TCM - Transitional Care Management

TCM codes 99495 and 99496 are used to report physician or qualified non-physician practitioner care management services for a patient following the patient’s discharge from:

·an inpatient hospital,

·partial hospital,

·observation status in a hospital,

·skilled nursing facility/nursing facility, or

·community mental health center

to the patient’s community healthcare setting, including:

·home,

·domiciliary,

·rest home, or

·assisted living.

TCM codes do not apply to patients who have only been seen in the emergency department.

Documentation and other rules

Requirements for billing TCM codes 99495 and 99496 include:

·the services are performed during the first 30 days of the beneficiary’s transition to the community setting following particular kinds of discharges;

·the healthcare provider accepts responsibility for the beneficiary’s care post-discharge from the facility setting without a gap; and

·the (new or established) patient has medical and/or psychosocial problems that require moderate or high complexity medical decision-making.

 

Documentation must include:

·date of initial discharge;

·date of post-discharge communication with patient or caregiver;

·date of the first face-to-face visit;

·medication reconciliation; and

·complexity of medical decision-making (moderate or high)

 

The TCM service period begins on the day of discharge and continues for the next 29 days. The reported date of service should be the 30th day.

The only codes bundled with TCM codes are care plan oversight services (CPT codes G0181 and G0182), and end-stage renal disease services (CPT codes 90951-90970). Additional services provided during the 30-day period (i.e., diagnostic tests, evaluation and management [e/m]services following the initial visit) can be billed separately.

The place of service reported on the claim should correspond to the place of service of the required face-to-face visit.

Medicare encourages practitioners to follow Current Procedural Terminology (CPT) guidelines when reporting TCM services. Medicare also requires that when a practitioner bills Medicare for services and supplies commonly furnished in physician offices, the practitioner must meet the “incident to” requirements described in Chapter 15, Section 60 of the Benefit Policy Manual 100-02.

It is important to emphasize that non-face-to-face services may be provided by licensed clinical staff members (i.e., an RN, LPN, CRN, but not an MA.) Such services include:

·communication with patient, family, guardian, caretaker, and/or other professionals;

·communication with home health agencies and other community services used by the patient;

·patient and/or family/caretaker education to support self-management, independent living, and activities of daily living;

·assessment and support for treatment regimen adherence and medication management;

·identification of available community and health resources; and/or

·facilitating access to care and services needed by the patient and/or family

For more information , please call 305-227-2383  or 1-877-938-9311

 

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