Both providers and patients must meet basic requirements to qualify for Medicare payment for Transitional Care Management (TCM). However, the failure to adhere to proper documentation and billing practices often prevent even physicians who meet these requirements from getting reimbursed appropriately. Outsourcing medical billing and coding to an experienced service provider is the ideal option to ensure adherence to the specific rules for billing and coding TCM and overcome payment issues.
Overview of TCM Coding Guidelines
Transitional Care Management (TCM) services (CPT codes 99495 and 99496) are provided to a patient whose medical and/or psychosocial problems require moderate or high-complexity medical decision making during transition from a care setting to the patient’s community setting. Expert medical coders in a medical coding company are well aware of the additional requirements and rules for billing TCM services, which are as follows:
- Both CPT codes 99495 and 99496 require direct communication (by telephone, email, or face to face) with the patient and/or caregiver within two business days of discharge (though this time restriction may be waived if the patient cannot be reached within two days)
- Moderate (99495) or high (99496) medical decision making is necessary for patients to qualify for TCM service
- Each code requires a face-to-face meeting with the patient, either within 14 calendar days (99495) or seven calendar days (99496) of discharge, and the face-to-face has to be reported along with TCM
- TCM services cover a 30-day time period, beginning on day of discharge from the hospital setting.
- TCM services are unique in that they include the non face-to-face services performed by clinical staff throughout the reporting period, for example: communication (direct, phone, or email) with patient and/or caregiver within two days of discharge, communication with home health agencies or other community services the patient utilizes, and patient and/or family caretaker education.
- TCM also includes non face-to-face services that may be performed by a physician or midlevel provider such as: obtaining and reviewing the discharge summary, or continuity of care documents, reviewing need for or follow-up on pending diagnostic tests and treatments, interaction with other healthcare professionals associated with the patient’s system-specific problems and establishment or re-establishment of referrals
- Another required component of TCM is medication reconciliation and management not later than the date of the face-to-face visit. This is to check for errors such as drug omissions, duplications, dosing errors, or interactions.
- Only a single individual or group can bill TCM services per patient per 30 days.
- As for date of service, starting January 1, 2016, CMS allows TCM billing on the date of the required face-to-face visit.
- The provider who bills for TCM services may also report hospital or observation discharge services. However, TCM services and services within a post-operative global period should never be billed.
- Documentation for TCM must include the timing of the initial post-discharge communication with the patient or caregivers, date of the face-to-face visit, complexity of medical decision-making, support that medication reconciliation was performed, and the non face-to-face services during the post-discharge period.
- TCM must not be reported in addition to care plan oversight services (G0181 and G0182), end-stage renal disease services (90951-90970), or chronic care management (CCM) services. While CCM (99490) can be billed at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional – per calendar month – CMS generally expects that CCM and TCM will not be billed during the same calendar month.
On their part, physicians need to keep track of all patients discharged, determine those who are candidates for TCM (moderate or high complexity), contacting them within two business days, and scheduling a face-to-face visit within either seven or 14 days from discharge. After documenting services provided, they can outsource medical billing and coding to secure the reimbursement they deserve.