Transitional care : How do code and bill?

Transitional care refers to the coordination and continuity of health care during a movement from one healthcare setting to either another or to home, called care transition, between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness.

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TCM includes services provided to a patient whose medical and/or psychosocial problems require moderate or high-complexity medical decision-making during transitions in care from an inpatient hospital setting (including acute hospital, rehabilitation hospital, long-term acute care hospital), partial hospital, observation status in a hospital, or skilled nursing facility/nursing facility, to the patient’s community setting (home, domicile, rest home, or assisted living).

CPT – Transitional Care Management Services (99495-99496)

TCM begin with the date of discharge and continues for the next 29 days.

The new Physician Fee Schedule includes transition care management (TCM) codes that allow for reimbursement of the non-face-to-face care provided when patients transition from an acute care setting back into the community.

CPT Code 99495 : 

  • Covers communication with the patient or caregiver within two business days of discharge.
  • This can be done by phone, e-mail, or in person.
  • It involves medical decision-making of at least moderate complexity and a face-to-face visit within 14 days of discharge.
  • The location of the visit is not specified. The work RVU is 2.11.

Coding Tips

If another individual provides TCM services within the postoperative period of a surgical package, modifier 54 is not required.

CPT Code 99496:

  • Covers communication with the patient or caregiver within two business days of discharge.
  • This can be done by phone, e-mail, or in person.
  • It involves medical decision-making of high complexity and a face-to-face visit within seven days of discharge.
  • The location of the visit is not specified. The work RVU is 3.05.

Non Face-to Face Services

Non-face-to-face services provided by clinical staff, under the direction of the physician or other qualified health care professional, may include:
pointing hand communication (with patient, family members, guardian or caretaker, surrogate
decision makers, and/or other professionals) regarding aspects of care,
pointing hand communication with home health agencies and other community services utilised by the patient,
pointing hand patient and/or family/caretaker education to support self-management, independent living, and activities of daily living,
pointing hand assessment and support for treatment regimen adherence and medication
pointing hand identification of available community and health resources, facilitating access to care and services needed by the patient and/or family
Non-face-to-face services provided by the physician or other qualified health care
provider may include:
pointing hand obtaining and reviewing the discharge information (eg, discharge summary, as
available, or continuity of care documents);
pointing hand reviewing need for or follow-up on pending diagnostic tests and treatments;
pointing hand interaction with other qualified health care professionals who will assume or
re assume care of the patient’s system-specific problems;
pointing hand education of patient, family, guardian, and/or caregiver;
pointing hand establishment or reestablishment of referrals and arranging for needed
community resources;
pointing hand assistance in scheduling any required follow-up with community providers and

Important Fact:

Light Bulb Effective February 2013, TCM codes can be utilized on New or established patients.

Light Bulb If the patient needs another visit during the 30 days,  an E/M visit you can bill additional visits other than the one bundled E/M visit in the TCM.

Light Bulb A physician or NPP may report both the discharge code and appropriate TCM code if he or she provided both services. However, Medicare will prohibit billing a discharge day management service on the same day that a required E/M visit
is furnished under the CPT TCM codes for the same patient. That is, you cannot count an E/M service as both a discharge day service and the first E/M under the TCM codes.

Light Bulb The discharge visit does not count. The initial contact must be made after the patient leaves the hospital. It is to make sure that the patient has the support necessary until they have their face-to-face visit within the 7 or 14 days as prescribed. The initial contact can be phone, e-mail, and text or direct face-to-face. It can be with the patient or their caregiver.

Light Bulb For the purposes of TCM, business days are Monday through Friday, except holidays, without respect to normal practice hours or date of notification of discharge. If two or more separate attempts are made in a timely manner, but are
unsuccessful and other TCM criteria are met, the service may be reported.

Light Bulb TCM services may be billed by only one individual during the 30-day period after discharge. If more than one physician or NPP submits a claim for TCM services provided to a patient in a given 30-day period following discharge, Medicare will pay the first claim that it receives that otherwise meets its coverage requirements.

Light Bulb Report the diagnosis for the conditions that require TCM services. Typically, these will be the conditions that the patient had at the time of discharge, which represents the start of TCM.

Light Bulb You should submit your bill on the 30th day after discharge. TCM covers 30 days of management services with one evaluation service bundled in to the code. The date of service on the claim would be the 30th day post the discharge.

Light Bulb These services be subject to co-insurance and deductible under Medicare.

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