Q&A: Transitional Care Management Contact Requirements after Discharge

“Communication” and “interactive contact” ambiguity creates a gray area for when to report these services.

By Michael D. Miscoe, JD, CPC, CASCC, CUC, CCPC, CPCO
Q: A patient is contacted by phone or email on business day 2 after discharge by the provider who is to perform transitional care management (TCM) services, but the patient does not reply back to the provider/staff until business day 5. Assuming the face-to-face encounter and all other requirements of the appropriate TCM code are satisfied, may we report the TCM service?
A: This is a great question because there is no clear answer. The TCM code descriptors and published CPT® Editorial Panel guidance are ambiguous. Let’s begin our TCM code analysis with Panel guidance published in the CPT® codebook:
TCM requires a face-to-face visit, initial patient contact, and medication reconciliation within specified time frames. The first face-to-face visit is part of the TCM service and not reported separately. Additional E/M services provided on subsequent dates after the first face-to-face visit may be reported separately. TCM requires an interactive contact with the patient or caregiver, as appropriate, within two business days of discharge. The contact may be direct (face-to-face), telephonic, or by electronic means. Medication reconciliation and management must occur no later than the date of the face-to-face visit [emphasis added].
These services address any needed coordination of care performed by multiple disciplines and community service agencies. The reporting individual provides or oversees the management and/or coordination of services, as needed, for all medical conditions, psychosocial needs and activity of daily living support by providing first contact and continuous access.
Medical decision making (MDM) and the date of the first face-to-face visit are used to select and report the appropriate TCM code. For 99496, the face-to-face visit must occur within seven calendar days of the date discharge and MDM must be of high complexity. For 99495, the face-to-face visit must occur within 14 calendar days of the date of discharge and MDM must be of at least moderate complexity.
Code  Selection

Type of MDM Face-to-face visit within 7 days Face-to-face visit
within 8 to 14 days
Moderate complexity 99495 99495
High complexity 99496 99495

MDM is defined by the 1995 and 1997 Documentation Guidelines for Evaluation and Management Services. The MDM over the service period reported is used to define the MDM of TCM. Documentation includes the timing of the initial post discharge communication with the patient or caregivers, date of the face-to-face visit, and the complexity of medical decision making.
Only one individual may report these services and only once per patient within 30 days of discharge. Another TCM may not be reported by the same individual or group for any subsequent discharge(s) within the 30 days. The same individual may report hospital or observation discharge services and TCM. However, the discharge service may not constitute the required face-to-face visit. The same individual should not report TCM services provided in the postoperative period of a service that the individual reported.
Note that the above instruction requires “interactive contact” within two business days between the provider and the patient. Compare that guidance with the CPT® definition of relevant TCM codes:
99495Transitional Care Management Services with the following required elements:
Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge [emphasis added]
Medical decision making of at least moderate complexity during the service period
Face-to-face visit, within 14 calendar days of discharge
99496Transitional Care Management Services with the following required elements:
Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge [emphasis added]
Medical decision making of high complexity during the service period
Face-to-face visit, within 7 calendar days of discharge
Charting Muddy Water
The question is whether “communication” can be a one-way event (as suggested by the code description), or whether it must be a two-way event (involving a response), as implied by the requirement for “interactive contact” in the Panel guidance.
The Panel does not precisely define “interactive contact.” Although it can be accomplished either by phone or electronic means (e.g., email), it’s unclear whether the Panel intended the contact to be merely initiated within two business days, or completed within that period (i.e., the patient responded to the telephone call or email).
If mere contact initiation is required by the provider, then not only would it be supported by the actual code description, which requires only “communication” with the patient, but you also must recognize that the code (like all codes) is intended to represent the work of the provider, not the patient.
For example: The provider contacts the patient within two-business days and leaves a message establishing an appointment time for the face-to-face encounter. The patient receives this message, comes to the physician’s office for the appointment, and the appropriate TCM work is performed. Although there was no “interaction” within two business days, the provider did “communicate” with the patient within the required time. In that respect, you could conclude that when the provider makes a call or sends an email to initiate contact, as required by the code, he or she has met the code requirements. If the patient does not receive the communication — or receives it, but never responds — you cannot report the TCM because there was no face-to-face encounter.
Resolution Depends on What Is Satisfied
You also could argue that these codes require exactly what the Panel suggests in its instructions: An “interactive” communication. Absent interaction between the provider and patient, followed by the requisite face-to-face encounter, the requirements of the TCM codes (according to Panel guidance) are not satisfied. But all is not lost: The physician, at the face-to-face encounter, could bill the appropriate outpatient evaluation and management (E/M) service. In this case, the patient’s failure to complete the attempted interactive contact within two business days should be documented as the basis for reporting an outpatient E/M, rather than TCM.
How to resolve this ambiguity is up to each individual payer. Because CMS generally defers to CPT® Editorial Panel guidance for resolving code selection issues (see Medicare Program Integrity Manual, IOM, Pub. 100-8, Ch. 3, §, which does not include secondary sources such as CPT® Assistant or CPT® Changes, this remains an open question that must be clarified by the Panel in upcoming guidance published in CPT®, by CMS through an MLN Matters® article, or through local guidance published by Medicare administrative contractors.
From a compliance risk perspective, in the scenario provided, you might consider erring on the side of caution and reporting the lower-value code (e.g., an outpatient E/M).
Michael D. Miscoe, JD, CPC, CASCC, CUC, CCPC, CPCO, has more than 20 years of experience in healthcare coding and over 16 years as a compliance expert, forensic coding expert, and consultant. He has provided expert analysis and testimony on a wide range of coding and compliance issues in civil and criminal cases and his law practice concentrates exclusively on representation of healthcare providers in post-payment audits as well as with responding to HIPAA OCR issues. Miscoe speaks on a national level, and is published in national publications on a variety of coding, compliance, and health law topics. He serves on AAPC’s Ethics Committee, National Advisory Board, and Legal Advisory Board, and is a member of the Johnstown, Pa., local chapter.

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Renee Dustman, BS, AAPC MACRA Proficient, is managing editor - content & editorial at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. Renee has more than 30 years' experience in journalistic reporting, print production, graphic design, and content management. Follow her on Twitter @dustman_aapc.

5 Responses to “Q&A: Transitional Care Management Contact Requirements after Discharge”

  1. jitendra says:

    nice post about transitional care management…..keep sharing

  2. Colleen says:

    Thankyou for this informative article. I so have a question regarding the jan 1 2016 TCM change. We can now send the claim in on the day the patient was seen, my question is…if the patient is re admitted within the 30 days and we have released the 1st TCM and now may have another visit after the next discharge, we now have 2 tcm for that month. so do we have to refund, recode to an ov level and refile the first visit?

  3. Peggy Capozzoli says:

    I have the same question as Coleen’s question above. For 2016, if we bill out the TCM on the same day (not wait the previously required 30 days) and the patient returns to the hospital in the interim of the 30 days. How is our original charge of the TCM handled? Is the original TCM then denied or is an insurance refund requested and then we bill a level??

  4. Alice Morgan says:

    That is a good question these ladies have posed. However, I do not see the answer. As a matter of fact, I have not seen the new rule for billing the TCM the day of the face to face visit and I just received an email from CGS’s Inquiry Unit and nothing was mentioned of this new ruling!

  5. A Torres says:

    You have mentioned that if face-to-face encounter occur after 14 days, TCM may not be reported. What code should the physician use if the patient was seen after the 14th day?