CMS’ Coding Rules for Transition Care Management

by | Published on Sep 8, 2017 | Medical Coding

CMS Coding
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This is an update on the July 3, 2017 blog “Ensuring Accurate Claim Submission for Transitional Care Management Services“.

Transitional care management (TCM) describes the oversight and coordination of healthcare services for patients transitioning from an inpatient hospital setting. Medical coding services for Transitional care management (TCM) involve using accurate codes in claims. Medicare encourages practitioners to follow CPT guidance in reporting TCM services. CPT guidance for TCM services states that only one individual may report TCM services and only once per patient within 30 days of discharge. Another TCM may not be reported by the same individual or group for any subsequent discharge(s) within 30 days.

The CPT codebook provides codes and guidelines to report TCM, which allows providers to recoup payment for services they may already provide to their patients.

Medicare CPT Codes for TCM

In an effort to better identify these preventable readmissions, Medicare created 2 new codes, 99495 and 99496, which are reimbursable for non-face-to-face and face-to-face transitional care coordination services. 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.

These codes can be used when,

  • 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 patient has medical and/or psychosocial problems that require moderate or high complexity medical decision-making

These codes for TCM Services come with the following required elements:

99495 99496
Communication (direct contact, telephone, electronic) with the patient and/or caregiver within two business days of discharge within two business days of discharge
Medical decision making of at least moderate complexity during the service period of high complexity during the service period
Face-to-face visit within 14 calendar days of discharge within seven calendar days of discharge

Medical decision making of at least moderate complexity during the service period of high complexity during the service period

Face-to-face visit within 14 calendar days of discharge within seven calendar days of discharge

  • Both TCM codes require communication with the patient or caregiver within two business days (not calendar days) of discharge.
  • Specifically, CPT guidelines state, “The contact may be direct (face-to-face), telephonic, or by electronic means [e.g., e-mail].”
  • TCM cannot be billed, if the face-to-face visit is not furnished within the required timeframe.
  • If the provider attempts to reach the patient or caregiver, but is unsuccessful within two business days, CPT allows you to still report the service.
  • Other reasonable and necessary Medicare services like chronic care management (CCM) may be reported during the 30 day period, with the exception of those services that cannot be reported according to CPT guidance and Medicare HCPCS codes G0181 and G0182.
  • CMS has established both a facility and non-facility MPFS payment to report TCM services when furnished in the outpatient setting. Practitioners should report TCM services with the place of service appropriate for the face-to-face visit.
  • 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).

Code selection is determined by the amount of time the patient is seen face-to-face post-discharge (7 or 14 days) and the medical decision-making complexity of the service. Patient eligibility is determined by whether they’re ordered a high-risk medication before admission and whether their insurance is contracted with the hospital’s outpatient pharmacy, among other factors.

Other CMS’ TCM Documentation rules

CMS recommends that TCM 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). Other documentation rules include:

  • The 30-day period for the TCM service begins on the day of discharge and continues for the next 29 days.
  • The date of service reported should be the date of the required face-to-face visit.
  • Claim can be submitted once the face-to-face visit is furnished and you need not hold the claim until the end of the service period.
  • The place of service reported on the claim should correspond to the place of service of the required face-to-face visit.
  • Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) will not be paid separately by Medicare under the Physician Fee Schedule. However, the face-to-face visit component of TCM services could qualify as a billable visit in an FQHC or RHC.
  • Physicians or other qualified providers who have a separate fee-for-service practice when not working at the RHC or FQHC may bill the CPT TCM codes, subject to the other existing requirements for billing under the MPFS.
  • TCM services can still be reported as long as the services described by the code are furnished by the practitioner during the 30-day period, including the time following the second discharge.

Medical billing and coding outsourcing makes documenting Transitional care management (TCM) services much easier for physicians. Professional billing companies help physicians stay free from complex documentation tasks and dedicate more time to patient care.

Meghann Drella

Meghann Drella possesses a profound understanding of ICD-10-CM and CPT requirements and procedures, actively participating in continuing education to stay abreast of any industry changes.

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