Transitional Care Management

Qualifying facilities for the patient’s inpatient medical stay include inpatient hospital, partial hospital, observation status in a hospital, skilled nursing or nursing facility, or a community mental health center. The qualifying facilities for the which the patient would be transitioning to include the home, domiciliary setting, rest home, or assisted living facility.

Transitional Care Management is for the subsequent 30-day period following the patient’s inpatient stay. The 30-day period begins on the date of discharge. The two CPT codes for which to bill TCM services are 99495 and 99496. The differences are as follows:

99495

• Communication with the patient and/or caregiver within 2 business days of the discharge date (considered Monday-Friday for TCM criteria)
• Medical decision making of at least moderate complexity
• A face-to-face visit within 14 calendar days of the discharge date

99496

• Communication with the patient and/or caregiver within 2 business days of the discharge date (considered Monday-Friday for TCM criteria)
• Medical decision making of high complexity
• A face-to-face visit within 7 calendar days of the discharge date

Important facts and information to reduce the most common TCM billing errors:

• TCM services reimburse at a higher rate than the billable E/M services.
• Home health certifications and the initial E/M will bundle with the TCM service billed.
• The discharge visit does not count for the initial post-contact requirement.
• TCM services are only payable to a single physician within the 30 days post-discharge.
• The physician completing the patient’s TCM services does not have to be the patient’s primary care physician.
• The appropriate diagnosis for the TCM service would relate to the patient’s state at the time of discharge. The diagnosis qualifying the patient for the TCM services should be billed.
• If the patient is re-admitted or becomes deceased prior to when the 30-day period concludes, the appropriate E/M service would be billed instead. The TCM period would restart at the patient’s next discharge date.
• TCM services should be billed on the 30^th date of the patient’s post-discharge care.

There are further coding limitations to what else may be billed per Medicare during the patient’s TCM period. You may reference cms.gov’s 2016 MLN document for further TCM information regarding guidelines and restrictions.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Transitional-Care-Management-Services-Fact-Sheet-ICN908628.pdf