Transitional Care Management

What is Medicare Transitional Care Management (TCM)?

Transitional Care Management (TCM) services address the hand-off period between the inpatient and community setting. After a hospitalization or other inpatient facility stay (e.g., in a skilled nursing facility), the patient may be dealing with a medical crisis, new diagnosis, or change in medication therapy. Family physicians often manage their patients’ transitional care.

TCM Coding

The two CPT codes used to report TCM services are:

• CPT code 99495 – moderate medical complexity requiring a face-to-face visit within 14 days of discharge
  
• CPT code 99496 – high medical complexity requiring a face-to-face visit within seven days of discharge

Requirements and Components for TCM

• Contact the beneficiary or caregiver within two business days following a discharge. The contact may be via telephone, email, or a face-to-face visit. Attempts to communicate should continue after the first two attempts in the required business days until successful.
• Conduct a follow-up visit within 7 or 14 days of discharge, depending on the complexity of medical decision making involved. The face-to-face visit is part of the TCM service and should not be reported separately.
• Medicine reconciliation and management must be furnished no later than the date of the face-to-face visit.
• Obtain and review discharge information.
• Review the need for diagnostic tests/treatments and/or follow up on pending diagnostic tests/treatments.
• Educate the beneficiary, family member, caregiver, and/or guardian.
• Establish or re-establish referrals with community providers and services, if necessary.
• Assist in scheduling follow-up visits with providers and services, if necessary.

Discharge from any of the following:

• Inpatient acute care hospital
• Long-term acute care hospital
• Skilled nursing facility/nursing facility
• Inpatient rehabilitation facility
• Hospital observation status or partial hospitalization

Health Care Professionals Who May Furnish and Bill TCM Services:

• Physician (any specialty)
  
• Clinical nurse specialist (CNS)
  
• Nurse practitioner (NP)
  
• Physician assistant (PA)
  
• Certified nurse midwife

Non-physicians must legally be authorized and qualified to provide TCM services in the state in which the services are furnished.

AAFP’s Position on TCM Services

The AAFP’s advocacy efforts have helped pave the way for Medicare payment for TCM services, giving family physicians an opportunity to be paid to coordinate care for Medicare beneficiaries as they transition between settings. We believe that family physicians should be compensated for the value they bring to their patients by delivering continuous, comprehensive, and connected health care.

What You Need to Know

As health care moves from volume to value, TCM services will be increasingly important. These services ensure patients receive the care they need immediately after a discharge from a hospital or other health care facility. Continuity of care provides a smooth transition for patients that improves care and quality of life, and helps prevent unnecessary readmission, thereby reducing costs.

Approaches to Help Your Practice Get Started

• Identify hospitals and emergency departments (EDs) responsible for most patients’ hospitalizations. With the shared goal of decreasing readmissions, develop a relationship with those hospitals to improve timeliness of notification, so the practice can reach out to patients within two business days of discharge.
• Add this service to decrease cost of care by reducing unnecessary readmissions.
• Add this service after the annual wellness visit and chronic care management (CCM) as the volume and associated revenue of this service is hard to anticipate.