Transitional care management (TCM) encompasses a broad range of services designed to ensure health care continuity, avoid preventable poor outcomes and promote the safe transfer of patients from one level of care to another, or from one type of setting to another. It is a critically important and growing area of health care management, most notably among highly vulnerable, chronically ill patients (Naylor, Aiken, Kurtzman, Olds & Hirschman, 2011).
Transitions are significant exchange points that can not only result in extra spending, but in exposing vulnerable patients to gaps in quality and safety. Nearly 13 percent of Medicare beneficiaries discharged from hospitals experienced three or more provider transfers during a thirty-day period. During these transitions costly mistakes can easily occur, such as not informing a long term health care facility of a new medication a patient was prescribed during their hospital stay.
Rehospitalization is often the end result of these types of mistakes. According to a study conducted in 2009, approximately 20 percent of Medicare beneficiaries discharged from hospitals were rehospitalized within thirty days, and 34 percent were rehospitalized within ninety days.
Section 3026 of the Affordable Care Act of 2010 established the Community-Based Care Transitions Program providing $500 million from 2011 to 2015 to health systems and community organizations that provided at least one transitional care intervention to high-risk Medicare beneficiaries. In addition, the Center for Medicare and Medicaid Innovation (Section 3021) has allocated $10 billion for the period 2011-2019 to identify, evaluate, and disseminate innovative care delivery and payment models, including transitional care.
The Requirements of Transitional Care Management
TCM services follow the patient’s discharge from one of the following inpatient hospital settings: inpatient acute care hospital, inpatient psychiatric hospital, long term care hospital, skilled nursing facility, inpatient rehabilitation facility, hospital outpatient observation or partial hospitalization and partial hospitalization at a community mental health center. Following discharge from one of the above settings, the patient must be returned to his or her community setting, such as his or her home, his or her domiciliary, a rest home or assisted living (CMS, 2013).
Three TCM components must take place during the 30 days beginning on the date the patient is discharged from a hospital inpatient setting: an interactive contact, certain non-face-to-face services and a face-to-face visit. An interactive contact must occur within 2 business days following the patient’s discharge to the community. This can take place via telephone, e-mail, or face-to-face. A direct exchange of information and appropriate medical direction by clinical staff with the patient and/or caregiver must take place. In other words, leaving a message and not reaching the patient would not qualify as an exchange. The TCM may not be billed if there is no successful communication within the 30-day period between the facility discharge and the date of service for the post-discharge TCM code.
Non face-to-face services include retrieving and reviewing discharge information, reviewing the need for, or following-up on, pending diagnostic tests and treatments, communicating with other health care professionals who will be responsible for care of the patient’s system-specific problems, providing education to the patient, family, guardian, and/or caregiver, establishing or re-establishing referrals and arranging for needed community resources and assisting in scheduling required follow-up with community providers and services.
Face-to-face services include communicating with agencies and community services used by the patient, providing education to the patient and anyone else involved in their care to support self-management, independent living, and activities of daily living, assessing and supporting treatment regimen adherence and medication management, finding available community and health resources and assisting the patient and/or family in accessing needed care and services.
Decoding TCM Codes
The Centers for Medicare and Medicaid Services (CMS) created new TCM codes in an effort to change the outpatient fee schedule to emphasize primary care and care coordination for beneficiaries, most especially in the post-hospitalization period. These codes mark the beginning of reimbursement for non-face-to-face activities, which are becoming increasingly important in our healthcare system (Doctoroff, 2013).
TCM services may be completed by certain health care professionals, which include physicians (any specialty) and certified nurse-midwives, clinical nurse specialists, nurse practitioners and physician assistants.
The TCM codes, 99495 and 99496, are available to health care professionals only once within the 30 days after hospital discharge.
The requirements for using CPT code 99495 are as follows: communication (direct contact, telephone, or electronic) with the patient and/or caregiver within 2 business days of discharge, medical decision-making of moderate complexity during the service period, and a face-to face visit within 14 calendar days of discharge.
The requirements for using CPT code 99496 are: communication (direct contact, telephone, or electronic) with the patient and/or caregiver within 2 business days of discharge, medical decision-making of high complexity during the service period, and a face-to-face visit within 7 days of discharge. Both codes allow the face-to-face visit to take place in the patient’s residence or a location other than a provider’s office (Bendix, 2013).
Regarding relative value units (RVUs), the Centers for Medicare and Medicaid Services values code 99495 at 4.82 total RVUs, or approximately $163, and code 99496 at 6.79 RVUs, or about $231.
These codes cannot be used with G0181 (home health care plan oversight) or G0182 (hospice care plan oversight) due to duplication of services (ACP, n.d.).
Practitioners have faced difficulty in having TCM services processed. Common errors in claim submissions can be avoided by verifying that all requirements for providing the service have been met, and if so, re-submitting any unpaid claims. It is important to verify the service began with a qualified discharge from a facility, and that the appropriate date of service is reported on the claim (CMS, 2013).
A common question among providers is if the patient is readmitted in the 30-day period, can TCM services still be reported. TCM services can be reported as long as they are provided by the practitioner during the 30-day period, including the time following the second discharge. Or, a practitioner can bill for TCM services following the second discharge (for a full 30-day period) as long as no other provider bills the service for the first discharge.
CPT (current procedural technology) 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.
Best Practices for Transitional Care Management
TCM has a number of evidence-based interventions that lead to reduced hospital admissions. Successful interventions have included comprehensive discharge planning, complete and timely communication of information, and medication reconciliation. Comprehensive discharge planning involves organizing follow up services prior to discharge and having hospital staff call patients one to three days after discharge to address any concerns; complete and timely communication of information involves sending written discharge summaries to outpatient providers one to two days after discharge; and lastly, medication reconciliation involves reconciling medications at each transition - inpatient, outpatient, or post-acute care - checking the accuracy of medication lists and dosages, and looking for contraindications (Dreyer, 2014).
While federal law has focused on reducing 30-day hospital admissions for specific conditions such as heart failure, in a systematic review conducted by Naylor, Aiken, Kurtzman, Olds and Hirschman (2011), it was found interventions achieved a positive imp
act through six or twelve months after the index hospital discharge among even more diverse patient populations. This review demonstrated there are many opportunities to achieve longer-term, higher-value health care. Naylor et al. (2011) support a number of goals to achieve this result including choosing effective interventions especially ones that provide comprehensive discharge planning and home follow-up or telehealth-facilitated monitoring post-discharge support.
For other commonly asked questions, click here: Frequently Asked TCM Questions.
Bendix, J. (2013). Making sense of the new transitional care codes: How to maximize revenue related to the federal government's drive to reduce rehospitalizations. Medical Economics.
CMS (2013). Frequently Asked Questions about Billing the Medicare Physician Fee Schedule for Transitional Care Management Services.
Department of Health and Human Services Centers for Medicare & Medicaid Services (2012). Transitional Care Management Services.
Doctoroff, L. (2013). New Codes Bridge Hospitals’ Post-Discharge Billing Gap. The Hospitalist.
Dreyer, T. (2014). Care Transitions: Best Practices and Evidence-based Programs. The Center for Healthcare Research and Transformation.
Naylor, Aiken, Kurtzman, Olds, & Hirschman (2011). The importance of transitional care in achieving health reform. Health affairs, 30(4), 746-754.
Naylor & Sochalski (2010). Scaling Up: Bringing the Transitional Care Model into the Mainstream. The Commonwealth Fund.