Transitional Care Management (TCM) was initiated by Medicare in 2013 and provides a continuous umbrella of medical care for a month after a patient is discharged from the hospital or other inpatient setting. TCM supports the patient and family by providing communication, education and oversight, ensuring the patient has received and is taking discharge medications correctly, and facilitating needed community resources or other medical services, such as outpatient consultations, titration of medication, and further procedures or testing. TCMs have been shown to improve patient care, decrease readmissions, and increase clinic revenues.
There are two TCM codes, for moderate complexity MDM, 99495 and for high complexity MDM, 99496. Moderate complexity requires an in-person clinic visit within 14 days of hospital/facility discharge, and high complexity, within 7 days of hospital/facility discharge.
The discharge summary, length and level of hospitalization, and comorbidities can guide you regarding complexity and whether the patient needs a visit within 1 or 2 weeks. While you can opt to charge a routine office visit, both TCM codes reimburse better. For a low complexity hospital discharge, a follow-up visit may not be needed. Emergency department visits aren’t eligible for TCM codes.
TCM codes are possible after a patient is discharged from any of these facilities:
1. Hospital
2. Rehabilitation Facility
3. Skilled Nursing Facility/Unit (SNF or SNU)
4. Long-Term Acute Care Hospitals (LTACH)
5. Psychiatric hospital or community mental health center
TCMs are then performed once the patient is discharged to their home environment, which includes a rest home (nursing home), assisted living center, or other group home. The patient can be new or established to your practice.
The requirements for a TCM code are straightforward:
- Call the patient within two business days of discharge, by clinical staff (not the front desk staff). This interaction may be in person, by telephone, or by electronic means (portal) but must include documentation of the interaction and the patient’s response or acknowledgment
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CPT Code
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RVU in 2022
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Compared to…
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RVU in 2022
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TCM-14 day discharge (99495)
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2.78
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Established Level 4 (99214)
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1.92
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TCM-7 day discharge (99496)
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3.79
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Established Level 5 (99215)
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2.80
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New Patient Level 3 (99203)
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1.60
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New Patient Level 4 (99204)
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2.60
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○ Documentation of inability to reach the patient and leaving a voicemail message doesn't count after a single attempt, but if two separate documented attempts are made within two business days, this requirement is met.
○ Clinical staff can make this call, schedule a follow-up visit, and trouble-shoot any immediate questions or concerns.
○ If the patient is seen in the clinic within two business days of discharge, this requirement is also met.
b. Review the patient’s hospital records, discharge information, medication reconciliation list, and any pending tests or studies. If any follow-up with other clinicians or patient education is needed, this should be provided or facilitated. You or your clinical staff can provide this, based on the complexity and skill sets involved.
c. See the patient in the clinic within 7 days (for high complexity), or 14 days (for moderate complexity). This visit must include a medication reconciliation. Interestingly, you technically don’t need to perform a physical exam (although that’s probably prudent!). You do have to document all the follow up and management in order to justify that the patient is either moderate or high complexity. You can now do this “face-to-face” visit by video telemedicine.
Note: Remember that medical decision-making refers to the complexity of the diagnosis and/or management, including the number of diagnoses or management options; the amount or complexity of medical records, diagnostic tests, or other information; and the risk of significant complications, morbidity, and/or mortality. Review the Medical Decision-Making table to make a determination of the complexity.
You can only bill for the TCM after all three steps discussed above are completed. If the patient doesn’t come for a visit within the allotted time, you forfeit the TCM but can bill a routine office visit. Likewise, if you can’t contact the patient in 2 business days and your staff only made one attempt, but they come for a visit within a week, you shouldn’t bill a TCM.
Only one provider can bill for a TCM visit on any patient and only every 29 days. Even if the patient ends up back in the hospital within the month, despite your best efforts, you can't bill for another TCM if it occurs within 29 days from the first discharge. You can bill separately for E/M visits within the 29 days for other issues (e.g., the patient develops a new problem or has a scheduled follow-up for other routine care), but you can't bill for a second TCM visit during that 29-day window. While you can bill for Chronic Care Management during the TCM, this must only be done when reasonable and non-overlapping in terms of time. In other words, you can't bill the time spent by clinical staff communicating with the patient to initiate the TCM visit as part of the time towards the CCM (chronic care management) code. This is intended to prevent physicians from “double dipping” by billing for other types of ongoing services during the TCM.
In summary, TCMs are often underutilized but provide good patient care during the month after hospital discharge and reduce readmissions. They also have higher reimbursement rates than routine office visits. Having a system for coordination of care for patients being discharged is crucial. This can include assigning a nurse or other clinical provider (not front desk staff) to begin any TCM by calling the patient within 2 days, documenting the call, obtaining records for you to review, and setting up an office visit within the appropriate time-frame. Remember you can always bill a routine office visit code, but TCMs are definitely preferable.
Let’s try a few examples:
Example 1: A 75-year-old patient is discharged from the hospital on Friday and your EHR system doesn’t notify you until Monday. Your nurse contacts the patient that day and answers some questions, refills a prescription, and schedules the patient for a visit on Thursday. Your nurse answers some questions again on Wednesday. You see the patient and document moderate complexity. Two weeks later, the patient has concerns and is seen again for another follow-up related to the hospitalization. You check labs and order new medications.
→ Billing Level: TCM, 99496 (Moderate complexity)
● Note: You don't charge the patient an additional 99214 visit because the patient is still within the 29 day window covered by the TCM (30 day period begins on day of discharge). However, you could cancel the original TCM and charge two 99214 visits for these two visits.
Example 2: A 63-year-old patient is discharged from the hospital on Tuesday and your nurse calls once on Wednesday and again on Friday. She reaches the patient on Friday and schedules a same-day appointment for an urgent hospital-related issue of moderate complexity and you order some labs.
→ Billing Level: 99214
● Note: The patient wasn’t reached within 2 business days of discharge.