Resources to Answer Your Coding Questions on Transitional Care Management

Physicians and practice managers often contact the Pennsylvania Medical Society’s (PAMED) practice support team with questions about the new TCM codes.

The following resource may help:

Highlights of TCM services

These are the new CPT codes (99495 and 99496) were created to account for the time a physician spends transitioning a patient out of institutional care and back into the community setting. Some highlights of TCM include:

CPT 99495: TCM services with the following required elements:

  • Communication (direct contact, telephone, electronic) with the patient 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

CPT 99496: TCM services with the following required elements:

  • Communication (direct contact, telephone, electronic) with the patient or caregiver within two business days of discharge
    Medical decision-making of at least high complexity during the service period
    Face-to-face visit within seven calendar days of discharge

Requirements for patients and physicians

To be eligible for the service, the patient’s condition must be of moderate to high complexity as defined by evaluation and management (E/M) documentation guidelines.

During the time period for TCM services, which includes the 30-day period beginning on the date of discharge, the physician must:

  • Contact the patient within two business days of discharge. The physician must have a face-to-face visit with the patient within the time frame listed for each code above. This first E/M service is not separately reportable, meaning that the practice may not bill for this E/M service if it intends to bill TCM codes. Medication reconciliation is required during the visit. Any subsequent medically necessary E/M service may be billed to Medicare.

Non-face-to-face services include: communication with the patient, caregiver, family, home health agency or other community services involved in the patient’s care; education to support activities of daily living; assessment and support of the treatment regimen and medication management; identification of community and health resources; and facilitating access to these resources.

  • Review the discharge summary to: determine the need for pending or follow-up tests and other services; interact with other health care professionals involved in the patient’s care; provide education of patient, family or caregiver; establish or reestablish referrals; and assist in scheduling medical care or community care.

Billing for TCM services

Physicians and other qualified non-physician practitioners may bill for TCM services. The Centers for Medicare and Medicaid Services (CMS) is modifying the prefatory instructions for the CPT TCM codes allowing a physician to bill these services for new patients. There is no restriction on physician specialty designation.

Medicare will pay for only one TCM claim for the 30-day period following discharge. Claims can be submitted no sooner than 30 days following discharge. The first claim to be filed will be paid. Medicare will not pay a second TCM claim in connection with a discharge that occurs within 30 days of the original discharge (i.e., the patient is readmitted and discharged within the same 30-day period).

Limitations on submitting claims for TCM services include:
A physician who reports a global procedure cannot bill for TCM services for the same time period.

A physician who bills TCM services cannot bill for the following services during the 30-day period:

  • Care plan oversight services (99339-99340, 99374-99380)
  • Prolonged service without direct patient contact (99358-99359)
  • Anticoagulant management (99363-99364)
  • Medical team conferences (99366-99368)
  • Education and training (98960-98962, 99071, 99078)
  • Telephone services (98966-98968, 99441-99443)
  • End-stage renal disease services (90951-90970)
  • Online medical evaluation services (98969, 99444)
  • Preparation of special reports (99080)
  • Analysis of data (99090-99091)
  • Complex chronic care coordination services (99487-99489)
  • Medication therapy management services (99605-99607)

CMS is hopeful that TCM will generate savings by reducing costly readmissions or prolonged hospitalizations. TCM is intended to improve the care of a patient who is discharged from an inpatient or observation admission, skilled nursing facility, or partial hospitalization program.

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