Angie Finnigan, CCS-P, CPMA, CPC
Aegis Compliance & Ethics Center, LLC
Transitional Care Management Compliance
Beginning January 1, 2013 Medicare began paying for Transitional Care Management Services (“TCM”) services (CPT codes 99495 and 99496) under the Physician Fee Schedule. Providers use these services for the management of a patient following discharge from an inpatient acute care hospital, inpatient psychiatric hospital, long-term care hospital, skilled nursing facility (“SNF”), inpatient rehabilitation, outpatient observation or partial hospitalization to a community setting (defined as patient home, patient domiciliary, rest home or assisted living). The 30-day TCM period begins on the day of discharge and continues for the next 29 days.
Who is Eligible to Provide TCM Services?
Health care professionals who may furnish and bill for TCM services include physicians and non-physician practitioners (“NPP”s) such as certified nurse midwives, clinical nurse specialists, nurse practitioners and physician assistants. Non-physician practitioners must be legally authorized and qualified to provide TCM services in the state in which the services are being furnished.
Components Required for TCM Services
There are three components required for TCM services. The first component is an interactive contact within 2 business days of discharge – this may be via telephone, email or face-to-face encounters. Either the physician or NPP, or licensed clinical staff who have the capacity to address patient status and needs beyond scheduling follow-up care must provide the interactive contact. If the first two attempts in two business days are unsuccessful, additional attempts to communicate in the required timeframe should be documented in the medical record. If all other TCM requirements are satisfied, the service may be reported.
The second component of TCM services is certain non-face-to-face services. Non-face-to-face services furnished by the physician or NPPs (unless determined not medically indicated or needed) include: obtain and review discharge information, review the need for follow-up on pending diagnostic tests and treatments, interact with other health care professionals if necessary, provide post-discharge education to the patient and/or caregivers, establish referral and arrange for needed community resources and assist in scheduling follow-up appointments. Non-face-to-face services furnished by licensed clinical staff under general supervision by the physician or NPP include: communicate with agencies and services used by the patient, provide education to support patient self-management or independent living, assess and support treatment, identify and provide available community resources and assist the patient and caregivers in assessing care and services.
The second required component for TCM services also includes a face-to-face visit furnished by the physician or NPP. This visit must be conducted within 7 or 14 calendar days of discharge, depending on the complexity of medical decision making required. The visit is part of TCM and may not be reported separately. Only one health care professional may report the TCM service. The date of service billed is the date of the face-to-face visit. Face-to-face services provided within 14 calendar days of discharge with medical decision making of moderate complexity are to be reported with CPT code 99495. CPT code 99496 is used for face-to-face services provided within 7 calendar days of discharge which have medical decision making of high complexity.
The final component required for TCM services is medication reconciliation and management. This must take place no later than the date of the face-to-face visit.
For services furnished on or after January 1, 2014, TCM services may be provided thru telehealth. The use of a telecommunications system may be used in lieu of a face-to-face encounter.
Minimum Documentation Requirements for TCM Services
The following is required documentation in the patient medical record: date the patient was discharged, date of the interactive contact with the patient and/or caregiver, date of the face to face visit and the complexity of medical decision making.
Billing Requirements for TCM Services
Items to remember when billing TCM services
- Only one health care professional may report TCM services
- TCM services may be reported once per patient in the 30 days post discharge
- The same health care professional may provide both the discharge and TCM services
- The face-to-face service may not occur on the day of discharge
- TCM services cannot be billed by the same practitioner during a global period
- Reasonable and necessary E/M services (other than the required face-to-face visit) may be reported to manage a patient’s clinical issues separately
When billing TCM services, do not bill the following:
- Care Plan Oversight services
- Home Health or Hospice supervision
- End-Stage Renal Disease (ESRD) services
- Chronic Care Management services
- Prolonged E/M services without direct patient contact