Managing ($) the Transition - Transitional Care Management

“Transition of care” refers to the movement of patients between healthcare practitioners, settings, and home as their condition and needs change. Research suggests that lack of coordination between acute care facilities and primary care providers can lead to higher hospital readmission rates and costs, which are increasingly scrutinized by governmental and third-party payers. 

In 2013, with the creation of two (2) new Current Procedural Terminology (“CPT”) codes 99495 and 99496 for Transitional Care Management (“TCM”), CMS allowed providers to bill for thirty (30) days of TCM.  Designed to incentivize providers to improve hospital readmission rates by allowing increased revenue opportunities for non-face-to-face activities, on average, TCM provides an additional $55-$125 per discharge as compared to a level four (4) established Evaluation and Management (“E&M”) service. 

However, navigating the metrics outlined by CMS to appropriately report and bill for TCM services can be challenging, finding its way to the Office of Inspector General (“OIG”) Work Plan for 2017. In this issue of HotStone, we highlight key elements of TCM to help practitioners seize the revenue opportunity, while learning how to mitigate risk associated with the complexity of the services and required data elements.

TCM Services Requirements

Per CMS, TCM includes:

  • Services required during the beneficiary’s transition to the community setting following particular kinds of discharges.
  • Health care professional accepts care of the beneficiary post-discharge from the facility setting without a gap.
  • Health care professional takes responsibility for the beneficiary’s care.
  • Beneficiary has medical and/or psychosocial problems that require moderate or high complexity medical decision making.

The thirty (30) day TCM period begins on the date the beneficiary is discharged from the inpatient hospital setting and continues for the next twenty-nine (29) days. Qualified healthcare professionals include physicians, Non-Physician Practitioners (“NPP’s”) legally authorized and qualified to provide the services in the State in which they are furnished, certified nurse-midwives, clinical nurse specialists, nurse practitioners, and physician assistants.

TCM Services Settings

TCM services may be furnished following the beneficiary’s discharge for one of the following inpatient hospital settings:

  • 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

Subsequent to discharge, the beneficiary must be returned to his or her community setting such as: his or her home, domiciliary, a rest home, or assisted living.

Key Elements of TCM

During the thirty (30) days beginning on the date the beneficiary is discharged from the inpatient setting, the following three (3) TCM components must be furnished:

An Interactive Contact

An interactive contact must be made with the beneficiary and/or caregiver within two (2) business days following the beneficiary’s discharge to the community setting via phone, email, or face-to-face. For Medicare purposes, if two (2) or more separate unsuccessful attempts within the required two (2) business days are documented, assuming all other TCM criteria are met to include a documented successful contact after the initial two (2) business days, the practitioner is eligible to report the service.

Certain Non-Face-to-Face Services

Unless it is determined a service is not medically indicated or needed, additional non-face-to-face services must be furnished to the beneficiary. Services furnished by the physician or other qualified healthcare providers include:

  • Obtain and review discharge information;
  • Review need for or follow-up on pending diagnostic tests and treatments;
  •  Interact with other health care professionals who will assume or reassume care of the beneficiary’s system-specific problems;
  • Provide education to the beneficiary, 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.

Services provided by clinical staff under the direction of a physician or other qualified healthcare provider include:

  • Communicate with agencies and community services the beneficiary uses;
  • Provide education to the beneficiary, family, guardian, and/or caretaker to support self-management, independent living, and activities of daily living;
  • Assess and support treatment regimen adherence and medication management;
  • Identify available community and health resources;
  • Assist the beneficiary and/or family in accessing needed care and services.

A Face-to-Face Visit

A face-to-face visit provided under a minimum of direct supervision and subject to “incident to” rules must be provided within the specified timeframes as outlined in the CPT codes: 

  • CPT Code 99495 Moderate medical decision complexity for face-to-face visit within 14 days of discharge.
  • CPT Code 99496 High medical decision complexity for face-to-face visit within 7 days of discharge.

Medical decision-making complexity is defined by the E&M Guidelines. It is important to remember that the initial face-to-face visit is part of the TCM service but subsequent face-to-face visits are billed separately. Medication reconciliation and management must be furnished no later than the initial face-to-face visit.

Proper Reporting of TCM Services

Proper reporting of TCM services can prove complicated without a workflow process that ensures all requirements have been met. Per CMS guidelines, at a minimum the following information must be documented in the beneficiary’s medical record; date beneficiary was discharged, date of interactive contact with beneficiary and/or caregiver, date of face-to-face visit and complexity of the medical decision making (moderate or high).

Use of a TCM thirty (30) day workflow tool to capture the required documentation elements will help to forgo common mistakes. In addition to structured workflow documentation, full understanding of TCM billing guidelines in relation to other reportable services will prevent duplicative billing and denials according to the TCM guidelines:

  • Only one healthcare professional may report TCM services.
  •  Report services once per beneficiary during the thirty (30) day TCM period.
  •  The same healthcare provider may discharge the beneficiary from the hospital, report hospital or observation discharge services, and bill TCM services. However, the required face-to-face visit may not take place on the same day of discharge.
  • Report reasonable and necessary E&M services (other than the required face-to-face visit) to manage the beneficiary’s clinical issues separately.
  • TCM services cannot be paid if any of the thirty (30) day TCM period falls within the global period for a procedure billed by the same practitioner.
  • The following services may not be reported during the TCM service period; Care Plan Oversight Services, home health or hospice supervision, End-Stage Renal Disease services, Chronic Care Management (“CCM”) where the CCM and TCM service periods overlap, prolonged E&M Services Without Direct Patient Contact, and any other services excluded by CPT reporting rules.

In summary, proactive documentation practices as well as a comprehensive understanding of TCM guidelines in relation to other services rendered, will ensure accurate reporting of TCM services while enhancing quality during transitions in patient care. 

SunStone offers services specifically geared to assisting hospital based and independent multi-specialty physician groups manage the ever-changing professional regulatory environment. If you have any questions, please contact Vonda Moon, Principal at vondamoon@sunstoneconsulting.comor Joli Fitzgibbons, Senior Manager at