Christine Davenport (christine.davenport@brooksrehab.org) is the Compliance Operations Manager at Brooks Rehabilitation in Jacksonville, FL. Monica Alexanderson (monica.alexanderson@brooksrehab.org) is the Manager of Brooks Center for Care Transitions for Brooks Rehabilitation in Jacksonville, FL.
Did you know there is a way to help avoid unnecessary inpatient readmissions and be reimbursed for providing post-discharge professional services to your patients? The Centers for Medicare & Medicaid Services (CMS) developed Transitional Care Management (TCM)[1] codes in recognition of care coordination that can improve patient care, enhance quality of life, and reduce healthcare costs. The TCM service focuses on the handoff between an inpatient setting and the community setting with a goal of avoiding unnecessary readmissions. Sounds good, right?
Our facility decided that these services could be beneficial to our patients who often require significant post-discharge assistance due to the severity of their conditions, such as traumatic brain injuries and strokes. Before initiating a program in your facility, you should be aware of the specific components for using TCM codes prior to implementation. Appropriate billing compliance will hinge on fulfilling these documentation requirements.
The CPT® codes
CPT codes 99495 and 99496 for TCM services became effective January 1, 2013, under the Physician Fee Schedule. The code descriptions, as provided by the American Medical Association’s CPT 2021 edition, are:
-
99495 – Transitional Care Management Services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 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 2 business days of discharge. Medical decision making of at least high complexity during the service period. Face-to-face visit, within 7 calendar days of discharge
Additional requirements for TCM services
A practical resource for detailed information on TCM services is the January 2019 Medicare Learning Network Fact Sheet for Transitional Care Management Services.[2] This fact sheet covers information on who may furnish TCM services, supervision requirements, service settings, and the components of TCM. Some of the key compliance items to check thoroughly are:
-
TCM services may be provided when a beneficiary discharges from an approved inpatient setting and specific discharge requirements are met:
-
Patient may be discharged from an inpatient acute or psychiatric hospital, long-term care hospital, skilled nursing facility, inpatient rehabilitation facility, hospital outpatient observation, or partial hospitalization at a community mental health center.
-
After discharge, the beneficiary must return to their community setting of home, domiciliary, rest home, or assisted living facility.
-
-
The required face-to-face visit must meet moderate- or high-complexity medical decision-making to be eligible for TCM:
-
Medical decision-making refers to the complexity of establishing a diagnosis and/or selecting a management option under the Evaluation and Management Guidelines in CPT. When calculating medical decision-making for TCM services, the 1995/1997 documentation guidelines would be used. The 2021 changes to Evaluation and Management Guidelines are not applicable to TCM services.
-
-
The 30-day TCM period begins on the beneficiary’s inpatient discharge date and continues for the next 29 days.
-
Physicians and nonphysician practitioners may perform these services.
-
CPT 99495 and 99496 may be performed via telehealth.
-
An interactive contact with the beneficiary by a qualified health professional and/or licensed clinical staff under the physician’s direction must be performed within two business days following discharge.
-
Documentation of at least two unsuccessful attempts and continued attempts until successful contact with the beneficiary is required.
-
Non-face-to-face care coordination services to the beneficiary, such as reviewing discharge information, following up on pending tests, providing education to beneficiary/family, assistance in arranging community resources, and referrals, are included in TCM services.
-
One face-to-face visit must occur within the time frames indicated in CPT codes 99495 or 99496.
-
Medication reconciliation and management on or before the date of your face-to-face visit is a required component.
