Transitional Care Management (TCM) FAQs

Q1: What is the Transitional Care Management (TCM) program?
The TCM program is a Medicare reimbursement program for physicians who provide non-face-to-face services and communication and a post-discharge, face-to-face consultation to patients with conditions that are considered to be moderate or high complexity. A post-discharge phone call should occur within 2 business days, and the face-to-face consultation must occur within 7 or 14 days, of discharge from an inpatient hospital setting, partial hospital, observation status in a hospital, or skilled nursing facility/nursing facility to the patient’s community setting. Refer to the last page of this document for a high-level overview of this process.

Q2: Are dual eligible patients covered under this service?
Yes.

Q3: What are some examples of the non-face-to-face services?

Clinical staff, under the supervision of the physician or other qualified health care professional, must, at a minimum, communicate with the patient within 2 days of discharge. This communication can be direct contact, telephone, or electronic. Clinical staff can also deliver additional non-face-to-face services, including:

  • Collecting and analyzing discharge information, which include discharge summary and CCDs
  • Care plan and treatment regimen support and medication management
  • Identifying, connecting, and managing referrals for patient with appropriate community resources, services, and care
  • Reviewing and following-up with diagnostic tests and treatments
  • Collaborating with other health care professionals regarding the patient’s care
  • Patient, family, and/or caregiver education

Q4: What is the difference between a moderate and high complexity patient?
CMS defines the following for medical clinical decision-making:

NYMP Medical clinical decision-making

Q5: What do I need to document in the medical record of my patient?
A physician’s office must record, at minimum, the following information for their patient(s):

  • Date of discharge
  • Date of interactive contact made with the patient or caregiver
  • Date of face-to-face visit
  • The complexity of medical decision making (moderate or high)

Q6: How will NYMP help support my TCM program?
Currently, NYMP is working with SNCH to improve the discharge planning, notification, and information sharing process. The improved process will facilitate better communication between hospitalists and the patients’ primary physicians. NYMP is also creating an integrated private health information exchange to aggregate information about admissions, discharges and transfers for NYMP patients, automating notifications about such activity from hospitals state-wide, and creating standardized discharge information sharing with physician practices. As members of the NYMP IPA and ACO, physicians will have access to these data feeds, which will support their TCM program.

Q7: What CPT codes do I bill for TCM? How much am I reimbursed for these codes?
There are two CPT codes associated with the TCM program: 99495 and 99496. The physician’s level of complexity medical decision for the patient determines which code the physician will bill and how quickly the patient must be seen post discharge:

NYMP - Billing and Reimbursement

Q8: What’s the difference between a TCM service and a regular office visit (e.g., CPT code 99214)?
In 2016, CMS will only reimburse up to $125, making the TCM services worth at least $70 more per visit. This additional revenue reimbursement can be used to support the non-face-to-face services that help support higher quality care.

NYMP - 99214 Services

Q9: When can I bill the TCM service? What date of service do I use?
The 30-day period for the TCM service begins on the day of discharge and continues for the next 29 days. The date of service you report should be the date of the required face-to-face visit. You may submit the claim once the face-to-face visit is furnished and need not hold the claim until the end of the service period.

Q10: Is this service to the deductible and co-insurance under Medicare?
Yes.

Q11: Who can bill for TCM services?
Just one physician can bill for TCM services within the 30-day period post-discharge for a patient. If CMS receives more than one bill for TCM services from various physicians, CMS will only pay the first one every 30 days.

Q12: Can I bill for TCM services twice in the 30 days?
If the patient gets readmitted within those 30 days, the physician cannot bill for an additional TCM visit, but the physician can bill for a regular office visit.

Q13: Are there any codes that I cannot bill at the same time as the TCM codes?
Yes. The codes that cannot be billed at the same time as the TCM codes include:

  • Care plan oversight services (99339, 99340, 99374-99380)
  • Prolonged services without direct patient contact (99358, 99359)
  • Anticoagulant management (99363, 99364)
  • Medical team conferences (99366-99368)
  • Education and training (98960-98962, 99071, 99078)
  • Telephone services (98966-98968, 99441-99443)
  • End state renal disease services (90951-90970)
  • Online medical evaluation services (98969, 99444)
  • Preparation of special reports (99080)
  • Analysis of data (99090, 99091)
  • Complex chronic care coordination services (99481X-99483X)
  • Medication therapy management services (99605-99607)

Sources:
American Academy of Family Practice
Centers for Medicare and Medicaid Services
Medicare Learning Network