Transitional Care Management: Know the Requirements before You Bill

KareoKnowing your carrier’s policy is the key to billing transitional care management (TCM), Jill Young, CPC, CEDC, CIMC, of Young Medical Consulting, LLC, told coders and other healthcare compliance professionals at AAPC’s 22nd annual HEALTHCON conference last month.

However, regardless of payer requirements, understanding the general concept of TCM is important. TCM occurs when providers render or oversee the management and coordination of services, including care for medical conditions, psychosocial needs, and activities of daily living.

“TCM is for certain patients. It’s not for every patient,” Young said during her presentation. “Just because you have sick patients doesn’t mean it’s TCM.”Tweet this Kareo story

TCM codes include the following:

99495—TCM services with the following required elements:

  • Communication (direct contact, telephone, electronic) with the patient and/or caregiver within two business days of discharge
  • Medical decision-making of at least moderate complexity during the service period
  • Face-to-face visit within 14 calendar days of discharge

99496—TCM with the following required elements:

  • Communication (direct contact, telephone, electronic) with the patient and/or caregiver within two business days of discharge
  • Medical decision-making of at least high complexity during the service period
  • Face-to-face visit within seven calendar days of discharge

Assuming all other requirements are met, providers may bill TCM when discharging patients from one of the following settings/statuses to the patient’s community setting (e.g., home, rest home, or assisted living):

  • Inpatient hospital (i.e., acute care facility, rehabilitation hospital, or long-term acute care hospital)
  • Skilled nursing facility(SNF)
  • Nursing facility
  • Observation status
  • Partial hospitalization

TCM does not apply when patients are discharged to a SNF.

Young reminded attendees that TCM is not restricted to certain specialties. However, she acknowledged that there is no clear definition of what technically initiates or triggers TCM. A phone call from the hospital to confirm a follow-up appointment, for example, is not appropriate. One audience member suggested that the discharge physician include the verbiage ‘initiate TCM’ in his or her discharge summary or specifically order TCM.

Young said an order is not technically required. The only requirement is that the provider initiating the TCM communicate with the community physician. Documentation is critical. This documentation should include any communication, coordination of care, and services that the patient requires.

Providers rendering services with either a 010 or 090 global period cannot bill TCM. “A lot of the TCM components are considered to be part of global care,” Young said.

Young also made it clear that any E/M services that the discharge physician provides on the date of discharge (i.e., 99217, 99234-99236, 99238-99239, or 99315-99316) do not qualify as the ‘face-to-face’ visit requirement for TCM.

“Why? Because it has the components of a discharge,” Young said. “If you are not billing these codes, then you could see the patient on the day of discharge and have that count as your 7- or 14- day face-to-face visit. Doctors that do provide the discharge service can subsequently provide TCM services, but the face-to-face visit must be on another day.”

The first face-to-face visit is considered part of the TCM service and not separately reportable. Additional reasonable and necessary E/M services required for managing the beneficiary’s clinical problems may be reported separately, she said.

Keep in mind that the 7- and 14-day requirement is mandatory, Young said. Providers must schedule a follow-up appointment within this timeframe in order to bill TCM. Providers cannot use a busy schedule as an excuse as to why they could not accommodate the patient within the timeframe, she added.

The face-to-face visit is typically provided in the physician’s office; however, it may also occur in the patient’s home or other location where the patient resides, Young said.

Young also clarified the business day requirement for communication. “If you cannot get a hold of people within that timeframe, and you provided the remainder of the services for TCM, consideration for payment would be made,” she said. “Exceptions can be made, but everything must be documented.” Business days are Monday through Friday, she added.

Medical decision-making is another important consideration. “It must be during the service period—not just in that first visit,” Young said.

Young provided the following other documentation suggestions:

  • Document the date, time, and content of the initial communication with the patient and/or caregiver. Identify who provides the care.
  • Summarize the inpatient course based on the discharge summary and conversations with the patient, caregiver, or others involved in the care.
  • Thoroughly document the face-to-face visit. Ensure that this documentation includes medication reconciliation and supports the medical necessity and complexity of the TCM services.
  • Document all communication with other individuals and agencies involved in the patient’s care.
  • Ask clinical staff to document the date, time, duration, and content of any communications involving the patient.

Young advised coders to check with their carrier to clarify these and other TCM requirements.

About the Author

Lisa A. Eramo, BA, MA is a freelance writer specializing in health information management, medical coding, and regulatory topics. She began her healthcare career as a...

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