Transitional Care Management has been created by the Centers for Medicare and Medicaid Services to provide reimbursement opportunities for communication with a patient following a facility or hospital discharge (these are specified below). The communication involves a "checking in" on the patient within two business days of their discharge date along with an office or home face-to-face visit within seven or fourteen calendar days of discharge depending on the complexity of the decision making centered around the patient.

CPT Codes To Know:

99495:

  • Communication with patient or caregiver within two business days of discharge (Business days are Monday-Friday except holidays). This may be a phone call, an email, direct contact, etc. 

  • Face-to-face visit within 14 days of discharge (Calendar).

  • During the service period the decision making surrounding the patient must be at least moderate complexity.

  • Covers a 30 day period.

  Average reimbursement: 

  • Facility: $112.00

  • Non-Facility: $166.50

99496:

  • Communication with patient or caregiver within two business days of discharge (Business days are Monday-Friday except holidays). This may be a phone call, an email, direct contact, etc. 

  • Face-to-face visit within 7 days of discharge (Calendar)

  • During service period the decision making surrounding the patient must be high complexity. 

  • Covers a 30 day period.

  Average reimbursement:

  • Facility: $162.00

  • Non-Facility: $234.97

       To check reimbursement for TCM in your area click the link below.
       https://www.cms.gov/apps/physician-fee-schedule/license-agreement.aspx

Services to be Provided Under TCM:

  Hospital Settings That a Patient may Transition From:

  • Long-Term Care hospital

  • Inpatient Acute Care hospital

  • Inpatient Psychiatric hospital

  • Skilled Nursing facility

  • Inpatient Rehabilitation facility

  • Hospital Outpatient Observation or Partial Hospitalization

  • Partial Hospitalization at a Community Mental Heath center

  Non Face-to-Face Services to be Provided Under TCM may Include: 

  • Connection made to patient and/or caregiver within two business days post hospital discharge (phone, email, face-to-face).

  • Communication with community services or home health agencies the patient may wish to utilize.

  • Education given to patient and/or caregiver that supports independent living, daily life, or self-management. 

  • Assessment and support of patient treatment regimen and management of prescribed medication.

  • Discern available community and health resources that may be of use to the patient.

  • Coordination of access to care and or services that may be deemed useful to patient.

       Note: These services may be provided by clinician staff when done under the               direction of the physician (or qualified healthcare professional).

  Non Face-to-Face Services to be Provided by the Physician may Include:

  • Collection and review of discharge information 

  • Review of patient's need for, or follow-up on, treatments and pending diagnostic tests.

  • Schedule and completion of Face-to-Face visit.

  • Communication between TCM physician and any qualified healthcare professional who may assume or re-assume patient care upon completion of TCM.

  • Education of caregiver and/or patient 

  • Arrangement or Re-arrangement of referrals and/or community services one may recommend to the patient.

  • Assistance with scheduling follow-ups with community providers and/or services.

       Note: These services can only be provided by a physician or other qualified                   healthcare professional.

What ThoroughCare Does for you:

  • Breaks TCM process into four easy steps (Review Discharge Info, Initial Communication, Non Face-to-Face, Face-to-Face / Finalize)

  • Provides tools to schedule/record the Initial Communication and a Face-to-Face visit 

  • Allows for organized documentation of non face-to-face requirements (ei. Medications on discharge, Appointment coordination, documentation of findings, etc)

  • Includes a checklist of patient progression through TCM

  • Keeps track of upcoming and missed deadlines

  • Supplies helpful tools to successfully fulfill TCM services

Other Information:

  • This service extends over a 30 day period.

  • If the patient is readmitted before end of 30 days then the TCM period will start over. If a face-to-face visit was completed already it can be billed as an Evaluation and Management visit.

  • A discharge visit does not count as the face-to-face visit for TCM

  • TCM may only be billed by a single practice for a given patient in the 30 day period.

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