Transitional Care Management: Coding and Documentation in Brief

Transitional care management (TCM) describes the oversight and coordination of healthcare services for patients transitioning from an inpatient hospital setting. The CPT codebook provides codes and guidelines to report TCM, which allows providers to recoup payment for services they may already provide to their patients. Medicare covers TCM services, but the requirements occasionally differ from those in the CPT codebook.

What's Included:

The basic services comprising TCM may be found in the TCM code descriptors:

99495 Transitional Care Management 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 Transitional Care Management 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 high complexity during the service period

• Face-to-face visit, within seven calendar days of discharge

Eligible transitions in care include discharges from an inpatient hospital, partial hospitalization, and hospital observation status. Transitions from a skilled nursing facility (SNF) or nursing facility to the patient's community setting (home, domiciliary, rest home, or assisted living community) also are included.

Making Initial Contact

Both TCM codes require communication with the patient or caregiver within two business days (not calendar days) of discharge. Specifically, CPT guidelines state, "The contact may be direct (face-to-face), telephonic, or by electronic means [e.g., e-mail]."

CPT defines business days as Monday through Friday, excepting holidays, "without respect to normal practice hours or date of notification of discharge." For example, if the patient is discharged on Tuesday, initial contact with the patient must be made before the end of business day, Thursday.

If the provider attempts to reach the patient or caregiver, but is unsuccessful within two business days, CPT allows that you still may be able to report the service. Medicare rules concur, "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" [emphasis added]. CMS rules further specify, "…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."

Source: "Transitional Care Management Services," Department of Health and Human Services Centers for Medicare & Medicaid Services:

Medical Decision-Making as a Qualifying Factor

The TCM code descriptors stipulates medical decision-making (MDM) of either moderate (99495) or high (99496) complexity. As such, not all post-discharge patients will qualify for TCM services.

CMS defines MDM as "the complexity of establishing a diagnosis and/or selecting a management option, which is determined by considering the following factors:

• The number of possible diagnoses and/or the number of management options that must be considered

• The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed

• The risk of significant complications, morbidity, and/or mortality as well as comorbidities associated with the patient's presenting problem(s), the diagnostic procedure(s), and/or the possible management options"

To qualify for a given level of MDM, two of the three elements must be met or exceeded.

Level of MDM

Number of Possible Diagnoses and/or Management Options

Amount and/or Complexity of Data to Be Reviewed

Risk of Significant Complications, Morbidity, and/or Mortality

Moderate Complexity

Multiple

Moderate

Moderate

High Complexity

Extensive

Extensive

High

Further detail of the MDM component may be found in the Documentation Guidelines for Evaluation and Management Services on the CMS website:http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/EMDOC.html

The Face-to-Face Requirement

TCM requires a face-to-face visit with the patient within 14 (99495) or seven (99496) calendar days of the patient's discharge from the inpatient setting. This visit is included as part of TCM and may not be reported separately.

Although not explicit in the code descriptors, medication reconciliation and management must occur no later than the date of the face-to-face visit, per both CPT and CMS. Medication reconciliation is the process of comparing a patient's medication orders to all of the medication that the patient has been taking, to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions.

Non Face-to-Face Services Comprise the Bulk of TCM

The requirements set forth in the TCM code descriptors represent only a portion of the work involved in providing these services. The bulk of the provider's (or staff's) efforts are primarily non face-to-face services to manage and coordinate the patient's care during the post-discharge period. Example services provided by a qualified healthcare professional (e.g., physician, or certified nurse-midwives, clinical nurse specialists, nurse practitioners, and physician assistants legally authorized and qualified to provide the services in the state in which they are furnished) include:

• Obtain and review discharge information (e.g., discharge summary or continuity of care documents)

• Review the need for, or follow up on, pending diagnostic tests and treatments

• Interact with other healthcare professionals who will assume 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

Clinical staff, under the direction of the physician or other qualified provider, may furnish certain TCM services. These include:

• Provide education to the beneficiary, family, guardian, and/or caretaker to support self-management, independent living, and activities of daily living

• Assess and support treatment regimen adherence and medication management

• Identify available community and health resources

• Assist the beneficiary and/or family in accessing needed care and services

A full list of services included in TCM can be found in the CPT codebook, and the previously referenced CMS Transitional Care Management publication.

Report Once per 30 Days, Maximum

TCM services are payable only once in the 30-day post-discharge period. The post-discharge period begins on the day of discharge and continues for the next 29 days.

Both CPT and CMS allow only a single provider to bill TCM, per discharge. Documentation of TCM services should include, at minimum:

• 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 MDM (moderate or high).

The individual billing for TCM services also may report hospital or observation discharge services. CMS differs from CPT in that it does not allow the face-to-face visit required for TCM to be furnished by the same provider on the same day as the discharge management service.

CMS stipulates that billing for TCM services should occur after the conclusion of the service (i.e., at 30 days post-discharge or thereafter). CPT^\ is more lenient, stating, "Only one individual may report these services and only once per patient within 30 days of discharge" [emphasis added].

CPT allows you to report TCM in addition to a procedure with a global period. Per CMS, a physician or NPP billing a procedure with a 10- or 90-day global period may not report TCM services, in addition.

Finally, both CPT and CMS prohibit billing TCM during the same 30-day period as other services, including care plan oversight, End-Stage Renal Disease services, complex chronic care coordination, and other services enumerated in the CPT codebook.

The above represents a summary of coding and documentation requirements to report TCM: Be sure to review the complete guidelines for your payer (whether they follow CPT\ or CMS guidelines) prior to reporting these services.