Provider Insider

Clinical Programs

Winter 2020 | Issue No. 8

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?

  1. 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.
  2. 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.
  1. 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.