Transitional Care Management, CPT Codes, 90951, g0182, 90970, 99359
Transitional Care Management
May 06, 2020
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.
The discharge may be from:
Inpatient acute care hospital
Inpatient psychiatric hospital
Long-term care hospital
Skilled nursing facility
Hospital outpatient observation
After inpatient discharge, the beneficiary must return to their community setting, such as:
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:
Healthcare professionals accepting care of the beneficiary post-discharge from the facility setting without a gap
Healthcare professionals taking responsibility for the beneficiary's care
Moderate or high complexity medical decision-making for beneficiaries who have medical and/or psychosocial problems
These healthcare professionals may furnish TCM services:
Physicians (any specialty)
Non-Physician Practitioners (NPPs) legally authorized and qualified to provide the services in the State where they furnish them
Certified Nurse-Midwives (CNMs)
Clinical Nurse Specialists (CNSs)
Nurse Practitioners (NPs)
Physician Assistants (PAs)
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.
Services Furnished by Physicians or NPPs
Physicians or NPPs may furnish these non-face-to-face services, such as:
Obtaining and reviewing discharge information (for example, discharge summary or continuity-of-care documents)
Reviewing the need for, or follow-up on, pending diagnostic tests and treatments
Interacting with other healthcare professionals who will assume or reassume care of the beneficiary's system-specific problems
Provide education to the beneficiary, family, guardian, and/or caregiver
Establish or reestablish referrals and arrange for needed community resources
Assist in scheduling required follow-up with community providers and services
Services Provided by Clinical Staff Under the Direction of a Physician or NPP
Clinical staff under the provider's direction may provide these services, subject to the State's supervision law, and other rules already discussed:
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.
The provider must furnish one face-to-face visit within certain timeframes described by the following two Current Procedural Terminology® (CPT) codes:
99495 – moderate medical complexity requiring a face-to-face visit within 14 days of discharge
99496 – high medical complexity requiring a face-to-face visit within seven days of discharge
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.
This list provides billing TCM services information:
Only one healthcare professional may report TCM services.
Report services once per beneficiary during the TCM period.
The same healthcare professional may discharge the beneficiary from the hospital, report hospital or observation discharge services, and bill TCM services. The required face-to-face visit may not take place on the same day you report discharge day management services.
Report reasonable and necessary evaluation and management (E/M) services (except the required face-to-face visit) to manage the beneficiary's clinical issues separately.
The healthcare provider may not bill TCM services and services within a post-operative global surgery period (Medicare does not pay TCM services if any of the 30-day TCM period falls within a global surgery period for a procedure code billed by the same practitioner).
When one reports CPT® codes 99495 and 99496 for Medicare payment, do not report the following codes during the TCM service period:
Care Plan Oversight Services
Home health or hospice supervision: HCPCS codes G0181 and G0182
Chronic Care Management (CCM) services (CCM and TCM service periods cannot overlap)
Prolonged E/M Services Without Direct Patient Contact (CPT® codes 99358 and 99359)
Other services excluded by CPT® reporting rules.
What is Necessary for documentation of TCM?
At a minimum, document the following information in the beneficiary's medical record:
Beneficiary discharge date
Beneficiary/Caregiver interactive contact date
Face-to-face visit date
Medical complexity decision-making (moderate or high)
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.