Coding Requirements for Transitional Care Management

Medicare pays for Transitional Care Management (TCM) services, when properly documented and billed. Per CPT and CMS both the healthcare provider and the patient receiving care must meet specific requirements ["Making the Most of Transitional Care Management."] Beyond those basic requirements, providers should be aware of the following rules: 

1. Included services

TCM services span a 30-day time period, which begins on the patient's discharge day from the hospital setting and continues for the next 29 days. In addition to the required contact and face-to-face meeting, TCM services include non face-to-face services performed throughout the reporting period. The non-face-to-face services distinguish TCM from other services that are predominately or exclusively face-to-face in nature.

Typical non-face-to-face services included in TCM (and which may be performed by clinical staff) are:

• Communication (direct, phone, or email) with patient and/or caregiver within two days of discharge

• Communication with home health agencies or other community services utilized by patient

• Patient and/or family caretaker education to support self-management, independent living, and activities of daily living

• Assessment and support for treatment regimen adherence and medication management (must occur no later than the face-to-face visit)

• Identification of community and health resources

• Facilitating access to care and services needed by the patient and/or caregiver

Non face-to-face services than may be performed by a physician or midlevel provider are:

• Obtaining and reviewing the discharge summary, as available, or continuity of care documents

• Reviewing need for or follow-up on pending diagnostic tests and treatments

• Interaction with other healthcare professionals who will assume or reassume care of the patient's system-specific problems

• Education of patient, family, guardian, and/or caregiver

• Establishment or re-establishment of referrals and arranging for needed community resources

• Assistance in scheduling any required follow-up for needed community resources

Medication reconciliation and management is a required component of TCM, and is the process of comparing a patient's medication orders to all of the medication that the patient has been taking to determine any errors such as drug omissions, duplications, dosing errors, or interactions. Medication reconciliation and management should happen no later than the date of the face-to-face visit.

2. Bill one TCM per patient per 30 days

Only a single provider may bill TCM services during a 30-day period, regardless of the number of providers who care for the patient during the reporting period. CPT Assistant (July 2013) advises:

Question: May more than one physician or physician group report TCM services during the same reporting period?

Answer: No. Only one reporting individual or group provides first contact and continuous access. This individual oversees the management and/or coordination of services, as needed, for all medical conditions, psychosocial needs, and activities of daily living support, during the 30-day reporting period.

Question: How many times may a TCM code be reported by that individual or group during the reporting period?

Answer: TCM services may be reported only once per patient by that single individual or group within 30 days of discharge.

3. Selecting a date of service

Since Jan. 1, 2016, CMS allows you to bill for TCM on the date of the required face-to-face visit. CMS's Frequently Asked Questions about Billing the Medicare Physician Fee Schedule for Transitional Care Management Services stipulates, "You may submit the claim once the face-to-face visit is furnished and need not hold the claim until the end of the service period."

The provider who bills for TCM services may also report hospital or observation discharge services (see CPT Assistant, Dec. 2013); however, CMS stipulates that the required TCM face-to-face visit required cannot be furnished by the same provider on the same day as the discharge management service.

You may never bill TCM services and services that are within a post-operative global period.

4. Documenting TCM for best billing results

At minimum, documentation for TCM must include the timing of the initial post-discharge communication with the patient or caregivers, date of the face-to-face visit, and the complexity of medical decision-making. The documentation should also support that medication reconciliation was performed, and the relevant, non face-to-face services performed throughout the post-discharge period.

If your office provides TCM services, design a template to guide you in covering all of the required elements for documentation and billing, including: date of discharge, date to bill (date of face-to-face visit), date of communication (within two days of discharge), date of the face-to-face visit, and any of the care coordination performed. Assign the Place of Service code that correlates to the face-to-face visit location.

5. When not to bill TCM

Even if you meet the requirements, you may not report TCM in addition to care plan oversight services (G0181 and G0182), end-stage renal disease services (90951-90970), or chronic care management (CCM) services. You may bill 99490, chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month… during the same calendar month as TCM, if the TCM service period ends before the end of a given calendar month and at least 20 minutes of qualifying CCM services are subsequently provided during that month; however, CMS expects that the "majority of the time, CCM and TCM will not be billed during the same calendar month."

*Read part 1 of this article "Making the Most of Transitional Care Management."

G. John Verhovshek, MA, CPC, is the managing editor for AAPC's publications. He has written, co-written, and edited dozens of coding and compliance resource manuals, including the "Part B Survival Guide (1st edition)" and "The Official CPC Certification Study Guide (1st edition)." E-mail him at g.john.verhovshek@aapc.com.