Most family medicine practices manage patients during care transitions, such as from hospital to home, but many practices fail to bill for this work because the rules for using transitional care management (TCM) codes can be confusing.
Here are answers to four common questions about TCM billing.
1. If a patient is discharged from the hospital on Monday afternoon, how do we count the two business days for the required phone call to the patient?
The first requirement of TCM is direct contact with the patient within two business days after discharge. The day of discharge doesn’t count as the first day, so count the next day as the first business day (in this case Tuesday) and contact the patient by the end of the second business day (in this case Wednesday). For a patient discharged on Friday, two business days would be by the end of the day Tuesday. The Centers for Medicare & Medicaid Services (CMS) adopted the CPT rule that two attempts to contact the patient count, even if you do not reach the patient.
2. If the patient’s follow-up appointment is within two business days, can we still bill TCM?
Yes. Sometimes the patient’s follow-up appointment occurs within the two business days after discharge. If so, and if you discuss the discharge, that appointment meets both the initial contact requirement and the face-to-face visit requirement. The exact CPT definition for the initial contact is “communication (direct contact, telephone, electronic).”
3. Does an emergency department visit qualify for TCM?
No. Emergency department visits are excluded. Patients are eligible for TCM services to help with the transition following discharge from inpatient or observation status, a nursing facility, or partial hospitalization.
4. Can I bill TCM for every patient discharged from the hospital?
No. Not all patients are eligible to receive TCM services. The patient must require additional support from either the physician, a nonphysician provider, or the practice’s clinical staff. This must be documented in the medical record. It might include coordinating care with physiatry and occupational therapy, providing additional education for the patient and caregiver (e.g., instruction about monitoring blood sugars or recording daily weights), coordinating services with home health or a durable medical equipment supplier, etc. The key is that additional work beyond the initial call and the face-to-face visit is required.
CPT describes the requirements as follows:
"TCM is comprised of one face-to-face visit within the specified timeframes, in combination with non-face-to-face services that may be performed by the physician or other qualified health care professional and/or licensed clinical staff under his/her direction."
"Non-face-to-face services provided by clinical staff, under the direction of the physician or other qualified health care professional, may include:
• communication (with patient, family members, guardian or caretaker, surrogate decision makers, and/ or other professionals) regarding aspects of care,
• communication with home health 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."
"Non-face-to-face services provided by the physician or other qualified health care provider may include:
• obtaining and reviewing the discharge information (eg, 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 reestablishment of referrals and arranging for needed community resources,
• assistance in scheduling any required follow-up with community providers and services."
CMS notes that the physician or other qualified health care professional would determine which of these non-face-to-face services are medically indicated or needed.
– Betsy Nicoletti, a Massachusetts-based coding and billing consultant
Additional reading: “Transitional Care Management Services: New Codes, New Requirements”
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