Transitional Care Management

Transitional care management (TCM) includes services provided to a patient with medical and/or psychosocial problems requiring moderate or high-complexity medical decision making during a transition of care from a hospital setting to home.

TCM Services:

The requirements for TCM services include:

  • The services are required during the beneficiary’s transition to the community setting following particular kinds of discharges
  • The health care professional accepts care of the beneficiary post-discharge from the facility setting without a gap
  • The health care professional takes responsibility for the beneficiary’s care
  • The beneficiary has medical and/or psychosocial problems that require moderate or high complexity medical decision making
  • The 30-day TCM period begins on the date the beneficiary is discharged from the inpatient hospital setting or other intensive care setting such as SNF and continues for the next 29 days.

 

Providers:

These health care professionals may furnish TCM services:

  • Physicians (any specialty)
  • These non-physician practitioners (NPPs) who are legally authorized and qualified to provide the services in the State in which they are furnished:
    • Certified nurse-midwives (CNMs)
    • Clinical nurse specialists (CNSs)
    • Nurse practitioners (NPs)
    • Physician assistants (PAs)

When we use “you” in this publication, we are referring to these health care professionals. MAs, CNMs, CNSs, NPs, and PAs may furnish non-face-to-face TCM services “incident to” the services of a physician and other CNMs, CNSs, NPs, and PAs.

 

Supervision

The required face-to-face visit must be furnished under a minimum of direct supervision and is subject to applicable State law, scope of practice, and the Medicare Physician Fee Schedule (PFS) “incident to” rules and regulations. The non-face-to-face services may be provided under general supervision. These services are also subject to applicable State law, scope of practice, and the PFS “incident to” rules and regulations. The practitioner must order services, maintain contact with auxiliary personnel, and retain professional responsibility for the service.

 

TCM Service Settings:

TCM services are furnished following the beneficiary’s discharge from one of theseinpatient 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
  • Partial hospitalization at a Community Mental Health Center

Following discharge from one of the above settings, the beneficiary must be returned to his or her community setting, such as:

  • His or her home
  • His or her domiciliary
  • A NursingHome
  • Assisted living

 

TCM Components:

During the 30 days beginning on the date the beneficiary is discharged from an inpatient setting, you must furnish these three TCM components:

1) Initial Contact

An interactive contact must be made with the beneficiary and/or caregiver, as appropriate, within 2 business days following the beneficiary’s discharge to the community setting. The contact may be via telephone, email, or face-to-face. It can be made by you or clinical staff who have the capacity for prompt interactive communication addressing patient status and needs beyond scheduling follow-up care. For Medicare purposes, attempts to communicate should continue after the first two attempts in the required 2 business days until they are successful. If you make two or more separate attempts in a timely manner and document them in the medical record but are unsuccessful, and if all other TCM criteria are met, you may report the service. CMS emphasizes, however, that we expect attempts to communicate to continue until they are successful. You cannot bill TCM if the face-to-face visit is not furnished within the required timeframe.

2) Certain Non-Face-to-Face Services

You must furnish non-face-to-face services to the beneficiary, unless you determine that they are not medically indicated or needed. Clinical staff under your direction may provide certain non-face-to-face services.

Physicians or NPPs may furnish these non-face-to-face services:

  • Obtain and review discharge information (for example, discharge summary or continuity of care documents)
  • 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

Clinical staff under your direction may provide these services, applicable State law, subject to the supervision and other rules discussed above:

  • Communicate with agencies and community services the beneficiary uses
  • Provide education to the beneficiary, family, guardian, and/or caretaker to supportself-management, independent living, and activities of daily living
  • Assess and support treatment regimen adherence and medication managementIdentify available community and health resources
  • Assist the beneficiary and/or family in accessing needed care and services

3) A Face-to-Face Visit

You must furnish one face-to-face visit within certain timeframes as described by the following two Current Procedural Terminology (CPT) codes:

  • CPT Code 99495 – Transitional care management services with moderate medicaldecision complexity (face-to-face visit within 14 days of discharge)
  • CPT Code 99496 – Transitional care management services with high medicaldecision complexity (face-to-face visit within 7 days of discharge)

The face-to-face visit is part of the TCM service, and you should not report it separately.

Billing TCM Services:

This list provides information on billing TCM services:

  • Only one health care professional may report TCM services.
  • Report services once per beneficiary during the TCM period.
  • The same health care professional may discharge the beneficiary from the hospital, report hospital or observation discharge services, and bill TCM services. However,the required face-to-face visit may not take place on the same day you reportdischarge day management services.
  • Report reasonable and necessary evaluation and management (E/M) services (other than the required face-to-face visit) to manage the beneficiary’s clinical issues separately.
  • You may not bill TCM services and services that are within a post-operative global period (TCM services cannot be paid if any of the 30-day TCM period falls within a global period for a procedure code billed by the same practitioner).
  • When you report CPT codes 99495 and 99496 for Medicare payment, you may not also report these codes during the TCM service period:
  • Care Plan Oversight Services
  • Home health or hospice supervision: HCPCS codes G0181 and G0182
  • End-Stage Renal Disease services: CPT codes 90951–90970
  • Chronic Care Management (CCM) services (CCM and TCM service periods cannot overlap)
  • Prolonged E/M Services Without Direct Patient Contact (CPT codes 99358 and 99359)
  • Other services excluded by CPT reporting rules
  • At a minimum, you must document this information in the beneficiary’s medical record:
    • Date the beneficiary was discharged
    • Date you made an interactive contact with the beneficiary and/or caregiver
    • Date you furnished the face-to-face visit
    • The complexity of medical decision making (moderate or high)