Transitional Care Management

Get the TCM Toolkit

Want to be reimbursed for TCM services? The AAFP's TCM Toolkit includes resources to help you get started, including:

  • TCM components and requirements
  • Steps to implement TCM in your practice
  • Patient materials
  • A 30-day worksheet
  • A TCM medical records request template

(Members Only)

TCM Live Webinar

Wednesday, October 25, 2017
12:00 PM Central

Stop leaving money on the table. The "Transitional Care Management: Getting Paid for What We Do Best!" live webinar, presented by Marc Price, D.O., provides an overview of the benefits of offering TCM services to Medicare beneficiaries. 

What is Transitional Care Management?

Transitional Care Management (TCM) addresses the handoff period between the inpatient and community setting.  After a hospitalization, the patient commonly has experienced a medical crisis, new diagnosis, or change in medication therapy.  Family physicians often manage their patients’ transitional care.

TCM Coding

In 2013, CMS implemented TCM codes. The two CPT codes use to report are:
•    99495 moderate medical complexity requiring a face to face visit within 14 days of discharge
•    99496 high medical complexity within 7 days of discharge

Requirements and Components for TCM

The guidelines for TCM include the following requirements:

  • Contact the patient within two business days of discharge
  • Conduct a follow-up visit within seven or 14 days of discharge, depending on the complexity of medical decision making involved. The face-to-face visit is part of the TCM service and should not be reported separately.
  • Medicine reconciliation and management must be furnished no later than the date of the face-to-face visit.

Service Settings Requirements

Discharge from any of the following:

  • Inpatient acute care hospital
  • Inpatient psychiatric hospital
  • Long-term care hospital
  • Skilled nursing facility
  • Inpatient rehabilitation
  • Hospital outpatient observation
  • Partial hospitalization

Health Care Professional Who May Furnish and Bill TCM:

  • Physicians (any specialty)
  • Certified nurse midwives (CNMs)
  • Clinical nurse specialist (CNS)
  • Nurse practitioners (NPs)
  • Physician assistants (PAs)

Non-physicians must legally be authorized and qualified to provide this service in the state in which they are furnished.

Interactive Contact

Interactive contact with the beneficiary or caregiver must occur within two business days following a discharge. Contact may be via telephone, email, or face-to-face visit. Attempts to communicate should continue after the first two attempts in the required business days until successful.

Required Components to Bill TCM

  • Obtain and review discharge information
  • Review need for and or follow up on pending test/treatments
  • Education of the beneficiary, family member, or caregiver
  • Establish or re-establish with community providers and services
  • Assist in scheduling follow-up visits with providers and services
  • Face-to-face visit must be furnished within seven to 14 days depending on the complexity of the patient
  • Medicine reconciliation and management must be furnished no later than the date of the face-to-face visit
     

The AAFP Position on TCM

The AAFP’s advocacy efforts have helped pave the way for Medicare reimbursement for TCM, giving family physicians an opportunity to be paid to coordinate care for Medicare beneficiaries as they transition between settings. We believe that family physicians should be compensated for the value they bring to their patients by delivering continuous, comprehensive, and connected health care.

What You Need to Know

As health care moves from volume to value, TCM will be increasingly important. This service ensures that the highest risk patients receive the care they need immediately after a discharge from a hospital or other health care facility. Continuity of care provides a smooth transition for patients that improves care and quality of life, and helps prevent unnecessary readmission, reducing costs.

Learn more about TCM with the AAFP TCM Toolkit»

Get the TCM Toolkit

Want to be reimbursed for TCM services? The AAFP's TCM Toolkit includes resources to help you get started, including:

  • TCM components and requirements
  • Steps to implement TCM in your practice
  • Patient materials
  • A 30-day worksheet
  • A TCM medical records request template

(Members Only)

TCM Live Webinar

Wednesday, October 25, 2017
12:00 PM Central

Stop leaving money on the table. The "Transitional Care Management: Getting Paid for What We Do Best!" live webinar, presented by Marc Price, D.O., provides an overview of the benefits of offering TCM services to Medicare beneficiaries.