Transitional Care Management

What is Transitional Care Management (TCM)?

Beginning January 1, 2013, the Centers for Medicare & Medicaid Services (CMS) began paying separately for transitional care management (TCM) services. These services are provided to Medicare beneficiaries whose medical and/or psychosocial problems require moderate- or high-complexity medical decision making during transitions in care from a hospital or other health care facility to a community setting (e.g., home, rest home, assisted living).

Two CPT codes are used to report TCM services:

  • 99495 (moderate complexity)
  • 99496 (high complexity)

Benefits of TCM

By approving TCM as a payable service, CMS recognized how important it is for physicians and other qualified health care providers to coordinate their patients’ care transitions. Ensuring continuity of communication and care so that a patient has a smooth transition from a hospital or other health care facility to his or her community setting improves care, improves the patient’s quality of life, reduces anxiety for the patient and his or her caregiver, helps prevent unnecessary readmissions, and reduces total health care spending.

One of the main goals of TCM is to ensure that the highest-risk patients receive the care they need immediately after discharge from a hospital or other facility. This involves primary care services such as reaching out to the patient after discharge to reconcile medications, scheduling timely primary care visits, developing a plan to address common problems, and coordinating with other post-acute care providers.

Patient Contact Requirements for TCM

To bill CPT code 99495:

  • Initiate patient or caregiver contact (direct, telephone, or electronic) within two business days of inpatient discharge
  • Conduct a face-to-face visit with moderate-complexity medical decision making within 14 calendar days of discharge

To bill CPT code 99496:

  • Initiate patient or caregiver contact (direct, telephone, or electronic) within two business days of inpatient discharge
  • Conduct a face-to-face visit with high-complexity medical decision making within seven calendar days of discharge

The billing period for TCM services encompasses the inpatient discharge and the next 29 days (total 30 days).

The Academy’s Position on TCM

The Academy supports the level of attention CMS is giving to TCM services by paying separately for them. Reporting CPT codes for TCM gives family physicians additional revenue to invest in the type of patient-centered, team-based care that is foundational to an advanced primary care practice.

What Members Need to Know

When a Medicare beneficiary has medical and/or psychosocial problems that require moderate- or high-complexity medical decision making, he or she benefits from management and coordination of care during the transition from a hospital or other health care facility to a community setting. As our health care system shifts from volume to value, the CPT codes for TCM give you the opportunity to be paid for the time and effort you and other care team members invest in effective population health management.

Tools for TCM

Transitional Care Management 30-Day Worksheet(2 page PDF) – Helps you and your staff document key information for a patient's transitional care summary (e.g., visit dates, discussion notes, medication changes) and rate your medical decision making in the 30 days after discharge.

Frequently Asked Questions: Transitional Care Management – Answers specific questions about who can bill for TCM services, what services are covered, how to report the CPT codes correctly, and when to submit the bill.

Transitional Care Management Medical Records Request Template(1 page PDF) – Makes it easy for you and your staff to request the release of a patient’s clinical information during his or her transition from a hospital or other health care facility.

The Academy’s Advocacy Work on TCM

AAFP Letter to the American Hospital Association on Medical Records for the TCM Code - July 13, 2016(2 page PDF) – Request for assistance promoting smooth care transitions by facilitating the timely release of discharge summaries and instructions from hospitals to primary care physicians

AAFP Letter to CMS on Medical Records for the TCM Code - March 15, 2016(2 page PDF) – Request for assistance promoting TCM by facilitating the timely release of medical records from hospitals and other health care facilities to primary care physicians

Response: CMS to AAFP on Medical Records for TCM Code(2 page PDF) – Response to the AAFP’s March 15, 2016, request for assistance

AAFP Letter to CMS on Discharge Planning Requirements(2 page PDF) – December 22, 2015 – Response to CMS’s proposed rule “Medicare and Medicaid Programs; Revisions to Requirements for Discharge Planning for Hospitals, Critical Access Hospitals, and Home Health Agencies”