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Transitional Care Management: Coding and Documentation in Brief

Transitional Care Management: Coding and Documentation in Brief

Transitional care management (TCM) describes the oversight and coordination of healthcare services for patients transitioning from an inpatient hospital setting. The CPT codebook provides codes and guidelines to report TCM, which allows providers to recoup payment for services they may already provide to their patients. Medicare covers TCM services, but the requirements occasionally differ from those in the CPT codebook.

What's Included:

The basic services comprising TCM may be found in the TCM code descriptors:

99495 Transitional Care Management Services with the following required elements:

• Communication (direct contact, telephone, electronic) with the patient and/or caregiver within two business days of discharge

• Medical decision making of at least moderate complexity during the service period

• Face-to-face visit, within 14 calendar days of discharge

99496 Transitional Care Management Services with the following required elements:

• Communication (direct contact, telephone, electronic) with the patient and/or caregiver within two business days of discharge

• Medical decision making of high complexity during the service period

• Face-to-face visit, within seven calendar days of discharge

Eligible transitions in care include discharges from an inpatient hospital, partial hospitalization, and hospital observation status. Transitions from a skilled nursing facility (SNF) or nursing facility to the patient's community setting (home, domiciliary, rest home, or assisted living community) also are included.

Making Initial Contact

Both TCM codes require communication with the patient or caregiver within two business days (not calendar days) of discharge. Specifically, CPT guidelines state, "The contact may be direct (face-to-face), telephonic, or by electronic means [e.g., e-mail]."

CPT defines business days as Monday through Friday, excepting holidays, "without respect to normal practice hours or date of notification of discharge." For example, if the patient is discharged on Tuesday, initial contact with the patient must be made before the end of business day, Thursday.

If the provider attempts to reach the patient or caregiver, but is unsuccessful within two business days, CPT allows that you still may be able to report the service. Medicare rules concur, "If you make two or more separate attempts in a timely manner and document them in the medical record, but are unsuccessful and if all other TCM criteria are met, you may report the service" [emphasis added]. CMS rules further specify, "…we expect attempts to communicate to continue until they are successful. You cannot bill TCM if the face-to-face visit is not furnished within the required timeframe."

Source: "Transitional Care Management Services," Department of Health and Human Services Centers for Medicare & Medicaid Services:

Medical Decision-Making as a Qualifying Factor

The TCM code descriptors stipulates medical decision-making (MDM) of either moderate (99495) or high (99496) complexity. As such, not all post-discharge patients will qualify for TCM services.

CMS defines MDM as "the complexity of establishing a diagnosis and/or selecting a management option, which is determined by considering the following factors:

• The number of possible diagnoses and/or the number of management options that must be considered

• The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed

• The risk of significant complications, morbidity, and/or mortality as well as comorbidities associated with the patient's presenting problem(s), the diagnostic procedure(s), and/or the possible management options"

To qualify for a given level of MDM, two of the three elements must be met or exceeded.

Level of MDM

Number of Possible Diagnoses and/or Management Options

Amount and/or Complexity of Data to Be Reviewed

Risk of Significant Complications, Morbidity, and/or Mortality

Moderate Complexity

Multiple

Moderate

Moderate

High Complexity

Extensive

Extensive

High

 

Further detail of the MDM component may be found in the Documentation Guidelines for Evaluation and Management Services on the CMS website: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/EMDOC.html

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