Transitional Care Management: Worth the Effort

By Raemarie Jimenez, CPC, CPMA, CPPM, CPC-I, CANPC, CRHC

New transitional care management (TCM) codes, introduced in CPT® 2013, allow providers to receive reimbursement for their efforts and the efforts of their staff to promote successful outcomes for patients transitioning from a facility setting (e.g., inpatient hospital, nursing facility) to a community setting (e.g., home, assisted living facility).

When you compare TCM payment rates to the new and established patient E/M codes, you will see they are significantly higher (The CMS national payment amount for 99495—TCM of moderate complexity —is $163.99, and for 99496—high complexity TCM—is $231.36.). The additional reimbursement compensates for non-face-to-face activities (e.g., communication with home health agencies) performed by the provider and/or clinical staff under the direction of the provider.

To qualify for the TCM codes, the service must include:

  • Communication (face-to-face, telephonic, or electronic) within two business days after discharge
  • A face-to-face encounter within seven to 14 days after discharge
  • Moderate to high medical decision-making

Only one provider may bill TCM, once per patient, within 30 days of discharge. CMS advises to bill the service at the end of the 30 day period.

A common question regarding these codes is, “What if the patient’s face-to-face encounter occurs prior to seven to 14 days?” The answer is bill the TCM code. The face-to-face encounter can occur prior to seven days, but if it occurs after day 14, do not bill TCM. However, a possible face to face visit may occur two business days after but seven days before discharge. If it occurs after 14 days, do not bill TCM.

If the patient is seen within seven days and there is only moderate MDM, report 99495 if all other information for TCM is documented.

To select the correct codes, make sure the discharge date is documented, as are the communication with the patient within the two days following discharge, the date of the face-to-face encounter, the medical decision making for the patient, and the activities performed for TCM. Consider creating a TCM flow sheet to capture all the elements needed to support the code.

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54 Responses to “Transitional Care Management: Worth the Effort”

  1. Sharon says:

    Is anybody able to tell me if this code is billable for specialists (cardiologists), or only for the PCP?

  2. Tonia says:

    It is able to be billed by specialits as well if you are the ones coordinating the care for the transition.

  3. Jenna says:

    What if another provider sees that patient before we do? How will that affect getting paid?

  4. bridget says:

    does anyone have a flow sheet or template for these codes?

  5. Teresa says:

    I would assume beings it is a code in CPT that any provider can bill. The clinic I work in is Internal Medicine. We have discussed using these codes and are piloting them right now. We are and have been doing this work and will now try to recieve reimbursement for it.

  6. Kimberly says:

    What DOS do you use when billing this code? Do you use the DOS that the actual Face to Face took place? We are confused on that part.

  7. Amy Gauthier says:

    Can this be billed out to all payors or is it just for Medicare?

  8. Marcie Moon says:

    Can anyone clarify billing post-op? Also, what documentation is needed to clarify coordination of care between PCP and specialist. Example: pt is seen by PCP within stated guidelines, but also has appt. with specialist that treated inpt. and the only way the specialist knows that the pcp was seen is bc the pt. stated. What is the protocol for the coordination of care?

  9. kelly says:

    What if the specialist are the ones to coordinate care but the PCP wants to bill for the TCM, how should that be handled since TCM is open to all providers being able to bill?

  10. Teresa says:

    These codes can be billed once every 30 day period. First claim in will most likely be the reimbursed claim.

  11. Rima says:

    if my doc discharges a patient from the hospital and patient has a follow up at the doctors office we are able to charge these codes as long as it is within 14 days?

  12. Mary Jane Zismer says:

    Someof our patients are cared for in the hosptial by a hospitalist. Are we still eliglbe to use the TCM code when we see them in the office if within the 14 days? Do we bill this in addition to the follow yup visit?

  13. Joan says:

    Rae Marie – Do you have an official citation from either the AMA or CMS that states that you may NOT bill TCM if the mandatory post-discharge visits occurs 2 days after the discharge? Everything I’ve read from these official sources only speaks to the fact that the TCM post-discharge visit (99495/99496) cannot happen on the same calendar day as the hospital discharge (99238-99239). I’ve never seen anything from CMS or the AMA that says that the post-discharge TCM visit can’t happen the following business day or even the business day after that.

    CMS released an FAQ last week (2/28) that answered some of the many TCM questions. The date of service is the date 30th day of the TCM period. For example, when TCM has been provided for a patient who was discharged on March 1st, had their post-discharge face-to-face service on March 7th, the date of service for reporting the 30 day TCM service is March 30th. They also stated that the place of service is the location where the post-discharge face-to-face service occurred. They validated that a total of 30 days of TCM must be provided in order for the TCM code to be billed, so if the patient expires before that 30 days is up, you can’t bill TCM (but you can bill any billable services that occurred between hospital discharge and the patient’s death).

    The key thing to remember is that CMS expects the documentation to demonstrate that, in addition to the included mandatory face-to-face post discharge visit, that there’s evidence of on-going efforts by the provider’s ancillary staff for that 30 day period focused on the kinds of activities that will potentially result in decreasing the chances that the patient will be rehospitalized.

    Hope this helps!

  14. Cynthia says:

    First and MOST IMPOTANT, there must be documentation that demonstrates the provider went above and beyond a simple E/M visit to provide services that contribute to the patient’s care needs related to the hospitalization. I will be auditing for that specific documentation during quality checks. To bill this service, the service must be provided and documented. An E/M visit will not meet transitional care definitions.

  15. Lynn Wojnowski says:

    Regarding TCM cpt codes, we are being told by several commercial payors that Medicare has assigned these codes to a status indicator of “B”. This means they are considered “bundled”, even if another service is not performed on the same day. They are also indicating there are no RVU’s or payment associated with these codes?

    Can anyone clarify if they are getting paid?

  16. Nan Woodruff says:

    Does this code also apply for discharge management from a rehab hospital?????

  17. John says:

    I can’t find the FAQ at CMS Joan is referring to. Can you give me more info on where to look. The description of these codes in the CPT book does not go into that much detail.

  18. Camille says:

    99495 –
    malpractice RVU: 0.14
    work RVU: 2.11

    99496 –
    malpractice RVU: 0.20
    work RVU: 3.05

    status A.

    see the physician fee schedule.

  19. Marie says:

    Same as John above I can not find the FAZ at CMS that Jaon is referring to PLEASE give the exact location that this question on TCM was discussed concerning not billing the codes till day 30 after discharge. Per the CPT it only states the codes are once per patient WITHIN 30 days of discharge.

  20. Chris Zim says:

    Regarding the 30 day filing question – I think you have to wait based on the following from the FAQ:

    What date of service should be used on the claim?

    The 30-day period for the TCM service begins on the day of discharge and continues for the next 29 days. The reported date of service should be the 30th day.

    If the codes became effective on Jan. 1 and, in general, cannot be billed until 29 days past discharge, will claims submitted before Jan. 29 with the TCM codes be denied?

    Because the TCM codes describe 30 days of services and because the TCM codes are new codes beginning on January 1, 2013, only 30-day periods beginning on or after January 1, 2013 are payable. Thus, the first payable date of service for TCM services is January 30, 2013.

    I would interpret this to mean that since it appears you are billing AFTER services are given, and you are billing for 30 days of service, I don’t see how you could bill any sooner than the 30 days – or you would be billing for something you haven’t yet rendered…

  21. Maria Tiberend says:

    Does any one have a documentation tool or flow chart that they are willing to share? Thank you!

  22. John says:

    I just found a FAQ on TCM at the AAFP website. It gives the most detailed info I have found to date. Also gives a TCM 30 day worksheet. Both are PDF files.

  23. Chrissy says:

    The following link to the AAFP has some great information:

    http://blogs.aafp.org/fpm/gettingpaid/entry/decoding_the_new_tcm_rules

    I actually had BCBS deny a claim stating it is a non-covered service. I don’t know if any of you have had the same problems, if so, what insurance companies are denying? Of course, the provider who billed the TCM code didn’t document correctly so I can’t appeal it but I was just wondering if anyone else has seen denials.

  24. Roxanne Thames says:

    Yes Nan Woodruff, these codes also apply to discharge from a rehab facility. The CPT book has a very detailed description of this information.

    Another person here mentioned getting a denial and one of my offices has received that same denial that it was a non covered service. I have the biller from that site calling the insurance company to get a more detailed/clear logic beside the rejection code on the eob.

  25. Pam Pearson says:

    I am wondering if someone can clarify clinical staff in the sentence below?

    “The additional reimbursement compensates for non-face-to-face activities (e.g., communication with home health agencies) performed by the provider and/or clinical staff under the direction of the provider.” Information that I have read states “licensed” provider… Can a medical assistant contact the patient and obtain the key history elements then get the provider on the phone to review the hisotry and determine risk?

    Pam

  26. pacha says:

    Hello everyone!

    I have a question about the TCM codes. our doctor PCP has his own practice and he did not see the patients at the hospital. Can we bill for TCM codes when the patient discharged from hospital and come back to the primary care physician. our medical coder said that we cannot bill for TCM codes because our physician did not see the patient at the hospital. Can some one help me with this please.

  27. Jen says:

    Is TCM billing different from the Physician Oversight (CPO G0179, G0180, G0181, G0182)?

  28. Joann says:

    Are there certain criteris that must be met in order to qualify as ‘moderate’ or ‘high’ level of care? How is that determined.

    Also, do commerical insurances have these codes, or is it just Medicare?

    Thanks

  29. KMATTE says:

    I have the same question as above. If we did not see the patient in the hospital can we still bill a TCM?

  30. Rebecca says:

    Patient discharged on a Saturday has an appointment in our office for Monday phone call was not made due to it being the weekend but patient is being seen within two days of discharge…Does this still qualify for transitional care coding?

  31. Heather says:

    The links above from Camille are broken. Can anyone provide active links?

  32. tracy helget says:

    Rebecca: Yes, since the appointment is within two BUSINESS days of discharge, the appointment can count as the contact.

  33. tracy helget says:

    Joann, the moderate or high complexity of care is determined using the same factors you would use in determining complexity of decision making for any E&M visit.

  34. tracy helget says:

    KMATTE, yes, you may use the TCM codes even if you did not see the patient in the hospital setting. The codes are intended to “transition” the patient from hospital care to self-care and keep them from returning to the hospital. The TCM codes are intended to be used, generally, by the PCP, but can be used by other providers. However, only ONE provider can claim the TCM codes.

  35. Gary says:

    I needed some clarification on non-face-to-face services component. The CPT guidelines are that..” it may be performed by the physician or other qualified helath care professional and /or licensed clinical staff under his or her direction”, My question is can a medical assistant do this componant of TCM or they need to be lisensed? As far as I understand MAs are not lisensed in the state of California.
    Please share your experience.
    Thanks alot.

  36. Susan Cooper says:

    Iam still confused about these codes.
    I understand you call or make some contact with patient 2 days after discharge. I know you document it. Do you see the patient in the office 7 or 14 days after discharge for a regular E/M code? Then on the 30th day you bill the TCM?
    Can anyone help?

  37. Tiffany Hahn says:

    Joann- I hope the link below helps re: the criteria under “Q2” I believe that answers your question
    http://www.aafp.org/dam/AAFP/documents/practice_management/payment/TCMFAQ.pdf

    Jen- Yes those are different the G codes you are referring too are Home Health/Home Care Services.

    Pacha- Yes you can bill the TCM codes even if the provider did not see the patient in the hospital. Our providers do not visit the patients in the hospital and we can bill the codes and have gotten paid I clarified this with CMS.

    Susan Cooper- The E/M code billed for the visit from the discharge would be the TCM codes, the visit should only be re: the discharge but we have it happen to where patients will bring up other issues not re: their discharge but you do not bill an E/M that day you would bill the E/M 30 days from the discharge, not the DOS.

  38. Hayat Lutes says:

    Do you need an order for a TCM visit?

  39. Jacque says:

    Can someone clarify whether you can submit a TCM for a patient even if they go back to the hospital before 30 days. When this code first came out the AAFP posted a FAQs document (Feb 2013) that stated:

    Q15: What happens if the patient is re-admitted before the 30 days are up?
    A15: the face-to-face visit would become the appropriate level E/M code for the service that was rendered. You would start your 30 days of service on the TCM over once the patient was discharged.

    Then in March 2013 CMS posted a FAQ stating:

    If the beneficiary is readmitted within the 30-day period, can TCM still be reported?
    Yes, TCM services can still be reported as long as the services described by the code are furnished by the practitioner during the 30-day period, including the time following the second discharge. Alternatively, the practitioner can bill for TCM services following the second discharge for a full 30-day period as long as no other provider bills the service for the first discharge. CPT guidance for TCM services states that only one individual may report TCM services and only once per beneficiary within 30 days of discharge. Another TCM may not be reported by any practitioner for any subsequent discharge(s) within 30 days.

    This confused my physician as to what we could do when a patient is readmitted to the hospital. Last year we went ahead and did not file TCM’s for patients who were re-admitted before the 30 day. But in Dec 2013 we had a patient re-admitted on the 30th day which is why we are revisiting this. Any advice is greatly appreciated.

  40. Jacque says:

    Hayat: You do not need an order for the TCM visit itself. The only reason you would need an order is if you needed an order to see the patient for a regular office visit. Is your physician the PCP? What insurance does your patient have? What is your practice specialty?

  41. Charles Wilt says:

    Has CMS published information about TCM educating beneficiaries about this service? If so, where can it be accessed?

  42. Dustin says:

    Has anyone determined what qualifies as a “transitional care” diagnosis? I would think it would have to be an life altering diagnosis. Can someone give me some examples of the diagnosis they are using, especially any Cardiologists.

  43. Joyce says:

    How is the TCM determined? Is it by the discharge physician? Not every stay may require a TCM (based on the moderate to high MDM), how do you differentiate between billing it and billing a follow up E&M? If the documentation does not support a moderate to high MDM can you bill it as an office visit (provided the documentation supports it)? If the patient had a regularly scheduled visit and in the interim happened to be in the hospital. Can the scheduled visit be the TCM visit? I would also think that you would still have to do the required call in 2 days, discharge documentation & medication review as well in order to have it meet the guidelines?

  44. Julie says:

    A question was just asked in our office, what if the patient passes away prior to the release of the 30 day claim. Can we still bill the TCM?

    Thanks

  45. Brittany says:

    Julie –

    No, per CMS you cannot bill TCM if the patient passes away w/in the 30 days. You must change your visits to regular E/M codes.

  46. Bryan Donovan says:

    Gary posted recently: “I needed some clarification on non-face-to-face services component. The CPT guidelines are that..” it may be performed by the physician or other qualified health care professional and /or licensed clinical staff under his or her direction”, My question is can a medical assistant do this component of TCM or they need to be licensed? As far as I understand MAs are not licensed in the state of California.
    Please share your experience.
    Thanks alot.”
    I have same question. Furthermore, I am wondering if a BSW can make referrals to social service agencies such as Meals on Wheels or Senior Companion, as it may come up as a need for the TCM beneficiary. I would consider this a non face-to-face interaction. These could be vital links made to keep people at home. However, a BSW is not licensed.
    If you care to share more or bounce ideas back and forth please email me at bwdonovan@yahoo.com. I am building a TCM program now and I am always looking for ideas and feedback.
    Thank you,
    Bryan Donovan
    Buffalo, New York

  47. Julie Y says:

    Provider bills out TCC code on the 30th day. Medicare pays and then takes back due to the fact the patient was readmitted to rehab again. The first discharge was with my provider and we billed 30 days after the discharge date. The patient then got readmitted some place else 15 days after their first discharge. Which is why Medicare is now taking back payment on my TCC. Since services were accurate to bill how is this really fair to the provider who performed services, was paid and then if the patient is readmitted some place else. How can Medicare really take back money. Appeal or bill out an E/M visit even though it’s much lower reimbursment and TCC was paid originally.

  48. Annette G says:

    I have a question regarding TCC billing. I know the 30 day rule starts with day of discharge, but what about the 7 or 14 days after d/c for pt. to be seen. Does day 1 start on day of discharge, or day after? Also when it says to contact the patient within 2 days of discharge, can they be called the day of discharge or is it the next two days after discharge. The rules are clear as mud and I cannot seem to nail the answer to this question down. Help would be really appreciated by anyone!!
    Thanks so much!

  49. Julie says:

    My understanding is that a Medical Assistant cannot perform these services, because guidelines require licensed practitioners, and a Medical Assistant is not a licensed professional.

  50. cecdkc says:

    Can anyone answer this question: last day patient was seen was 12/29. The patient’s insurance changed 1/1. If we bill the new insurance on the 30th day, We anticipate denial, as the TCM began prior to coverage; we also anticipate a denial from the original insurance, as most of the 30 days occurred after their coverage terminated. Suggestions??

  51. Beverly says:

    Could you verify for me, from what I read about TCM, we can’t bill it if we have billed CPO within the last 30 days. Is this true? What about billing CPO if it has been 30 days since the last CPO, and the TCM has been billed within less than 30 days?

  52. ASaiz says:

    Thank you for your comment. You’ll find a lot of suggestions and better answers to your question in the Member Forums.

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