Transitional care is necessary to ensure the safety and well-being of patients after they have been discharged from an inpatient stay.

It’s also a time to educate the patient on the next course of action and what is to be expected after the transitory period is over.

When we look at the numerous benefits of transitional care management (TCM) services, it’s understandable why Centers for Medicare & Medicaid Services (CMS) created a separate fee schedule for these services back in 2013.

Let’s look at how CMS defines TCM services and its scope. It’s a good way of understanding what TCM services constitute.

Duration of Transitional Care Management Services

The duration of TCM is for 30 days, beginning on the date when the patient is discharged, and continuing for the next 29 days.

Location of Discharge

The patient can be discharged from an inpatient setting such as in a hospital or nursing facility, or they can be discharged from a partial hospitalization setting such as outpatient observation or a community mental health center.

The Transitional Care Management CPT Codes

The Transitional Care Management CPT Codes

There are two TCM CPT codes that can be used to bill a TCM episode. Each one covers three mandatory elements which have to be provided in order for the codes to be billed.

They are: making initial contact with the discharged patient within 2 business days, medical decision-making of a certain complexity during the 30-day service period, and a face-to-face visit within a certain allotted time period after the discharge.

The complexity of decision-making and the time period allotted to the care team to get back to the patient, are two criteria that separate the two CPT codes below.

CPT Code 99495

CPT code 99495 covers TCM services with the following required elements: Communication consisting of interactive contact (either direct contact, telephone, email or other electronic) with the patient and/or caregiver within 2 business days of discharge, non-face-to-face services consisting of medical decision-making of at least moderate complexity during the service period, and face-to-face visit within 14 calendar days of discharge.

National reimbursement average : $176.50

CPT Code 99496

CPT code 99496 covers TCM services with the following required elements: Communication consisting of interactive contact (either direct contact, telephone, email or other electronic) with the patient and/or caregiver within 2 business days of discharge, non-face-to-face services consisting of medical decision-making of high complexity during the service period, and face-to-face visit within 7 calendar days of discharge.

National reimbursement average : $236.77

These two codes can be billed by only one physician or non-physician practitioner (NPP) for one patient during the TCM period.

It’s possible for the same healthcare professional to discharge a patient, report hospital or observation charge services and bill TCM services. However, the required face-to-face visit cannot happen on the same day of the discharge.

At the very minimum, CMS recommends physicians and NPPs document the patient discharge date, the first interactive contact date, the face-to-face visit date, and the medical complexity decision making in the patient’s medical report.

Medical Complexity Decision

The complexity of medical decision-making refers to the level of difficulty in diagnosing and selecting a care management option.

It hinges on:

The number of possible diagnoses and/or the amount of care management options in consideration.

The breadth and/or complexity of medical records, diagnostic tests, and/or other information that needs to be looked at.

What Can be Billed Concurrently?

Both chronic care management and remote patient monitoring services can be billed concurrently with TCM services. For other codes that can be billed concurrently with TCM, please refer to pages 7 through 10 in this CMS booklet on TCM services.

TCM services cannot be billed concurrently with principal care management. For other non-billable services that cannot be billed concurrently, please refer to the bulleted list under the TCM services following the discharge header in this article.

Update for 2022

This year’s final rule has granted rural and federally qualified clinics permission to bill for both CCM and TCM in the same month. Previously, only general care providers were allowed to do this.

Benefits of Transitional Care Management

Benefits of Transitional Care Management

Eliminating Any Service Gaps

TCM services ensure that there is no service gap after the patient has been released into their community setting.

The community setting here includes the patient’s home, any senior centers, nursing homes, assisted living facilities, etc.

Reducing Readmissions & Saving Costs

Just like chronic care management and remote patient management, one of the big value additions of TCM is its ability to reduce costly readmissions.

When TCM is done right, it results in the reduction of 30-day post-discharge medical expenses and increased outpatient office visits.

In one 9-month study, readmissions were reduced by as much as 73%. Patient satisfaction and confidence with self-care significantly improved, and total cost savings of $214,192 was achieved, excluding the costs of administering the program.

Increased Relevance for Vulnerable Segments of Population

For the older population segments, the benefits of TCM are more palpable.

In a meta-analysis of 15 quantitative studies and 4 qualitative studies consisting of over 30,000 patient records, it was found that people over the age of 65 who received TCM services were 1.7 times less likely to be readmitted to the hospital compared to the comparison group.

Easily Scalable and Appropriate for All Settings

Whether in city hospitals or rural primary care systems, it is possible to cut readmissions in half when TCM services are scaled with an increased frequency of calls and visits.

Such finding is supported by many studies that have proved the association between using a workflow to scale TCM and the subsequent reduction of readmissions.

Compatible with Telehealth

In a study looking at over 44,000 TCM visits during the pandemic, telehealth TCM visits accounted for 15.4% of all visits. Later, this percentage rose to 73.3% during the initial pandemic period and declined to 33.6% during the later pandemic period. 

Thus, depending on the situation, there is a wide acceptance of telehealth being used as an alternate method of follow-up TCM visits to in-person visits.

Who Can Provide TCM Services?

Physicians and the following non-physician practitioners are authorized to provide TCM face-to-face visit services in their respective states, and supervise other clinical staff to provide non-face-to-face TCM services.

  • Physician Assistants
  • Nurse Practitioners
  • Clinical Nurse Specialists
  • Certified Nurse-midwives

The aforementioned positions are also able to provide the non-face-to-face TCM services themselves, under the general supervision of a physician.

How to Ace TCM Services? Step by Step.

How to Ace TCM Services? Step by Step

For a healthcare organization or physician’s practice, there is an ideal way to run a TCM program that streamlines care coordination and optimizes the patient experience throughout their care journey, from an inpatient setting to the community.

Firstly, there is a need to identify patients discharged from inpatient settings through admission-discharge-transfer data.

Then, there is the need to follow up with the patient and schedule TCM visits for them with their primary care providers. When physicians are equipped with the right tools, they find it easier to do such patient outreach.

Such tools ensure that every patient’s post-discharge care is accounted for.

The highest-risk patients are prioritized for the TCM program, so they are able to get the care that they need, and so that the likelihood of their successful reintegration into society is raised.

Physicians also individualize care plans for the patient and walk them through what they need to know so clear expectations are set.

This may require more time from the physician’s schedule at first, but with the help of the right tool that coordinates TCM, such a practice can be better facilitated, resulting in greater savings and better patient outcomes.

For hospitals who want greater adoption of TCM, tracking each patient outcome and relaying this information to their providers, is a great way to get everyone aligned on the same goal.

If more value can be provided for each patient at a lower cost, it’s a great win for value-based healthcare organizations such as accountable care organizations, which can acquire a share of the savings that is generated from the Medicare program.

For healthcare organizations participating in Quality Payment Program, high-quality TCM services results in a good performance in both the Merit-based Incentive Payment System and the Alternative Payment Models tracks.

The participating organizations generate more revenue via payment incentives due to quality improvements.

What Findings Show- Advice for Running a TCM Operation

What Findings Show- Advice for Running a TCM Operation

Have a Consistent Approach

In a study of 1,000 call records of a post-discharge transitional care program, it was found that successful completion of the first two calls was significantly associated with an increased likelihood of scheduling or completing the follow-up visit, follow-up procedure and reporting a new adverse event.

Two or three calls were favoured as opposed to one call. There was a diminishing return after the third call.

Thus, it’s important to note that more than one attempt should be made to fulfil the first requirement of the three TCM elements.

Use Health Information Technology

Electronic Health Record (EHR) adoption has increased over the years, and for good reason.

It increases providers’ access to health information, reduces redundancies in analyzing patients’ health history and improves communication between care team members, including physicians, NPPs, and other clinical staff.

Shockingly, some studies suggest that only 12 to 34 % of discharge summaries reach outpatient care teams by the time the patient sees a physician.

Using health information technology standardizes such processes and ensures speed and visibility in the transmission of such information.

Using health information technology also helps in many other areas of care management such as medication reconciliation. There is evidence that over half of all medication errors occur at the transitional point of care. Given how important this stage of care is for the patient, it’s important to invest in proper care coordination tools.

Separating the Roles

Due to the complexity of care (either moderate or high) of patients who are candidates for TCM, it’s best if the non-face-to-face care duties are appropriately delegated to either the clinical staff or physicians and other mid-level NPPs.

For example, patient education regarding daily living and supporting self-management can be handled by the clinical staff. Assessment and support of treatment and medication adherence is another area that can be assigned to the clinical staff.

On the other hand, reviewing discharge information such as pending tests, discussing with other providers and specialists on the best course for treatment, and establishing referrals have to be done by a physician, or by NPPs under the general supervision of a physician.

Realizing the Value of Transitional Care Management

Realizing the Value of Transitional Care Management

With the push for more value-based care in today’s health care, it’s great that there is a way to be reimbursed for episodes of care that require a lot of coordination behind the scenes, such as when a patient is discharged.

Physicians and their care teams can be more accountable for such episodes knowing that their time is accounted for by the system.

In this way, they are able to help patients that require moderate to high complexity decision-making even as they change their settings.

Transitional care management services tend to be a requisite for senior citizens that suffer from chronic illnesses such as diabetes, chronic pulmonary obstructive disease, heart failure and arthritis.

TCM is also quite useful for post-acute care, such as for those patients recovering from an operation, or any worrisome condition such as a stroke.

To best equip healthcare providers to manage transitions for patients suffering from both chronic and acute conditions, Humhealth streamlines communication between the provider, clinical staff, the caregiver, and the patient.

Alerts are strategically set up at critical junctions, where the care team knows when to follow up, when to reattempt a contact, when to schedule a face-to-face visit, and when to remind the patient to adhere to the care plan.

All such events are recorded by the same system that administers the workflow, so billing is made easy at the end of the 30 days.

Furthermore, the platform also helps the provider schedule or arrange any follow-up care or services as required.

If you are a healthcare organization, or private practice looking to implement TCM services, we hope you follow the best practices as laid out in this article.

If you need any help in streamlining an ideal workflow based on the recommendations and/or capturing revenue from such a program, please get in touch with us.












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