Transitional Care Management 2013, Medicare began paying for transitional care management (TCM) as part of a multi-year In strategy to recognize and support primary care and care management. In this month’s column, we will review some of the most important coding and billing guidelines for TCM services. Who Can Receive TCM Services? in order to qualify for tcm, the patient must be transitioning from an institutional setting to a community setting. institutional settings in this context include inpatient acute care or psychiatric hospitals, long term care hospitals, skilled nursing facilities, inpatient rehabilitation facilities, hospital outpatient observation or partial hospitalization, and partial hospitalization at a community mental health center. community settings include the patient’s home, domiciliary care, rest homes, and assisted living facilities. the 2013 cPt® manual states that tcm services are for patients with “medical and/or psychosocial problems” that require moderate or high complexity medical decision making (mdm) during the transition period. the 2013 cPt manual also states that tcm services apply only to established patients. however, cms stated in the mPfs 2013 final rule that they intended to issue policies allowing tcm services to be provided to new patients for medicare billing purposes, and the cms transitional care management fact sheet, issued in june of 2013, does not indicate that the patient must be an established patient of the provider. Who Can Provide TCM Services? tcm services are not restricted to any particular medical specialty. in the 2013 medicare Physician fee schedule final rule, cms stated, “We continue to expect that most community physicians who are furnishing tcm services will be primary care physicians and practitioners.” however, cms went on to add that, in some circumstances, specialists such as cardiologists or oncologists might be “in the best position to furnish transitional care coordination after a hospital discharge.” in addition to physicians of any specialty, tcm can also be furnished by nonphysician practitioners (nPPs) such as physician assistants and nurse practitioners as long as state law permits them to furnish such services. finally, some of the components of tcm can be performed by licensed clinical staff, as discussed later in this article. What Codes Are Used to Report TCM? tcm services are reported with the following cPt codes: Code Description 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 the differences between the two codes are: • code 99495 requires at least moderate complexity mdm, while 99496 requires high complexity mdm. • code 99495 requires a face-to-face visit within 14 days of discharge, while 99496 requires a visit within seven days. medical decision making for tcm is defined the same way it is for any e/m service. however, when determining the level of By Jackie Miller, RHIA, CCS-P, CPC 34 hbma billing • november.december.2013
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