Transitional Care Management (TCM) is designed for patients whose medical and / or psychosocial problems require moderate or high complexity medical decision-making during transitions from the inpatient setting to a community setting.

Physicians and non-physician practitioners may be eligible to bill for the service – if it is within their scope of practice in the state they are licensed. The American Medical Association (AMA) has assigned CPT codes 99495 and 99496 to report these services.

TCM services begin when your patient is discharged to home, nursing home or assisted living from the following 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
During the 30 days after discharge three care services must occur –
  • An interactive contact
  • Non-face to face services provided by the physician or their clinical staff
  • A face to face visit with the physician or a Non-Physician Provider (NPP)
  1. The physician or clinical staff under the physician’s direction needs to have contact with the patient or caregiver withintwo business days of discharge. The business day after discharge is day one. If a patient is discharged on Friday, the contact should be made by Tuesday night. The patient or caregiver can be contacted by phone or in person. Attempts to contact the patient must be documented. For example, a typical contact includes answering questions about medications, such as finding out if the patient has a barrier to getting to the pharmacy. In addition, providers should assess if the patient requires other services. Please note: ​Scheduling the follow up appointment(s) alone won’t generate payment. The requirement for contact can be met without an actual exchange; it is expected that attempts to contact the patient or caregiver after the first two days have passed without any contact. For example, calls Monday at 9:00 a.m and again at 9:30 a.m. would likely not pass an audit. It is best to wait a between calls. However, no rule of timing between calls exists.
  2. The second requirement to meet the criteria is that contact is done in a way that does not require face-to-face interaction. This can include identifying the need for community or social services, reviewing medical records regarding the hospitalization, or helping the patient or caregiver navigate immediate needs.

This introduction to TCM is not intended to provide complete billing and coding guidelines. Providers are encouraged to consult AMA guidelines.

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The following codes are used to report TCM services –

  • 99495 requires the first two requirements and a face-to-face with moderate decision-making within 14 days of discharge.

  • 99496 requires the first two requirements and a face-to-face with high decision-making within seven days of discharge.

Common coding mistakes are –

  • To report 99496 high decision-making when the patient is seen during the first seven-day period, but only moderate decision-making was required.
  • Not performing a medication reconciliation.
  • Improper or insufficient documentation to support services.

Don't miss the next issue!

Changes to the ICD-10 diagnosis codes for 2019 will go into effect on October 1st.

Nearly 300 new codes have been created, from codes that address current social issues to codes that more accurately describe surgical wound location and depth.

Look for “Coding Alert” the Fall Quartz Communicator (September) for an exploration of these new codes and what they mean for your facility.