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Transitional Care Management

What is Transitional Care Management (TCM)?

To improve the coordination of care for Medicare patients between the acute care setting and community setting, the Centers for Medicare & Medicaid Services created two billing codes for Transitional Care Management (TCM). The goal of TCM is for a provider to “oversee management and coordination of services, as needed, for all medical conditions, psychosocial needs and activity of daily living support.” TCM requires initial contact with the patient within two business days after discharge, a face-to-face visit within a specified period of time, and moderate or high medical decision making during the 30-day service period.

TCM services may be furnished following a beneficiary’s discharge from one of the settings listed below to a community setting:

  • 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

The following healthcare professionals may furnish TCM services:

  • Physicians (any specialty)
  • These non-physician practitioners (NPPs) who are legally authorized and qualified to provide the services in the state in which they are furnished:
    • Nurse practitioners (NPs)
    • Physician assistants (PAs)
    • Certified nurse-midwives (CNMs)
    • Clinical nurse specialists (CNSs)

The TCM service period is 30 days and begins on the date the beneficiary is discharged from the acute care setting and continues for the next 29 days. During this time, the billing provider should furnish the following three components:

  1. Interactive contact must be made with the patient and/or caregiver, as appropriate, within two business days following the patient’s discharge to the community setting. The contact may be via telephone, email, or face-to-face. It can be made by the billing provider or clinical staff who has the capacity for prompt interactive communication addressing patient status and needs beyond scheduling follow-up care.
  2. The billing provider must furnish non-face-to-face services to the beneficiary, unless they determine that they are not medically indicated or needed. Clinical staff under the direction of the billing provider may provide certain non-face-to-face services, such as helping patients and caregivers access community and health resources or providing self-management education.
  3. The billing provider must furnish one face-to-face visit within certain timeframes, as described by the CPT code. This visit may be provided by telehealth if it meets CMS requirements for billing telehealth.

Additional resources are available through CMS:

Resources are also available through the American Academy of Family Practice's Family Practice Management, May-June 2013 issue, Transitional Care Management Services: New Codes, New Requirements.

Why provide TCM to your patients?

Transitional care management (TCM) is intended to reduce potentially preventable readmissions and medical errors during the 30 days following discharge from the acute care setting. The TCM codes recognize the additional work required to provide support to patients after discharge.

How do I identify patients who would benefit from TCM?

TCM requires communication between the acute care setting and outpatient provider. Developing processes to notify the patient’s primary care provider of an acute care admission and discharge facilitates TCM. As a part of a larger cultural shift to coordinated care, acute care and outpatient providers may need to reassess their workflows and processes. For example, in a hospital setting, discharge planners can coordinate with the patient’s outpatient provider. In Critical Access Hospitals with rotating family practice coverage for inpatient care, the hospital provider will often see the same patients they discharged in the clinic setting. Approaches for identifying patients eligible for TCM should be tailored to the healthcare system and resources in each community.

How can I educate patients about TCM and what to expect?

The acute care provider and/or clinical staff can educate patients about TCM prior to discharge. They should inform the patient that they will be contacted within two business days and that they will be scheduled for a face-to-face visit. Some organizations schedule the face-to-face visit prior to the patient’s discharge from the acute care setting. Patients should be aware that TCM is subject to co-insurance and deductible under Medicare.

What are the billing codes for TCM?

There are two CPT codes that may be used to bill for TCM:

  • CPT Code 99495 ($105-$211): TCM services with moderate medical decision complexity (face-to-face visit within 14 days of discharge)
  • CPT Code 99496 ($153-$299): TCM services with high medical decision complexity (face-to-face visit within 7 days of discharge)

When billing for TCM, healthcare professionals should note the following:

  • Only one healthcare professional may bill TCM services.
  • Services may only be billed once per beneficiary during the TCM period.
  • The same healthcare professional 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 as discharge day management services.
  • TCM may not be billed during a post-operative global period or with certain other codes, such as home health, hospice, and chronic care management (CCM).

How do I document TCM in my electronic health record (EHR)?

At a minimum, documentation for TCM must include:

  • Date the beneficiary was discharged
  • Date of the interactive contact with the beneficiary and/or caregiver
  • Date of the face-to-face visit
  • The complexity of medical decision making (moderate or high)

The AAFP's Transitional Care Management Services: New Codes, New Requirements provides documentation checklists for the initial interactive contact and the face-to-face visit.

Who in my organization should I engage when designing and implementing TCM?

Implementing TCM requires cooperation between the acute care setting and outpatient provider to review and redesign processes and workflows. Leadership and medical staff in the practice and acute care setting should champion the change. Nursing staff should be involved in designing the process. Working with coding and billing staff prior to implementation is important for developing complete documentation and systems to bill for the service.

Are there any special considerations for Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) billing for TCM?

RHCs and FQHCs can bill for the face-to-face visit component of TCM as an RHC or FQHC visit. TCM services can be billed as a visit if it is the only medical service provided on that day with a RHC or FQHC practitioner and it meets the TCM billing requirements. If TCM is furnished on the same day as another visit, only one visit can be billed.

RHCs and FQHCs may not bill for CCM and TCM services, or another program that provides additional payment for care management services (outside of the RHC AIR or FQHC PPS payment), for the same beneficiary during the same time period.

Additional Resources