Making the Most of Transitional Care Management

June 22, 2016
G. John Verhovshek, MA, CPC

TCM helps patients transition from the hospital to the community. Many physicians, however, miss deserved reimbursement because they lack documentation.

Transitional Care Management (TCM) services (CPT codes 99495 and 99496) are intended to help patients transition successfully from a hospital stay back to a community setting. Many healthcare providers already meeting the requirements to bill TCM miss deserved reimbursement because they lack documentation and billing information. Here are two important areas for providers to consider.

1. Provider and patient must qualify

Medicare pays for TCM services, when properly documented and billed. Per CPT and CMS, both the healthcare provider and the patient receiving care must meet specific requirements.

Provider requirements: CMS allows physicians (of any specialty) to furnish TCM services. CMS also allows legally authorized and qualified non-physician practitioners (NPPs) - specifically including certified nurse-midwives (CNMs), clinical nurse specialists (CNSs), nurse practitioners (NPs), and physician assistants (PAs) - to perform TCM.

Note: TCM services also may be performed "incident to" a provider's services for Medicare payers. See the MLN "Transitional Care Management Services" (March 2016) for more information.

Patient requirements: Patients who qualify for TCM services must be moving from:

• Inpatient acute-care hospital;

• Inpatient psychiatric hospital;

• Long-term care hospital;

• Skilled nursing facility;

• Inpatient rehabilitation facility;

• Hospital outpatient observation or partial hospitalization; or

• Partial hospitalization at a community mental health center.

Into:

• The patient's home;

• The patient's domiciliary;

• A rest home; or

• Assisted living.

CPT Assistant (August 2013) clarified that you may report the TCM services codes if the patient is on hospice, for instance if the patient was discharged home on home-hospice services. TCM services are not appropriate when a patient is discharged from the hospital setting and transferred to a skilled nursing facility.

Patients who qualify for TCM services may be either new or established. CPT and CMS define a new patient as one who has not received a face-to-face service from the physician/qualified health care professional or another physician /qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, with the past three years.

2. Additional requirements

Beyond the qualification requirements for the provider and patient, each TCM code descriptor defines additional elements:

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

Both codes require direct communication (by telephone, email, or face to face) with the patient and/or caregiver within two business days of discharge (i.e., weekends and Federal holidays do not count as business days). If the patient cannot be reached within two days, this strict time requirement may be waived. CMS has stated, "If two or more separate attempts are made in a timely manner and documented in the medical record, but are unsuccessful, and if all other TCM criteria are met, the service may be reported. We emphasize, however, that we expect attempts to communicate to continue until they are successful, and TCM cannot be billed if the face-to-face visit is not furnished within the required timeframe."

Source: "Frequently Asked Questions about Billing the Medicare Physician Fee Schedule for Transitional Care Management Services" (March 2016)

Each code further requires a minimum level of medical decision making (MDM) on the provider's part. Patients' whose conditions do not necessitate moderate (99495) or high (99496) MDM do not qualify for TCM services. For example, if a 27-year-old, otherwise healthy woman delivers a healthy baby by cesarean section and is discharged two days later, she does not qualify for TCM because the provider's MDM would be lower than the required moderate complexity needed for TCM.

Resource: See the E&M Service Guidelines in the CPT codebook for more information to determine the complexity of medical decision making.

Lastly, each code requires a face-to-face meeting with the patient, either within 14 calendar days (99495) or seven calendar days (99496) of discharge. As noted above, this requirement is absolute. The face-to-face visit is part of the TCM and is not reported separately.

Take action: Verify all patients discharged, each day, and determine which individuals are candidates for TCM, with either moderate or high complexity. Contact those patients within two business days, and schedule a face-to-face visit with them within either seven or 14 days from discharge.

*Read part 2 of this article "Coding Requirements for Transitional Care Management."

G. John Verhovshek, MA, CPC, is the managing editor for AAPC's publications. He has written, co-written, and edited dozens of coding and compliance resource manuals, including the Part B Survival Guide (1st edition) and The Official CPC Certification Study Guide (1st edition). E-mail him at g.john.verhovshek@aapc.com.