Wondering about the new Transitional Care Management Services? Wonder no more!

What are Transitional Care Management Services?

March 8 2013 update: FAQ posted


In 2013 CPT defined two new CPT codes that describe a service to patient recently discharged from a hospital.  These two new codes, 99495 and 99496 can be found in your 2013 CPT book and have an effective date of January 1, 2013, so don’t use them until then.

99495:  Transitional Care Management Services with the following required elements:

  • Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge
  • Medical decision making of at least moderate complexity during the service period
  • Face-to-face visit, within 14 calendar days of discharge.

99496:  Transitional Care Management Services with the following required elements:

  • Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge
  • Medical decision making of at least high complexity during the service period
  • Face-to-face visit, within 7 calendar days of discharge.

Even more exciting, CMS is going to recognize and pay for these services!  These services are intended to improve the care of a patient who is discharged from an inpatient or observation admission, skilled nursing facility or partial hospitalization program.  Despite the CPT definition of these as services provided to established patients, Medicare allows billing TCM to new or established patients.

Who may perform and bill for these services?

A physician, Nurse Practitioner, Physician Assistant or Clinical Nurse Specialist may bill for the service.  There is no restriction on specialty designation for the physician.  However, a surgeon may not bill the service on their patient who is in a global period.  Only one physician may bill for the TCM for any one patient’s discharge from the hospital, and the physician must wait until 30 days after the discharge to bill for the service.  The first physician who submits a claim will be paid.  The physician who discharges the patient may also provide TCM services for that patient, according to Medicare.

What does the service include?

First, in order to be eligible for the service, the patient’s medical and/or social problems must be of moderate or high complexity, as defined by the E/M Documentation Guidelines.  The service is defined as including the 29 days post discharge.  During that time, the clinician or clinical staff must:

  • Contact the patient within two business days of discharge, by phone, in person or by email
  • The clinician must have a face-to-face service with the patient within the time frames listed for each code above, and this first E/M service (typically, it will be an office visit but could be a home visit) is not separately reportable.  That is, the practice may not bill for this E/M service if it intends to bill TCM codes.  Medication reconciliation is required at that visit.
  • Non-face-to-face services by the clinical staff during the 29 day post-discharge period that includes: communication with the patient, caregiver, family, home health agency and/or other community services involved in the patient’s care; education to support activities of daily living; assessment and support of the treatment regimen and medication management; identification of community and health resources and facilitating access to these resources.
  • The clinician should obtain and review the discharge summary; review the need for pending or follow up diagnostic tests; interact with other healthcare professionals involved in the patient’s care; provide education of patient, or family, or caregiver; establish or reestablish referrals and assist in scheduling medical care or community care.

Can we bill any services during the 30-day post discharge period?

Yes.  Second and subsequent E/M services after the initial bundled E/M service may be reported.  Other diagnostic or therapeutic services may be billed.

How do we interpret moderate and high medical decision making?

The same way as it is interpreted using the Documentation Guidelines.  As a rule of thumb, 99214 requires moderate MDM and 99215 requires high complexity MDM.

Anything else we can’t report with these codes?

Well, yes.  The CPT book lists a series of codes that may not be reported with TCM codes 99495 or 99496.   The list includes some active, payable codes and many codes that would not be paid under the Medicare Physician Fee Schedule or most insurances.  (CPT develops the codes, and then Medicare and other third party payers develop reimbursement policies.  Just because there is a code doesn’t mean a practice can be paid for it.)  The codes that may not be billed with the TCM codes are Care Plan Oversight (99339, 99340, 99474-99380), prolonged services without patient contact (99358, 99359), anticoagulant management (99363, 99364), medical team conferences (99366–99368), education and training (98960-98962, 99441-99443), end stage renal disease services (90951-90970), online medical evaluation (98969, 99444). Preparation of special reports (99080), analysis of data (99090, 99091), complex care coordination services (99487—99489), or medication therapy services (99605—99607) during the time period covered by the TCM codes, which is 29 days after discharge.  Of course, many of the codes in the list above are not reimbursed by most Medicare.

Anything else we should know?

Document it. Document the non-face-to-face activities of the Transitional Care Management Services to show that the criterion are met.  Document medicine reconciliation, the first non-reported E/M service, contact within two days of discharge.   Review the list of what is included and document when performed.