There are three kinds of care for a Medicare patient after being an inpatient. They are Transitional Care, Chronic Care Management, and Complex Care Management. Each of these is a critical component of primary care that contributes to better health and care for beneficiaries. 

Transitional care management (TCM) is the coordination and continuity of healthcare during a movement from one healthcare setting to either another or to home. It addresses the period between the inpatient stay 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. 

Home, Domiciliary Care, Rest Home, or Assisted Living Facility.

The requirements for TCM services include services during the beneficiary's transition to the community setting following particular kinds of discharges: 

Note: CNMs, CNSs, NPs, and PAs may furnish non-face-to-face TCM services "incident to" the services of a physician and other CNMs, CNSs, NPs, and PAs.
 
One must furnish the required face-to-face visit under minimum direct supervision, subject to applicable State law, scope of practice, and the Medicare Physician Fee Schedule (PFS) incident to rules and regulations and may provide the non-face-to-face services under general supervision. These services are also subject to applicable State law, scope of practice, and the PFS incident to rules and regulations. The practitioner must order services, maintain contact with auxiliary personnel, and retain professional responsibility for the services. 

Within two (2) business days following the beneficiary's discharge, a member of the practice must make an interactive contact with them and/or their caregiver via telephone, email, or face-to-face. You or clinical staff can address patient status and needs beyond scheduling follow-up care. Report the service if you make two or more unsuccessful separate attempts in a timely manner. Document your attempts in the medical record if you meet all other TCM criteria. Continue your attempts to communicate with the beneficiary until they are successful. If the face-to-face visit is not within the required timeframe, you cannot bill TCM services (for more information, see the Face-to-Face Visit section). 

The provider must furnish non-face-to-face services to the beneficiary, unless you determine they are not medically indicated or needed. Clinical staff under your direction may provide certain non-face-to-face services. 

• Communicate with agencies and community services the beneficiary uses 
• Provide education to the beneficiary, family, guardian, and/or caretaker to support self-management, independent living, and activities of daily living 
• Assess and support treatment adherence and medication management
• Identify available community and health resources 
• Assist the beneficiary and family in accessing needed care and services
  

The 30-day TCM period begins on the beneficiary's inpatient discharge date and continues for the next 29 days. The provider must furnish medication reconciliation and management on or before the date of your face-to-face visit. 

CPT® Code 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 

CPT® Code 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 

Medical decision-making is selected according to the definitions in the 1995 and 1997 E/M Guidelines.

Telehealth Services
A provider may furnish CPT codes 99495 and 99496 via telehealth. Medicare pays for a limited number of Part B services a physician or practitioner furnishes to an eligible beneficiary via a telecommunications system. Using eligible telehealth services substitutes for an in-person encounter. 

When one reports CPT® codes 99495 and 99496 for Medicare payment, do not report the following codes during the TCM service period: 

As healthcare moves from volume to value, TCM will be increasingly important. This service ensures that patients receive the care they need immediately after a discharge from a hospital or other healthcare 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.

Maxine Lewis, CMM, CPC, CPC-I, CPMA, CCS-P, is a member of the National Society of Certified Business Consultants and is a nationally recognized lecturer, author, and consultant in the healthcare industry, combining more than 40 years of practical experience in the medical office with an in-depth understanding of coding, reimbursement, and management issues of the medical profession.