What Is TCM in Medical Billing & How to Bill for It?

Transitional Care Management (TCM) is a coordinated healthcare service supporting patients as they transition from an inpatient setting, such as a hospital or skilled nursing facility, back to their home. Its primary objective is to prevent avoidable hospital readmissions and improve overall health outcomes. TCM is an integral part of value-based care initiatives, focusing on patient support.

Understanding the Scope of Transitional Care Management

Transitional Care Management encompasses services delivered over a 30-day period following a patient’s discharge. Interactive contact with the patient or their caregiver within two business days of discharge can be via telephone, email, or direct conversation. This initial contact helps understand immediate needs and sets the stage for ongoing care coordination.

During the TCM period, healthcare providers perform activities such as medication reconciliation and management to ensure understanding of prescriptions and avoid adverse drug events. Patient and caregiver education is also provided, covering the patient’s condition, medication usage, and self-management strategies. This empowers patients to participate in their recovery.

Providers also communicate with other healthcare professionals to ensure a unified approach. This collaborative effort helps streamline care and address potential issues. Arranging necessary follow-up appointments, including a required face-to-face visit, and addressing psychosocial needs or barriers to care are parts of the TCM service.

Billing Codes and Criteria for Transitional Care Management

Billing for Transitional Care Management services involves specific Current Procedural Terminology (CPT) codes based on patient medical complexity and interaction timing. The two primary CPT codes for TCM are 99495 and 99496, covering a 30-day service period from the date of discharge. Only one provider can bill for TCM services for a patient within this 30-day period.

CPT code 99495 is for TCM services with moderate medical decision-making complexity, requiring a face-to-face visit within 14 calendar days of discharge. CPT code 99496 applies to TCM services with high medical decision-making complexity, requiring a face-to-face visit within seven calendar days of discharge. Medical decision-making complexity considers diagnoses, data review, and complication risk.

Both codes mandate substantial non-face-to-face services throughout the 30-day post-discharge period. These services include communicating with the patient or caregiver, medication reconciliation, and coordinating care transitions. Medication reconciliation must be completed no later than the date of the face-to-face visit.

Accurate documentation supports a TCM claim. This includes the patient’s discharge date, initial interactive contact date, and required face-to-face visit date. Detailed notes on medication reconciliation, care coordination activities, and medical decision-making complexity are also necessary.

Claim Submission and Reimbursement Considerations

Claims for Transitional Care Management services are typically submitted after the 30-day service period concludes and all components are documented. This submission usually occurs electronically through a clearinghouse. The reported date of service is generally the 30th day, marking the completion of the period.

Reimbursement rates for TCM services vary significantly based on the specific payer, such as Medicare, Medicaid, or commercial insurance, and the geographic location. TCM is recognized as a high-value service, impacting hospital readmissions and patient outcomes. Medicare, for example, has established specific payment rates for these codes.

Qualified healthcare professionals can bill for TCM services. This includes physicians and non-physician practitioners like nurse practitioners, physician assistants, certified nurse-midwives, and clinical nurse specialists. These providers oversee the patient’s care during the transition period.