Transitional Care Management

Transitional Care Management (“TCM”) Services – CPT codes 99495 and 99496 – were introduced by Medicare in January 2013. While it is commonly known that TCM services are reimbursable by Medicare and Medicare replacement plans, many may not be aware that other payers reimburse for TCM services as well. TCM services offer providers an opportunity to maximize reimbursement for care likely being rendered but not billed or not billed properly. The following includes a broad overview of TCM services.

TCM services are provided to facilitate patient transition 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.

As to the applicable dates for TCM services, TCM represents 30 days of post-discharge care. The reported date of service on the claim would be the date on day 30 with day of discharge being day 1. Place of service on the claim would be where the face-to-face visit takes place, which is a key component of the TCM service, as further described below.

Providers that may offer TCM services include physicians and NPPs who are legally authorized and qualified to provide services in the state, including certified nurse midwives, clinical nurse specialists, nurse practitioners and nurses and physician assistants. Only one provider will be reimbursed for a TCM service for a patient in a 30 day period. Importantly, the service cannot be charged in a global period by a provider that is restricted by global requirement care.

During the 30 day TCM service, which commences the date of patient discharge, the following three services must be rendered and documented to meet the requirements to bill TCM codes.

  • First, an interaction with the patient by phone, email or face-to-face within two business days following discharge is required.
  • Second, a face-to-face visit must be documented within specific time frames for each of the TCM services. Medication reconciliation and management must be made and documented no later than the date of the first the face-to-face visit.
  • Third, the documentation for the TCM services must include the date the beneficiary was discharged, date interactive contact with the patient and/or caregiver was made, date the face-to-face visit was furnished and the complexity of the medical decision-making.

If the patient is readmitted within the 30 days, the TCM service can still be billed as long as the other requirements for the charge have been met. However, TCM services for the patient can only be charged every 30 days by one physician or qualified provider as they include 30 days of care.

If you would like additional information or the opportunity to discuss the billing of TCM services, please don’t hesitate to contact Precision Practice Management.