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Transitional Care Management — Time to Get It Right!

Transitional Care Management — Time to Get It Right!

We can all agree that the face of medicine is changing. How care models are designed is essential to a successful, measurable healthcare quality outcome. In the past, providing care for a chronically ill patient with multiple comorbidities and frequent jumps between an acute care setting and their community often meant a great deal of behind-the-scenes work for healthcare professionals, with very little revenue reimbursement potential. In 2013, CPT® introduced two new codes for transitional care management (TCM) that allowed healthcare providers to capture the significant amount of work involved in managing these complex cases. Since then, however, there has been confusion about when these services can be performed, what needs to be documented, and how to code claims. Let’s clear up the confusion once and for all.

Understand the TCM Codes

To properly report these services, we first need to understand the TCM codes. The overall goal of TCM is to reduce the number of subsequent readmissions to an acute care facility by giving patients and their caregivers the knowledge and skills to address healthcare needs as they arise. These services utilize an evidence-based care coordination approach with the goal of streamlining care and addressing the most pressing needs of the patient at any given time. This is a multidisciplinary approach, with an emphasis on teamwork between community resources such as home health, the ancillary staff members who are accustomed to the patient’s needs, and the provider who relies on the entire team in managing the patient’s condition.

According to the definition of these services in CPT® 2021 Professional Edition, published by the American Medical Association, TCM services “are for a new or established patient whose medical and/or psychosocial problems require moderate or high complexity medical decision making during transitions in care from an inpatient hospital setting (including acute hospital, rehabilitation hospital, long-term acute care hospital), partial hospital, observation status in a hospital, or skilled nursing facility to the patient’s community setting (home, domiciliary, rest home, or assisted living).”

TCM is composed of both face-to-face and non-face-to-face services. Unlike most other evaluation and management (E/M) codes, TCM services span a period of time versus a single snapshot date of service. Time devoted to the entirety of the service begins upon discharge from an acute care facility to the patient’s community setting and continues for the next 29 days. The service is billed at the end of this period, with a date of service at least 30 days post-discharge.

A brief overview of the codes shows three key requirements:

99495 Transitional 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
  • Medical decision making of at least moderate complexity during the service period
  • Face-to-face visit, within 14 calendar days of discharge

99496 Transitional 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
  • Medical decision making of high complexity during the service period
  • Face-to-face visit, within 7 calendar days of discharge

CPT® clarifies, “Within 2 days of discharge is Monday through Friday except holidays without respect to normal practice hours or date of notification of discharge.” This means that if your provider conducts normal practice hours on Saturdays, it counts as a normal business day during which you have a chance to make contact with your patient. If the provider attempts communication by any means (telephone, email, or face-to-face), and after two tries is unsuccessful and documents this in the patient’s chart, the service may be reported.

In relation to providing the first face-to-face visit, calendar days mean every day of the week regardless of operating hours: For 99495, the provider has up to 14 days after discharge to see the patient face-to-face. For 99496, the provider has up to seven days to see the patient face-to-face to evaluate their status post-discharge. The first face-to-face visit is an integral part of the TCM service and may NOT be reported with an E/M code. If in the next 29 days additional E/M services are medically necessary, these may be reported separately. You cannot report an E/M visit and a TCM service on the same day.

Why Both Face-to-Face and Non-Face-to-Face Visits?

Because of the complexity regarding most patients who qualify for this service, there is a great deal of coordination between various healthcare providers to address all of the patient’s care needs. Examples of non-face-to-face services for the clinical staff include:

  • Communication with the patient or caregiver by phone, email, or in person.
  • Communication with various community services the patient may need, such as home health, prescription delivery, or durable medical equipment vendors.
  • Education to the patient or caregiver on activities of daily living and supporting self-management.
  • Assessment and support of treatment compliance and medication dosing adherence.
  • Identifying potential community services that the patient may benefit from and arranging access to the services as appropriate.

Examples of non-face-to-face services by the physician or other mid-level provider can include:

  • Reviewing discharge information, including pending testing or treatment.
  • Discussion with other providers responsible for conditions outside the scope of the TCM physician.
  • Working with clinical staff to formulate education for the patient and/or caregiver.
  • Establishing or reestablishing referrals for specialized care and assisting in the follow-up scheduling with these providers.

It is also incumbent that the physician reviews the patient’s medication log no later than the face-to-face visit occurring either seven or 14 calendar days after discharge, depending on the severity of the patient’s condition and the likelihood of readmission. Typically, the reconciliation of the medication log can be started by clinical staff reaching out in the two business days post-discharge. The physician will need to verify that the log has not changed at the time of the face-to-face visit.

MDM Requirements Apply

The same requirements for medical decision making (MDM) apply to TCM codes as they do to standard E/M codes. With the changes to Office and Other Outpatient Services (99202-99215) in CPT® 2021, there have been questions regarding the use of the new CPT E/M Office Revisions Level of Medical Decision Making (MDM) table. At this time, CPT® directs us to use the MDM guidelines for E/M services. Based on this guidance, our understanding is the 2021 MDM guidelines should be applied when leveling the complexity of the TCM service.


ONLINE UPDATE: A new CMS guideline regarding Transitional Care Management services was published in July 2021 that lists the old 1995/1997 MDM calculation.  


TCM Services Following Discharge

Only one healthcare provider may bill for TCM during the 30-day period following discharge. Usually, these codes are in the realm of primary care, but there are circumstances where the patient’s condition that required admission is managed by a specialist. For example, if a patient has a history of atrial fibrillation and congestive heart failure and they are admitted due to exacerbation of these conditions, TCM services following discharge would logically be provided by the patient’s cardiologist. This provider is best suited to provide comprehensive care and arrange the appropriate care model for these conditions. If a provider has privileges at a hospital and discharges one of their own patients, they may bill for TCM services. But be cautious: A provider cannot report discharge day management services AND perform the required face-to-face visit to initiate TCM on the same day.

Let’s say an orthopedic surgeon performs a total hip replacement on a patient. You may NOT bill for TCM services if the 30-day TCM period falls within the global period for that procedure. It would be up to the patient’s primary care physician to bill TCM if they deem it medically necessary.

There are services that CANNOT be billed during the 30-day TCM period by the same provider because they are considered duplicative of the work performed for TCM. Such non-billable services include:

  • Home healthcare oversight (G0181)
  • Hospice care plan oversight (G0182)
  • Care plan oversight (99339, 99340, 99374-99380)
  • Chronic care coordination services (99439, 99487, 99489-99491)
  • Prolonged services without direct patient contact (99358, 99359)
  • Medical team conferences (99366-99368)
  • Education and training (98960-98962, 99071, 99078)
  • Telephone services (98966-98968, 99441-99443)
  • End stage renal disease services (90951-90970)
  • Online medical evaluation services (98970-98972)
  • Preparation of special reports (99080)
  • Medication therapy management services (99605-99607)

Documentation Requirements

To support a TCM service, documentation must contain, at a minimum, the date the patient was discharged from acute care, the date the provider contacted the patient (two days post-discharge), the date the provider saw the patient face-to-face (either seven or 14 days), and the complexity of the MDM (moderate or high). The Centers for Medicare & Medicaid Services (CMS) has not issued specific documentation requirements of the face-to-face visit, but it is safe to assume that, at a minimum, the following elements must be documented in the patient’s record:

  • Date of discharge;
  • Date interactive contact was made with the patient and/or caregiver;
  • Date of the face-to-face visit; and
  • Complexity of MDM.

It is also important to note that TCM can be provided as a telemedicine service. When telemedicine is used, the best practice is to document the technology used and whether the patient agreed to the visit.

Essential Information

It’s important for your organization to have a thorough understanding of the E/M codes for TCM to ensure full and accurate reimbursement. Equally important, knowing the specifics of TCM billing and documentation will help your organization avoid auditing issues in the future.


Resources:

CPT® 2021 Professional Edition

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

www.cms.gov/medicare/medicare-fee-for-service-payment/physicianfeesched/downloads/faq-tcms.pdf

Evaluation and Management – CEMC

Elizabeth Hylton

About Has 3 Posts

Elizabeth Hylton, CPC, CEMC, is a senior auditor with AAPC’s Audit Services Group (formerly Healthcity). She began her coding career by identifying claims submission errors involving ICD-9 and CPT® codes on hospital claims. Hylton has worked as a charge entry specialist for a local family medicine practice; a coding tech I at Carolinas Medical Center–Northeast; a front desk clerk/coder at Sanger Heart and Vascular Institute; an auditor/educator for Carolinas HealthCare System; and a business office supervisor for one of the larger physician groups within Carolinas HealthCare System, where she gained experience with LEAN.

23 Responses to “Transitional Care Management — Time to Get It Right!”

  1. Mary F Eshbaugh says:

    “Time devoted to the entirety of the service begins upon discharge from an acute care facility to the patient’s community setting and continues for the next 29 days. The service is billed at the end of this period, with a date of service at least 30 days post-discharge.”

    This is confusing. If the patient must be seen face to face within 7 or 14 days after discharge how are we supposed to bill with a date of service at least 30 days post discharge? Do we bill the day we saw them or the day 30 days after discharge? If we bill 30 days later how would the insurance know if we saw the patient within the required time frame?

    My team lead says this is the old requirement and it has since been changed. Please advise.

  2. Sarah Britton, CRC says:

    “The service is billed at the end of this period, with a date of service at least 30 days post-discharge.”
    Thank you for the article and insight! I wanted to point out the comment above, I believe to be incorrect. Per CMS FAQ on TCMs (link above):
    “• 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 date of service you report should be the date of the required face-to-face visit. You may
    submit the claim once the face-to-face visit is furnished and need not hold the claim until the end of
    the service period.”

  3. Robin Bretey says:

    Just to clarify. The billing of the TCM should be billed 30 days after discharge from acute facility?? Not the day of the face to face with physician.

  4. Kat G says:

    Hello, our office is open on Saturdays but only for a half day. Is that still considered a business day for contacting the patient post discharge?

  5. Amy Griffin says:

    According to the MLN booklet by CMS dated July 2021 the list of services that can be billed concurrently has been updated to include services such as ESRD, CCCM, CCM, and prolonged E/M services. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/transitional-care-management-services-fact-sheet-icn908628.pdf

  6. Renee Dustman says:

    We recently discovered a new CMS guideline regarding Transitional Care Management services published in July 2021 (see link below) that lists the old 1995/1997 MDM calculation.

    https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Transitional-Care-Management-Services-Fact-Sheet-ICN9086

    Since the implementation of the 2021 EM guidelines the industry has been questioning the use of the new MDM calculations. This was a topic our quality team researched earlier in the year and could not find anything definitive only a suggestion to use the 2021 guidelines. Based on CPT instructions to use the current MDM calculation our understanding was to use the 2021 guidelines. The CMS publication overlapped the time this article was written and the publication in HBM.

  7. Renee Dustman says:

    Per CMS’s TCM booklet at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Transitional-Care-Management-Services-Fact-Sheet-ICN908628.pdf
    ” the “30-day period,”
    which begins when a physician discharges the patient from an inpatient stay
    and continues for the next 29 days.

  8. Renee Dustman says:

    For the purposes of TCM, business days are Monday through Friday, except holidays, without respect to normal practice hours or date of notification of discharge.

  9. naomi says:

    Are commercial insurance reimbursing on these codes? Like FL Blue, UHC, Humana etc.

  10. Donna Morais says:

    Can TCM be billed for a Facility with a Rendering PCP on the claim?

  11. Susan Garland says:

    Seeking clarification on the definition of attempts –
    Documentation states “This writer attempted phone call to patient for the purpose of follow up after hospital admission, discharged yesterday. Unable to leave message on both provided phone numbers as voicemail states “not available”. ”
    Would the act of calling 2 phone numbers be considered 1 attempt all together or count as 2 separate attempts??

  12. Lee-Fifield says:

    Susan, calling two different phone numbers would be two separate attempts.

  13. Mary says:

    Does the date of discharge count as day ONE of the 7 day and 14 day ?

  14. Charity Evans says:

    Kind of confused because the webinar titled “Transitional Care Management Good Patient Care with Good Payment for Time Spent” instructs us to use the 2021 E/M Guidelines and the hyperlink noted in this article doesn’t work. Is it possible to update either the link or provide clarification on both ends as to which is correct?

  15. Lee-Fifield says:

    Charity, I am sorry the link was broken. It has been fixed. You can now link from either the article or the resources section.

  16. Becky Blouin says:

    Since some commercial insurance do pay for 99495 & 99496 Transitional Care Encounters – has anyone run into the charges going to patient deductible? The patient gets a substantial bill for an encounter that was NOT patient initiated in the first place. We make first contact and we ask them to come in withing 7-14 days following discharge. BCBS put this charge to a patients deductible – I thought charges to deductible must be patient initiated?? Thoughts?

  17. Chris Silva says:

    Is it appropriate to bill additional E/M to the TCM if provider addresses other conditions during the same visit that require to be assessed for lets say medication refills?

  18. Dawn says:

    I have providers billing TCM and the minimal documentation requirements are met , such as the interactive telephone call, and OV within the 14 days , and Moderate MDM level. Hospital records are reviewed and labs may be ordered. At office visit, patient is doing well and there is no other communication during the 29 days, nothing else is being done. Should this be billed as a regular office visit?

  19. Brey says:

    The hyperlink is still not working correctly on CMS website. Has anyone verified with CMS if it is appropriate to use 95/97 E/M guidelines, or 2021 OP E/M guidelines regarding MDM?

  20. Denise says:

    Does the time of discharge count? If a pt is discharged on Monday at 12pm is the initial contact expected to be made by Wednesday at 12 pm?

  21. Devon C Newman, CPC says:

    I have encountered numerous Outreach entries which state, “Pt d/c’d from hospital on 8/26/22. Will be seen by PCP within 48 hours of d/c.
    No TOC call required.” I am tempted to call, “Shenanigans” on this but, I can see the point if the pt is discharged on Monday and seen on Wednesday, perhaps. However, in one particular instance, the pt was discharged Friday and seen Monday, so, technically that would not be within 48 hours as the “count” begins on the day OF discharge with regards to the face to face TCM visit, as opposed to the “2 business days” for the outreach. Can you please speak to the credibility of this last situation? It seems to me that the criteria regarding the outreach were not met here… but I have been known to overthink things. Thank you

  22. Renee Dustman says:

    In the scenario, where the patient was discharged on Friday and seen on Monday, it would be considered within “2 business days.” The weekends and holidays should not be counted.

    Marina A. Gregory, CPC, CPMA, CEMC