Transitional Care Management Services Guidlines
Who can provide TCM
- Physicians (any specialty)
- Non-physician practitioners (NPPs) legally authorized and qualified to provide the services in the State where they furnish them:
- Certified nurse-midwives (CNMs)
- Clinical nurse specialists (CNSs)
- Nurse practitioners (NPs)
- Physician assistants (PAs)
You may provide TCM services, beginning the day of the beneficiary’s discharge from one of these
inpatient hospital setting
- inpatient acute care hospital
- inpatient psychiatric hospital
- long term care hospital
- skilled nursing facility
- inpatient rehabilitation facility
- hospital outpatient observation or partial hospitalization
- partial hospitalization at a Community Mental Health Center
Patient must be discharged to:
- Rest home
- Assisted living facility
Skilled nursing facilities do not apply.
Interactive Contact Two Days
Within 2 business days following the beneficiary’s discharge, you must make an interactive contact with them and/or their caregiver. The provider or clinical staff can address patient status and needs beyond scheduling follow-up care.
- Must be interactive within the next two business day
- Contact can be with patient or caregiver
- Can be direct, over the phone or electronically (eg. through eVigils)
- Report the service if you make two or more unsuccessful separate attempts in a timely manner
- If you have documented attempts, reach patient on Day 3+, and meet the face-to-face requirement you can still bill for TCM services
Non-face-to-face services to the beneficiary
You must furnish non-face-to-face services to the beneficiary unless you determine they are not medically indicated or needed.
Physicians or NPPs may furnish these non-face-to-face services:
- Obtaining and reviewing any discharge information given to patient
- Review the need for any follow-up diagnostic tests or treatment
- Interact with other healthcare professionals involved in patient’s after care
- Provide education to patient, family members or caregivers
- Establish referrals and arrange community resources that patient can be involved in to regain activities of daily living
- Assist in scheduling the follow-up visit to physician
Clinical Staff Services
Under the direction of a Physician or NPP Clinical staff under your direction may provide these services, subject to the State’s supervision law:
- Communicate with agencies and community services the beneficiary uses
- Provide education to the beneficiary, family, guardian, and/or caretaker to support selfmanagement, independent living, and activities of daily living
- Assess and support treatment adherence and medication management
- Identify available community and health resources
- Assist the beneficiary and family in accessing needed care and services
Face-to-Face Visit & Telehealth
You must furnish one face-to-face visit within certain timeframes described by the following two CPT codes:
- Code 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
- Code 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 high complexity during the service period; Face-to-face visit, within 7 calendar days of discharge
You should not report the TCM face-to-face visit separately.
- You may furnish CPT codes 99495 and 99496 via telehealth. Medicare pays for a limited number of Part B services a physician or practitioner furnishes to an eligible beneficiary via a telecommunications system. Using eligible telehealth services substitutes for an in-person encounter.
Medical Decision Making (MDM)
MDM refers to the complexity of establishing a diagnosis and/or selecting a management option by considering these factors:
- The number of possible diagnoses and/or the number of management options that must be considered
- The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed
- The risk of significant complications, morbidity, and/or mortality as well as comorbidities associated with the patient’s presenting problem(s), the diagnostic procedure(s), and/or the possible management options
You must furnish medication reconciliation and management on or before the date of your face-to-face visit.
At a minimum, the following must be in the beneficiary’s medical record:
- Date of discharge
- Date interactive contact was made with patient and/or caregiver
- Date of face-to-face visit
- Complexity of medical decision making (moderate or complex)
If during the month, the patient is seen more than once for a follow-up visit, any other visit made during the 30 days can be billed separately using an Evaluation and Management (E/M) code. The TCM codes are used when the provider wants to assume responsibility for the patient’s post-discharge services to try to prevent the patient from getting readmitted to the hospital.
The codes must be billed using the seventh or 14th day as the date of service and only one healthcare professional may report this service. If more than one physician assumes care and a claim is denied, the provider can bill the visit using an E/M code. The TCM service may be reported once during the entire 30-day period.
If a surgeon is caring for the patient in the hospital after surgery, TCM cannot be billed for upon discharge as those services are part of the global period of the surgical procedure.
Billing TCM Services
- Only one health care professional may report TCM services.
- Report services once per beneficiary during the TCM period.
- The same health care professional may discharge the beneficiary from the hospital, report hospital or observation discharge services, and bill TCM services. The required face-to-face visit may not take place on the same day you report discharge day management services.
- Report reasonable and necessary evaluation and management (E/M) services (except the required face-to-face visit) to manage the beneficiary’s clinical issues separately.
- You may not bill TCM services and services within a post-operative global surgery period (Medicare does not pay TCM services if any of the 30-day TCM periods falls within a global surgery period for a procedure code billed by the same practitioner).
FY2020 Final Rule
After considering public comments on our questions and proposals, and in light of our goal of increasing [the] utilization of TCM services, we are finalizing our proposal to allow concurrent billing of the care management codes currently restricted from being billed with TCM. This includes allowing concurrent billing of TCM with the 14 codes specified in Table 20, as well as CPT codes 99490 and 99491, which we have identified as codes that also fit this policy. We are finalizing for both TCM codes the proposed increases in work RVUs and the RUC-recommended direct PE inputs. We look forward to working with the public and other stakeholders to potentially further refine our billing policies through future notice and comment rulemaking.