Subpages:
What is TCM?
Definition and Overview
Key Components of TCM
Benefits of TCM for Patients and Providers
What are the CPTS used for the TCM program?
How can EHI help with the TCM Program?
Table of Contents
1. What is TCM
Transition Care Management (TCM) is focused on coordinating patient care during the transition period between inpatient settings. The objective is minimizing any complications and avoiding readmissions during the 30 days following the discharge from the acute care settings. Studies have shown that TCM will reduce the post discharge readmission and mortality rate.
CMS has identified two different CPT codes for the TCM program. The goal of TCM is to provide coordination of care services for the traditional Medicare patients between the acute care to community setting. The provider is to "oversee Management and coordination of services as needed for all medical conditions including psychosocial needs and activity of daily living support.”
TCM requires that communication contact to be done within two business days after the patient is discharged and face to face contact is required within 30 days.
TCM service may be furnished upon patient discharge from the following settings:
Inpatient acute care hospital
Inpatient psychiatry hospital
Skilled nursing facility
Long term care hospital
Inpatient rehab facility
Hospital outpatient observation or partial hospitalization
Partial hospitalization at a community mental health center
After inpatient discharge, patients can come back to community settings:
Home
Domiciliary like a group home/boarding house
Nursing facility
Assisted living facility
2. Benefits of TCM
Transition of care helps by reducing the readmission, improving care coordination, increasing patient satisfaction, and providing continuous care during the transition period, thus reducing the overall health care cost.
The main goal of the TCM is to reduce the post discharge readmission by providing seamless care and avoiding any complication during the transition.
Better care coordination and patient education leads to improved patient outcomes and better quality of life.
Better communication with patients and seamless care management during the transition will result in improved patient outcomes.
TCM programs can help equip care givers with education and information that will aid in patient care at home.
TCM helps establish effective communication with all the key health care providers and community to ensure complete care.
TCM helps provide patients with education and self-care to promote better health outcomes at home.
Post discharge check in and monitoring are important to identify any issues and address them promptly.
TCM aims to reduce the overall readmission and reduce overall health care costs.
TCM can help with medication reconciliations and adherence.
3. Who can provide TCM Services
TCM services include face to face services and non-face to face services. These health practitioners can provide the TCM Services:
TCM codes are care management codes. Auxiliary personnel may assign them for TCM non-face-to face services under the general supervision of the physician or nurse practitioner subject to applicable state law, scope of practice, and the Medicare Physician Fee Schedule incident to rules and regulations.
CNMs, CNSs, NPs, and PAs may also provide the non-face-to-face TCM services incident to the physician’s services.
4. What are the components of TCM?
When a patient discharges from an approved inpatient setting, providers must follow at least these TCM components during the 30-day service period:
Interactive contact
Providers or clinical staff under the direction contact the patients or caregiver by phone, email, or face-to-face within 2 business days after the patients' discharge from inpatient or partial hospitalization setting.
“Clinical staff” means someone who is supervised by a physician or other qualified health care professional and is allowed by law, regulation, and facility policy to perform or assist in a specialized professional service but does not individually report that professional service.
The interactive contact must be performed by clinical staff who can address patient status and needs beyond scheduling follow-up care.
Report the service if you make two or more unsuccessful separate contact attempts in a timely manner (and if you meet the other service requirements, including a timely face-to-face visit).
Document your attempts in the patient’s medical record.
Continue trying to contact the patient until you are successful.
Face-to-face visits are required to bill for TCM services within the required time.
4.1 Non-Face-to-Face Services
You and your clinical staff (as appropriate) must provide patients with medically reasonable and necessary non-face-to-face services within the 30-day TCM service period.
Clinical staff under your direction may provide certain non-face-to-face services.
4.2 Physician or NPP Non-Face-to-Face Services
Physician or NPP Non-Face-to-Face Services Physicians or NPPs may provide these non-face-to-face services:
Review discharge information (for example, discharge summary or continuity-of-care documents)
Review the patient’s need for, or follow up on, diagnostic tests and treatments.
Interact with other health care professionals who may assume or reassume care of the patient’s system-specific problems.
Educate the patient, family, guardian, or caregiver.
Establish or reestablish referrals and arrange needed community resources.
Help schedule required community providers and services follow-up.
4.3 Auxiliary Personnel Under Physician or NPP General Supervision non-face-to-face services
Auxiliary Personnel Under Physician or NPP General Supervision Non-Face-to-Face Services Auxiliary personnel may provide these non-face-to-face TCM services under general supervision:
Communicate with the patient.
Communicate with agencies and community service providers the patient uses.
Educate the patient, family, guardian, or caregiver to support self-management, independent living, and activities of daily living.
Assess and support treatment adherence, including medication management.
Identify available community and health resources.
5. What are CPT codes for the TCM Program?
You must provide 1 face-to-face visit within the time limits described by these 2 CPT codes:
99495 — Transitional care management services required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge. At least a moderate level of medical decision making during the service period face-to-face visit, within 14 calendar days of discharge
99496 — Transitional care management services required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within two business days of discharge. High level of medical decision making during the service period face-to-face visit, within seven calendar days of discharge
Do not report the TCM face-to-face visit separately.
Telehealth Services - TCM can be provided using CPT codes 99495 and 99496 through telehealth. CMS will pay for a limited number of Part B services that are provided to an eligible patient using a telecommunications system.
Medication Reconciliation & Management - Must provide medication reconciliation and management on or before the face-to-face visit date.
TCM concurrent billing- You can bill certain other care management services concurrently with TCM services when medically reasonable and necessary and if time and effort are not counted more than once.
Medical Decision-Making MLN Booklet- Patients who get TCM must need moderate medical decision making (if you are billing CPT code 99495) or high-level medical decision making (if you are billing CPT code 99496).
The levels of medical decision making are defined in the 2023 CPT E/M Guidelines. Medical decision making, which refers to establishing diagnoses, assessing the status of a condition, and selecting a management option, is defined by 3 elements:
Problems: The number and complexity of problems addressed during the encounter.
Data: The amount and complexity of data to be reviewed and analyzed, like medical records, diagnostic tests, and other information.
Risk: The risk of complications and morbidity or mortality of patient management.
6. What are TCM services Billing requirements:
Only 1 physician or NPP may report TCM services.
Report services once per patient during the TCM period.
The same health care professional may discharge the patient from the hospital, report hospital or observation discharge services, and bill TCM Services.
The required face-to-face visit cannot take place on the same day you report discharge day management services.
The same health care professional may discharge the patient from the hospital, report hospital or observation discharge services, and bill TCM services. The required face-to-face visit cannot take place on the same day you report discharge day management services.
Report reasonable and necessary E/M services (except the required face-to-face visit) to manage the patient’s clinical issues separately.
TCM services cannot be billed within a post-operative global surgery period (CMS does pay TCM services if any of the 30-day TCM period falls within a global surgery period for a procedure code billed by the same practitioner).
7. Practice and Provider documentation requirements.
Practice and provider at a minimum must document the following information in the patients’ medical records.
Patient discharge date
Patient or caregiver first interactive contact date
Face-to-face visit date
Medical decision making (moderate or high)
8. How can Enable Healthcare Inc (EHI) help?
Enable Healthcare can help guide and support your practice in APCM and value-based care programs.
Provide documentation software as well as end-to-end services.
Communicate with TCM patients via phone call, emails, text messages within the desired time frame of two days.
Communicating with the respective agencies and community providers that patient visits.
Help set up face-to-face visits with the respective providers to ensure proper follow-up and identify any issues and provide appropriate treatment and management services.
Educate the patients, family, guardian, or care giver to support self-management, independent living, and activities of daily living.
Medication reconciliation and Management prior to in person face-to-face visit with providers within the time periods.
Identify community and health resources.
Help the family and patient access needed care and support services.
Help generate billing upon meeting the requirements for the program and the practice.
Ready to Implement Transitional Care Management in Your Practice?
Enable Healthcare is here to guide you through every step of the TCM process, from patient enrollment to billing and care coordination. Our team of experts provides the tools and support you need to ensure seamless transitions of care and improve patient outcomes.
Contact us today to learn how we can help your practice succeed with TCM and other value-based care programs!
Sources:
Internet and google.
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