Series Part IV: Transitional Care Management

Transistional Care Services (TCM) were created to help facilitate the handoff period of patients transitioning from the hospital and/or facility setting to a community setting. They must return to their community setting (i.e., home, domiciliary, nursing, or assisted living). The patient has medical and/or psychosocial problems that require moderate or high complexity medical decision making.

Approved Facility Discharge Settings:

● Inpatient acute care hospital
● Inpatient psychiatric hospital
● Inpatient rehabilitation facility
● Long-term care hospital
● Skilled nursing facility
● Hospital outpatient observation or partial hospitalization
● Partial hospitalization at a community mental health center

Three Components of TCM:

(1) Interactive Contact – must be made within two business days following the beneficiary’s discharge to the community setting by telephone, e-mail, or face-to-face. Contact may be made by physician or clinical staff. However, if made by clinical staff, their contact must go beyond just scheduling follow-up care. They must be able to address the patient’s needs and status.

Physicians or Advance Practice Providers (ACPs) may furnish the following:
 Obtain and review discharge information
 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 the beneficiary’s system-specific problems
 Provide education to the beneficiary, family, guardian and/or caregiver
 Establish or re-establish referrals and arrange for needed community resources
 Assist in scheduling required follow-up with community providers and services

Licensed Clinical Staff may provide – State law, supervision, and other rules apply:
 Communication with agencies and community services the beneficiary 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 regimen adherence and medication management
 Identify available community and health resources
 Assist the beneficiary and/or family in accessing necessary care and resources

(3) Face-to-Face TCM Service – may be provided via telehealth. The face-to-face visit is a component of TCM services and should not be reported separately with an E/M code. This component may be provided as “incident to” when requirements including direct supervision, have been met.

CPT Codes

• 99495 – Transitional Care Management – Moderate MDM ($210.79)
• 99496 – Transitional Care Management – High MDM ($285.09)

TCM Supervision Requirements:

• Face-to-face TCM = direct supervision (feet in the suite!) by physician or ACP.
• Non-face-to-face TCM = general overall direction, presence not required.

Approved Providers:

Providers recognized to perform E/M (Evaluation and Management) services may report TCM.

Physician (any specialty)

Clinical nurse specialist (CNS)

Nurse practitioner (NP)

Physician assistant (PA)

Certified nurse midwife

Document:  Dates and Activity Details

• Date of discharge,
• Date of interactive contact (with patient and/or caregiver),
• Date of face-to-face visit, and
• Date(s) of non-face-to-face services
• Date of Medication Reconciliation (not to occur any later than the face-to-face visit is performed)

and documentation supporting – 

Complexity of medical decision making:
 Moderate, or
 High

For more comprehensive information, explore the resources provided below. Care management services encompass a wide array of activities and can be quite intricate. This article only scratches the surface. If you intend to start utilizing these services, ensure you familiarize yourself with which care management services are bundled, overlap, or can be reported separately. Many guidelines have similar wording.

If your group would like to talk more about these services, please feel free to reach out to [email protected] or [email protected].

Resources:

MLN Matter Article, MM11560 – Calendar Year (CY) 2020 Medicare Physician Fee Schedule (MPFS) Final Rule – Transitional Care Management 

CMS-1715-F- Revisions to Payment Policies under the Medicare Physician Fee Schedule, Quality Payment Program and Other Revisions to Part B for CY 2020 

Transitional Care Management Services Fact Sheet

Targeted Probe and Educate (TPE) Transitional Care Management

AAFP Article