How to code and bill for transitional care management

The goal of transitional care management (TCM)  codes is to achieve increased involvement of primary care physicians (PCPs) in order to improve patient care and reduce mistakes in care coordination that can lead to readmission.

A 2007 Medicare Payment Commission Advisory Report to Congress indicated that 19% of all Medicare patients discharged from the hospital were readmitted within 30 days of discharge, at a cost of $15 billion. To help solve this problem, the American Medical Association (AMA) and the U.S. Centers for Medicare & Medicaid Services (CMS) worked together to introduce new CPT codes for TCM services and add them to the Medicare Physician Fee Schedule.  

During the proposals, the AMA and CMS identified a number of components that they felt were essential to ensuring better patient outcomes.

When TCM is required

TCM services are required during the beneficiary’s transition to a community setting following particular kinds of discharges.   The beneficiary must have medical problems that require moderate or high complexity medical decision making.  

The physician must accept and take responsibility for the care of the beneficiary post-discharge from the facility setting without a gap. The 30-day TCM period begins on the date that the beneficiary is discharged from the inpatient hospital setting, and continues for the next 29 days. The reported date of service should be the 30th day.

TCM services are furnished following the beneficiary’s discharge 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 at a community mental health center. 

One key consideration is that in order to qualify as a TCM service, the beneficiary must be returned to his or her community setting, such as his or her home or assisted living facility. 

During the 30 days beginning on the date the beneficiary is discharged from the inpatient setting, the following three TCM components must be furnished.

01/ Interactive contact

Physicians must make an interactive contact with the beneficiary and/or caregiver, as appropriate, within two business days following the beneficiary’s discharge to the community setting. The contact may be via telephone, e-mail, or face-to-face.  

A successful attempt requires a direct exchange of information and appropriate medical direction by clinical staff with the beneficiary and/or caregiver and not merely receipt of a voicemail or e-mail without response from the beneficiary or caregiver. 

For purposes of this requirement, business days are Monday through Friday, except holidays, without respect to normal practice hours or date of notification of discharge.  For Medicare purposes, attempts to communicate should continue after the first two attempts in the required two business days until they are successful.  

TCM cannot be billed if there was no successful communication within the 30-day period between the facility discharge and the date of service for the post-discharge TCM code.

02/ Non-face-to-face services

Furnish non-face-to-face services to the beneficiary, unless it’s determined that they are not medically indicated or needed. 

Certain non-face-to-face services may be furnished by licensed clinical staff under the general supervision of a physician, however.  For example, a physician or non-physician practitioner (NPP) may obtain and review discharge information (for example, discharge summary or continuity of care documents), review need for or follow-up on pending diagnostic tests and treatments, interact with other healthcare professionals who will assume or reassume care of the beneficiary’s system-specific problems, provide education to the beneficiary, family, guardian or caregiver, establish or re-establish referrals and arrange for needed community resources or assist in scheduling required follow-up with community providers and services. 

Licensed clinical staff under the direction of a physician or NPP may communicate with agencies and community services used by the beneficiary, 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, or assist the beneficiary in accessing needed care and services.

03/ Face-to-face services

One face-to-face visit must be furnished within certain timeframes as described by the CPT codes: 14 days for 99495, or seven days for 99496. Medication reconciliation and management must be furnished no later than the date of the face-to-face visit.  

This face-to-face visit is part of the TCM service and is not reported separately. The place of service reported on the claim should correspond to the place of service of the required face-to-face visit.  

Non face-to-face services

Despite the importance of the face-to-face service required as part of the TCM codes, the non-face-to-face services such as communication, referrals, education, identification of community resources, and medication management constitute the truly essential features that distinguish TCM from those services that are predominantly or exclusively face-to- face in nature. 

When billing TCM services, only one healthcare professional may report TCM services, and TCM services may be reported only once per beneficiary during the 30-day 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 that discharge day management services are reported.  

Necessary evaluation and management services-other than the required face-to-face visit-to manage the beneficiary’s clinical issues should be reported separately. TCM services cannot be paid if any of the 30-day TCM period falls within a global period for a procedure code billed by the same practitioner.

When using codes 99495 and 99496 for Medicare, practices must also report the following codes during the TCM period:

Care plan oversight services: Healthcare Common Procedure Coding System (HCPCS) codes G0181 and G0182

End-Stage Renal Disease services: (90951 – 90970)

Medical Team Conferences (99366-99368) 

Telephone Services (98966-98968, 99441-99443)

Document the following information in the patient’s record:

Date of discharge,

date interactive contact was made,

date the face-to-face visit occurred and 

the complexity of medical decision making.

Obstacles doctors encounter

The first obstacle practices often encounter when using TCM services is establishing a reliable system for the inpatient-to-practice handoff. Since hospitalists or residents often care for patients in the hospital, PCPs do not make rounds and frequently are not notified when patients are admitted or discharged.

The person handing the discharge varies. While a physician writes the discharge orders, often a nurse explains the orders to the patient. If a nurse case manager is involved in any home care, the communication to the physician  might be made, but that is not necessarily part of the care manager’s responsibilities.

So who is responsible for notifying the PCP when a patient has been discharged from an inpatient setting?  If you ask a hospitalist, a health information management director or a care manager, you will probably get three different answers. 

There are many challenges, including not knowing who the PCP is, lack of timely documentation of the discharge summary for the PCP and patients changing their minds about being seen by a visiting nurse or case manager once they arrive at home.

In healthcare systems with a shared electronic health record and where community physicians use the same system, the chances are better that the system can work. Where hospitals and practices remain on different systems, PCPs should try to work with the hospital administration, care management department, and hospitalist service to explore ways to communicate effectively.