Transitional care management (TCM): Medicare codes and toolkit
Here's how to ensure your Medicare patients get the best care—and you get paid appropriately.
When Medicare patients are ready to leave the hospital or health care facility, the journey isn’t over—for you or your patient. You may provide what’s known as transitional care, between the facility and the patient’s home or new community care setting.
Family physicians should be compensated for the value they bring to their patients by delivering continuous, comprehensive and connected care. Our advocacy efforts helped pave the way for Medicare payment for transitional care management (TCM) services.
With health care delivery moving to value-based models, these services will be increasingly important as continuity of care helps prevent unnecessary readmission and reduces costs.
What is TCM?
After a hospitalization or stay in another inpatient facility—like a skilled nursing facility, psychiatric hospital or rehab facility—the patient may be dealing with a medical crisis, new diagnosis or change in medication. As a family physician, you may manage your patient’s transitional care as they move and get settled.
Medicare TCM billing and coding
TCM means continuity of care—as well as continuity of rules and questions. Which patients are eligible? For how long? How does my practice get paid? When do I file?
Here’s key information plus answers to some common questions.
CPT codes for transitional care management
TCM may be provided to new or established patients. The two CPT codes used to report TCM services are:
- 99495: Moderate medical decision making. Requires communication with the patient or a caregiver within two days of discharge and a face-to-face visit within 14 days of discharge.
- 99496: High medical decision making. Requires communication with the patient or a caregiver within two days of discharge and a face-to-face visit within seven days of discharge.
Requirements and components for TCM
Medication reconciliation and management no later than the date of the face-to-face visit
Obtain and review discharge information
Review need for diagnostic tests/treatments and/or follow up on pending diagnostic tests/treatments
Educate the patient, family, guardian, or caregiver
Establish or re-establish referrals with community providers and services, if necessary.
Assist in scheduling follow-up visits with providers and services, if necessary
Medicare payment guidelines for TCM
TCM also includes non-face-to-face care provided by a physician and clinical staff. What are some examples?
Non-face-to-face services provided by the physician or other qualified health care provider may include:
- Obtaining and reviewing discharge information (e.g., discharge summary, as available, or continuity of care documents)
- Reviewing need for, or follow up on, pending diagnostic tests and treatments
- Interaction with other qualified health care professionals who will assume or reassume care of the patient’s system-specific problems
- Education of patient, family, guardian and/or caregiver
- Establishment or re-establishment of referrals and arrangement of needed community resources
- Assistance in scheduling any required follow up with community providers and services
Non-face-to-face services provided by clinical staff, under the direction of the physician or other qualified health care professional, may include:
- Communication (i.e., direct contact, telephone, electronic) with the patient and/or caregiver within two business days of discharge. Clinical staff contacting the patient must be able to address the patient status and needs beyond scheduling follow-up care.
- Communication with agencies and other community services utilized by the patient
- Patient and/or family/caretaker education to support self-management, independent living and activities of daily living
- Assessment and support for treatment regimen adherence and medication management
- Identification of available community and health resources
- Facilitating access to care and services needed by the patient and/or family
Why shouldn’t I just bill an office visit (e.g., CPT code 99214) instead?
TCM accounts for all the services you and your team deliver during the 30-day post-discharge period. This includes the 7- or 14-day face-to-face visit. This visit does not have to meet a documentation level of service such as a 99214 or 99215 other than the medical decision-making component. You can bill it as an office visit if documentation requirements are met should the patient die or be re-admitted.
Does the required face-to-face visit have to be in the office?
No. While the visit will typically be in the office, it may also be in the patient’s home or another location where the patient resides. TCM may also be provided via telehealth. For the eligible telehealth services, the use of telecommunication systems substitutes for an in-person encounter. Learn more about telehealth requirements.
Can I report TCM and other care management services (e.g., CCM) in the same month?
Yes. CMS will allow concurrent billing of TCM with other care management services, such as CCM and RPM/RTM. However, time and effort may not be counted more than once. For example, time spent providing TCM activities cannot be counted toward the time for CCM.
Additionally, TCM and APCM may not be reported in the same month when provided by the same physician for the same patient.
Can more than one physician report TCM services for the same patient during the 30-day post-discharge period?
No. TCM services may be billed by only one individual during the post-discharge period. If more than one physician submits a claim for TCM services provided to a patient in a given 30-day period following discharge, Medicare will pay the first claim it receives that otherwise meets its coverage requirements.
When do I bill for TCM?
You should submit your bill on the 30th day of the post-discharge period. TCM covers 30 days of management services with one evaluation visit included. The date of service on the claim would be the 30th day post-discharge.
What happens if the patient is re-admitted before the 30 days expire?
The face-to-face visit would become the appropriate level E/M code for the service that was provided. You would start over your 30 days of service on the TCM once the patient is discharged.
Is there cost-sharing for TCM?
Yes, TCM is subject to deductible and co-insurance.
How is a “business day” defined, and what happens if I can’t reach the patient and/or caregiver in that timeframe?
For the purposes of TCM, business days are Monday through Friday, except holidays, without respect to normal practice hours or date of notification of discharge. If two or more separate attempts are made in a timely manner, but are unsuccessful and other TCM criteria are met, the service may be reported. Medicare, however, expects attempts to communicate to continue until they are successful.
Attempts to communicate should continue after the first two attempts in the required two business days until you are successful. If you make two or more separate attempts in a timely manner and document them in the medical record, but are unsuccessful in making contact and if all other TCM criteria are met, you may report the service. CMS expects attempts to make contact to continue until successful.
Compliance and documentation best practices
At a minimum, the following is required to be documented in the beneficiary’s medical record:
The date the beneficiary was discharged
The date you made interactive contact with the beneficiary and/or caregiver
The date you provided the face-to-face visit
Complexity of medical decision-making (moderate to high)
How to implement TCM in your practice
Adding TCM services can be advantageous for both your patients and your practice, provided you establish a solid foundation for how you’ll provide care and how you’ll bill for it. Follow these three steps to lay the groundwork:
- Identify hospitals and emergency departments responsible for the most patient hospitalizations. With the shared goal of decreasing readmissions, develop a relationship with those hospitals to improve timeliness of notification, so your practice can reach out to patients within two business days of discharge.
- Add TCM to decrease the cost of care by reducing unnecessary readmissions.
- Add TCM after the Medicare annual wellness visit and chronic care management, as the volume and associated revenue of this service is hard to anticipate.
Toolkit features
Understand key components and requirements to get paid for TCM services
Follow the step-by-step TCM implementation guide for a successful launch
Use the staff script to perform TCM follow-up calls
Track your patients’ status and progress with a 30-day worksheet
Download and complete the TCM medical records request form
Distribute the patient handout to help your patients understand how to get the care they need upon discharge from an inpatient setting