Transitional Care Management
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.
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 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.