Medicare guidelines.
- Interactive contact
You must establish an interactive contact with the patient (or the primary caregiver) within two days of discharge from the inpatient facility. The interactive contact can be made via telephone, email, or face-to-face.
You must ensure that the provider or clinical staff has the time to communicate with the patient and manage their care medical needs for 29 days post-discharge from the hospital.
If you cannot contact the patient within two days, you are required to document this in the medical record. However, you can still bill TCM if you meet all the other TCM criteria.
- Non-face-to-face service
The physician or medical staff can provide non-face-to-face TCM services. The non-face to face services includes (a) retrieval and review of the patient discharge summary, (b) educating the patient’s primary care team on self-management, independent living, (c) arranging for referrals, (d) communicating with other providers, healthcare agencies, other care services, and community services (e) follow-up support to ensure regime adherence and medication management.
- Face-to-face service.
You are required to document at least one face-to-face visit within specific timeframes. For TCM services for moderate medical decision complexity, the face-to-face visit must happen within 14 days of discharge. It is reported using CPT code 99495.
For TCM services with high medical decision complexity, the first face-to-face visit must happen within seven days of discharge. It is reported using CPT code 99496.
Refer to this CMS guide on medical decision-making levels for transitional care management.
Transitional Care Management Billing
Here are some additional guidelines for transitional care management billing:
- The billing for transitional care management is submitted as a one-time fee, usually after 30 days of the discharge date. In general, all TCM medical billing must document direct contact with the patient within two days, a face-to-face visit within 7 or 14 days of discharge, and the level of medical decision making. Please ensure that you document all the contact dates in the medical claim.
- You can submit the claim if the face-to-face visit is documented.
- Only one physician or NPP at your medical practice can report TCM services for a patient only once during the 30 days.
- The health care professional discharging the patient from the hospital can also be the one billing for TCM services.
- Medicare does not allow you to bill TCM services within a post-operative global surgery period.
- Avoid billing CCM (chronic care management) and TCM in the same calendar month. CCM and TCM should be billed in the same calendar month only if the TCM service period ends that month.
- You can report necessary E/M services for managing patients’ clinical issues separately, but not on the same day as TCM service.
- Here are the TCM reimbursement rates (as per CPT) for Medicare in 2022:
As healthcare shifts from volume to value of care, transitional care management will be increasingly important. Offering TCM immediately after discharge from a hospital facility ensures smooth transition and helps prevent unnecessary readmission. Transitional care management improves the quality of care, reduces the cost of care, and helps medical practices improve their bottom line. Knowing these benefits, the decision to implement a TCM program for your medical practice is the obvious choice.
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