Transitional Care Management—Frequently Asked Questions (FAQs)
Why is transitional care management (TCM) important?
Transitioning care effectively is a core competency for all high-performing, value-based organizations, regardless of payer mix. Transition of care support is pivotal to achieving the Quadruple Aim:
What current procedural terminology (CPT) codes do I use to report TCM?
The level of medical decision-making and the time frame for the face-to-face visit determines which CPT code to use (e.g., if the patient requires moderate complexity decision-making and is seen within seven days post-discharge, 99495 must be used).
Why shouldn’t I just bill an office visit instead (i.e., CPT 99214)?
This code represents the second highest level of care for established office patients with a reimbursement of $108 and a 1.5 RVU. Comparatively, CPT 99495 reimbursement is $168 and a 2.11 RVU, and CPT 99496 is $237 and a 3.05 RVU.
What is required to document in the patient’s medical record?
At a minimum, the following is required:
- Date the patient was discharged.
- Date of the interactive contact with patient or caregiver.
- Date of the face-to-face visit.
- Complexity of medical decision-making (moderate or high)—more information on medical decision-making can be found below.
What care settings qualify for TCM?
Patients discharged to their home from the following settings qualify for transitional care management:
- Inpatient acute care hospital
- Inpatient psychiatric hospital
- Long-term care hospital (LTCH)
- Skilled nursing facility
- Inpatient rehabilitation facility
- Hospital outpatient observation or partial hospitalization
- Partial hospitalization at a community mental health center
Can a provider bill for a TCM visit for both new and established patients?
Effective February 2013, TCM codes can be billed for new and established patients.
What are the three components required to bill a TCM?
- An interactive contact by the physician or clinical staff with the patient and/or caregiver via telephone, email, or face-to-face to address needs beyond scheduling follow-up care.
- Certain non-face-to-face services must be furnished by physicians or APPs. For example:
- Obtain and review discharge information.
- Review the need for, or follow up on, pending diagnostic tests and treatments.
- Interact with other health care professionals who will assume or resume care of the patient’s system-specific problems.
- Provide education to the patient, family and/or caregiver.
- Establish or reestablish referrals and arrange for needed community resources.
- Assist in scheduling required follow-up with community providers and services.
- Face-to-face visit within 14 days of discharge. The CPT code is determined by the level of medical decision-making (moderate or high) and if the follow-up appointment was within 7 days or 8-14 days post-discharge. Medication reconciliation must be completed on or before the date of the face-to-face visit.
What does the Coordinated Care central care management team do regarding TCMs?
The clinically integrated network has developed a centralized population health care management team that can support practices in these workflows. They have begun delivering a daily discharge list of value-based contract attributed lives to practices and will work on delivering these to all practices this coming year. They have also begun providing TOC calls for a couple practices utilizing best practice scripting and assessment tools.