The ins and outs of Transitional Care Management coding

Transitional Care Management (TCM) codes allow physicians and nonphysician providers (NPPs) to be paid for work they and their clinical staff already do without payment, namely patient transitions from a facility to home. This includes coordinating with other healthcare professionals and community groups, providing education to the patient and family, and other non-face-to-face follow-up during a 30-day period.

The CPT codes for TCM were developed in 2013, which the Centers for Medicare & Medicaid Services (CMS) recognize for payment. Although any specialty physician or NPP can report these codes, CMS considers them an important support for primary care.

TCM requires a phone call or other direct communication between the practice and the patient or family member within two business days of the patient’s discharge from a facility. CMS has clarified that attempting to reach the patient multiple times unsuccessfully would not preclude billing for TCM. The payment for the first post-facility visit is included in the TCM payment and non-face-to-face medical and clinical follow-up for the 30 days after discharge.

There are two differences between the two codes. Code 99496 requires that the patient condition meets the high-complexity criteria at least once during the TCM period and that the patient is seen within seven calendar days. Code 99495 requires that the patient meet the moderate-complexity criteria and have the face-to-face visit within 14 days of discharge. Since 2016, the practice may bill for the service on the day of the face-to-face visit and doesn’t need to wait until the end of the 30-day period.

The physician or NPP must review the discharge summary. The clinical staff must perform medication reconciliation. Not all patients who are discharged from a facility are eligible for the service, only those whose medical or psychosocial conditions are complex and require either the medical or clinical staff to spend additional non-face-to-face time in the transition from the facility to home.

Examples of patients who would be eligible for TCM include: a chronically ill patient, admitted with an exacerbation of congestive heart failure, who also has chronic kidney disease and a history of frequent Emergency Department (ED) visits; patients with housing and transportation problems or a history of frequent admissions or ED visits; patients who take multiple medications with frequent medication adjustments also may be eligible.

The payment rates (see Table 1) are significantly higher than for an office visit, reflecting the additional work that the medical provider and clinical staff do.

The first barrier to reporting TCM is making direct contact in two business days. Practices are able to call the patient but often don’t know if the patient was admitted or discharged. Many systems use hospitalists and the primary care physician isn’t notified of admission or discharge. A patient may be treated at a tertiary care center and the first notification the primary care physician receives is a discharge summary, which typically is not within two business days. Integrated delivery systems or community hospitals may be better able to develop reliable communication between the hospital medical staff or case management and primary care.

TCM documentation is different from an office visit template. It makes sense to import the documentation of the phone call into the patient visit if labeled as such. At this call, staff members confirm the appointment. They may also confirm that the patient filled their prescriptions and ask if the patient needs to talk with a clinical staff member. The office visit is performed and documented, and should note that the hospital discharge summary was reviewed.

Finally, there needs to be documentation for the post-visit, non-face-to-face work that the medical or clinical nursing staff does in the 30-day period after discharge. That might include phone calls with the patient or family member and coordination with community agencies or other healthcare professionals. These need to be documented either in the visit for the TCM or in phone call notes. The latter is often used since the visit is usually locked after a physician or non-physician provider has seen the patient. If there is no further follow-up after the E&M service by either clinical staff or the provider, TCM should not be reported.

Theodore Capron, MD, a family physician in New Hampshire, notes two problems: Doing accurate medication reconciliation and determining whether to bill the higher-level TCM visit that requires high-complexity medical decision-making. “It was sometimes hard to know the truth about the patient’s medical list,” Capron says. “Is truth what the hospital says the patient should be taking, what the PCP says he/she should be taking or what the patient is actually taking?” This is a problem whether or not TCM is reported.

Determining whether to bill the higher-level TCM visit can be tricky. Although the patients are complex, the definition of high complexity used for this code is the one developed by the CMS Documentation Guidelines. Capron correctly notes that it looks like the medical decision-making requirements for a Level 5 established patient visit. 

Debra J. Korff, RN, MBA, MGMA member, director, clinical operations, Northwest Community Medical Group, Arlington Heights, Ill., helped successfully integrate TCM into her organization’s primary care practice by building a TCM team. She notes that they hired two medical assistants who, although practice employees, have organizational ties to the practice manager for the hospitalist group. These medical assistants visit the hospital patients and set up the follow-up appointment before the patient leaves the hospital, then communicate discharge information to the practice. Their transition to an integrated medical record also solved communication problems and allowed for integrated medication lists and access to the discharge summary.

Reporting TCM services provides payment for services that primary care practices already perform. However, it does require effective communication with hospitals and it can change workflow and documentation. CMS has helped practices by allowing the visit to be billed on the day of the face-to-face service and allowing the service to be billed even if there was no direct contact in the first two business days, as long as the practice documents repeated efforts. If a group is not performing this service, now is a good time to review the requirements.