Transitional care management and reimbursement opportunities
CMS requirements
The 30-day TCM period begins on a person’s inpatient discharge date and continues for the next 29 days. Patients qualify for TCM services when they are discharged from one of the following settings:
- Inpatient acute care.
- Hospital outpatient observation or partial hospitalization.
- Skilled nursing facility.
- Inpatient rehabilitation facility.
- Long-term care hospital.
- Inpatient psychiatric hospital.
- Partial hospitalization at a community mental health center.
The following health care professionals may furnish TCM services:
- Physicians (any specialty)
- Nurse practitioners
- Physician assistants
- Certified nurse-midwives
- Clinical nurse specialists
Required components for TCM:
- Interactive contact with the patient or caregiver within two business days after discharge via phone, email or in person, or two or more unsuccessful separate attempts in a timely manner.
- Non-face-to-face services:
- Review of discharge summary or continuity of care documents.
- Review need for, or follow up on, pending diagnostic tests and treatments.
- Interact with other health care professionals who will assume or reassume care of patient’s system-specific needs.
- Provide education to patient and family/caregiver.
- Establish or reestablish referrals and arrange for needed community services.
- Assist in scheduling required follow-up with community providers and services.
- Communicate with agencies and community services that the patient 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.
- Face-to-face visit.
- Medication reconciliation and management must take place no later than date of face-to-face visit.
- Documentation of medical decision making (moderate or high).
CPT codes:
***Level of medical decision making and then time frame for face-to-face visit determines which CPT code to use. For example, if patient is moderate complexity decision making and seen within seven days of discharge, the CPT code 99495 must be used.
***Aetna, Anthem, Cigna, Humana and Kaiser reimburse for TCM services and follow CMS requirements.
Next steps
The CIN is currently developing tools to help support the TCM services; look for this in the next newsletter.
Please contact [email protected] with any questions.