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Transitional Care Management

Transitional care management provides a comprehensive care plan that can increase patient satisfaction, reduce healthcare costs, and improve outcomes in a variety of post-acute care facilities like healthcare centers, hospitals, and nursing homes.

Even after a patient is discharged, they may still be dealing with a medical crisis or struggling to cope with a new diagnosis. Patients with chronic conditions are most at risk during this period which provides an opportunity for primary care physicians to help manage their patients' transitional care, and get paid for it, too.

What is Transitional Care Management (TCM)?

The Centers for Medicare and Medicaid Services (CMS) guide to transitional care defines TCM as the coordination of services needed for all medical conditions during a 30-day period to support a patients' transition from one setting of care to another. Most often, this transition involves a patient moving from an inpatient setting to an outpatient environment such as the provider's clinic, patient's home, nursing home, or assisted living facility. The transitional care period begins the day a patient is discharged from an inpatient care facility and continues for the next 29 days.

What are the components of transitional care?

When a patient is moved from one care setting to another you are required to perform at least three of the following TCM services during the 30-day service period.

Interactive contact

The first requirement is interactive contact. Within two business days of the patient being discharged, you need to contact them or their caregiver by phone, email, or meet with them in person to talk about their needs and schedule any follow-up care.

If you are unable to get in touch, keep trying to communicate with the patient until you are successful. And be sure to document all of your attempts in the patient's medical record. If the face-to-face visit falls outside the required timeframe, you will not be able to bill for transitional care services.

Non face-to-face services

Beyond the initial follow up, there are non face-to-face services that you must also perform as part of this payment. The one exception is if you determine that these services are not medically necessary.

These services include:

  • Reviewing discharge information and the patients' need for follow-up care
  • Communication with other providers who may assume care of the patient
  • Patient, family and caregiver education, and
  • Helping the patient schedule any needed care or services

Services provided by physicians or non-physician practitioners

According to the official CMS guidelines, services provided by clinical staff under the supervision of a physician also qualify for reimbursement.

Non face-to-face services that may be performed by clinical staff may include:

  • Communication with the patient or their caregiver
  • Communication with community services the patient may use
  • Patient, family and caregiver education, and
  • Helping the patient or family access needed care and services

What are the billing requirements for TCM?

If you plan to report transitional care services, here are a few tips to keep in mind:

  • Only one physician or non-physician provider may report TCM services
  • Report services once per patient during the TCM period
  • The same healthcare provider may discharge the patient from the hospital, report observation discharge services, and bill TCM services
  • The required face-to-face visit can't take place on the same day discharge management services are reported
  • Report any reasonable and necessary E/M (except the required face-to-face visit) to manage the patient's medical issues separately
  • You can't bill TCM services and services within a post-operative global surgery period because Medicare will not pay TCM services if any of the 30-day TCM period falls within a global surgery period for a procedure code billed by the same provider
  • At a minimum, you must document the following in the patient's medical record:
    • Patient discharge date
    • Patient or caregiver first interactive contact date
    • Face-to-face visit date
    • Complexity of medical decision making (moderate or high)

If during the 30-day TCM period, the patient is seen more than once for a follow-up visit, you may bill these visits separately using an evaluation and management (E/M) code.

What CPT codes do I use to bill transitional care services?

There are two CPT codes that may be used to report TCM: CPT 99495 and CPT 99496.

What is CPT code 99495?

Code 99495 allows for the reimbursement of transitional care management services for patients who require medical decision making of at least moderate complexity.

Billing for code 99495 also requires:

  • Direct communication with the patient or caregiver within two business days of discharge
  • A face-to-face visit within two weeks (14 days) of the patient's discharge

Practitioners who are eligible to bill for CPT code 99495 include physicians or other qualified health professionals (QHPs) – including physician assistants (PAs) or nurse practitioners (NPs). Qualified health professionals may also include non-physician practitioners (NPPs), certified nurse-midwives (CNMs), or clinical nurse specialists (CNSs).

What is CPT code 99496?

Code 99496 allows for the reimbursement of transitional care services for patients who require a high level of medical decision making.

Billing for code 99496 also requires:

  • Direct communication with the patient or caregiver within two business days of discharge
  • One face-to-face visit must be performed within one week (7 days) of the patient's discharge

Eligible billing practitioners for CPT code 99496 include physicians or other qualified health professionals such as physician assistants (PAs), nurse practitioners (NPs), certified nurse-midwives (CNMs), clinical nurse specialists (CNSs), or non-physician providers (NPPs).

How much can these services pay?

Payments for transitional care services may vary by payer and Medicare's reimbursement can vary depending on your geographic location and the setting in which the care is provided. Your reimbursement from Medicare also depends on the conversion factor in effect at the time the claims are paid.

The nationally unadjusted reimbursement rates are outlined in the tables below.

As of January 2022, CPT code 99495 provides a one-time reimbursement of $209.02, while CPT code 99496 offers a one-time reimbursement of $281.69.

You can see how much these services have increased in value over the past four years. And remember, these are nationally unadjusted payment rates so your reimbursement may vary a bit depending on where you are in the country.

Here's an example of how much you could make in one month:

If you provide transitional care for 50 patients who require medical decision making of at least moderate complexity (CPT code 99495), and you bill each of those encounters at $209, you could add nearly $10,500 in revenue per month. That can be a significant opportunity to boost your bottom line, assuming that all of the care you are providing is medically necessary and meets all of the billing requirements.

Summary

The goal of transitional care management is to prevent a patient from being readmitted to a hospital or acute care facility for the same medical condition. For that reason, TCM is different from other care management programs like chronic care management and remote patient monitoring and can be billed concurrently with care services you may provide under those models.

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