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.