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    How to code and bill for transitional care management

    The goal of transitional care management (TCM)  codes is to achieve increased involvement of primary care physicians (PCPs) in order to improve patient care and reduce mistakes in care coordination that can lead to readmission.

    A 2007 Medicare Payment Commission Advisory Report to Congress indicated that 19% of all Medicare patients discharged from the hospital were readmitted within 30 days of discharge, at a cost of $15 billion. To help solve this problem, the American Medical Association (AMA) and the U.S. Centers for Medicare & Medicaid Services (CMS) worked together to introduce new CPT codes for TCM services and add them to the Medicare Physician Fee Schedule.  

    During the proposals, the AMA and CMS identified a number of components that they felt were essential to ensuring better patient outcomes.

     

    When TCM is required

    TCM services are required during the beneficiary’s transition to a community setting following particular kinds of discharges.   The beneficiary must have medical problems that require moderate or high complexity medical decision making.  

    The physician must accept and take responsibility for the care of the beneficiary post-discharge from the facility setting without a gap. The 30-day TCM period begins on the date that the beneficiary is discharged from the inpatient hospital setting, and continues for the next 29 days. The reported date of service should be the 30th day.

    TCM services are furnished following the beneficiary’s discharge from an inpatient acute care hospital, inpatient psychiatric hospital, long-term care hospital, skilled nursing facility, inpatient rehabilitation facility, hospital outpatient observation or partial hospitalization at a community mental health center. 

    One key consideration is that in order to qualify as a TCM service, the beneficiary must be returned to his or her community setting, such as his or her home or assisted living facility. 

    During the 30 days beginning on the date the beneficiary is discharged from the inpatient setting, the following three TCM components must be furnished.

     

    01/ Interactive contact

    Physicians must make an interactive contact with the beneficiary and/or caregiver, as appropriate, within two business days following the beneficiary’s discharge to the community setting. The contact may be via telephone, e-mail, or face-to-face.  

    A successful attempt requires a direct exchange of information and appropriate medical direction by clinical staff with the beneficiary and/or caregiver and not merely receipt of a voicemail or e-mail without response from the beneficiary or caregiver. 

    For purposes of this requirement, business days are Monday through Friday, except holidays, without respect to normal practice hours or date of notification of discharge.  For Medicare purposes, attempts to communicate should continue after the first two attempts in the required two business days until they are successful.  

    TCM cannot be billed if there was no successful communication within the 30-day period between the facility discharge and the date of service for the post-discharge TCM code.

     

    02/ Non-face-to-face services

    Furnish non-face-to-face services to the beneficiary, unless it’s determined that they are not medically indicated or needed. 

    Nancy M. Enos, FACMPE, CPC
    Nancy M. Enos, FACMPE, CPC-I, CPMA, CEMC, CPC, is an independent consultant and coding instructor. She owns and operates Enos ...

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