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Dan Murdoch

October 27, 2023
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What is Transitional Care Management: CPT Codes & Examples

What is Transitional Care Management: CPT Codes & Examples

Transitional care management, or TCM, was created by the Centers for Medicare & Medicaid Services (CMS) to help improve care coordination for patients transitioning from an inpatient setting, such as a hospital or skilled nursing facility, to their home.

This includes individuals who have been discharged after a stay in the hospital and those who may need additional support and services following a significant medical event, such as surgery.

What is transitional care management?

TCM is a procedure that allows healthcare providers to oversee and coordinate various services for patients during this delicate time, ensuring they receive the necessary care and support to help them transition back into their everyday routines.

The primary purpose of transitional care management is to improve patient outcomes by providing more comprehensive and coordinated care while transitioning from one healthcare setting to another.

This includes addressing any potential issues or complications that may arise after discharge, as well as ensuring that patients have access to necessary follow-up appointments, medications, and community resources.

Transitional care management CPT

CPT codes are used to identify and bill for specific medical services provided to patients.

For transitional care management, two principal CPT TCM codes are used: 99495 and 99496.

  • CPT code 99495 covers the initial TCM service for a patient within 14 days of discharge from an inpatient facility or hospital stay. This includes communication with the patient or caregiver, medication reconciliation, and creating a comprehensive care plan.

  • CPT code 99496 covers ongoing TCM services for up to 30 days following discharge. This may include additional communication with the patient or caregiver, coordination of care with other providers, and assistance accessing necessary community resources.

Transitional care management requirements

To bill for TCM services, healthcare providers must meet specific requirements set by CMS.

These include:

  • The patient must be transitioning from an inpatient setting to their home or another setting where they will receive continued care.
  • The patient must have a moderate or high level of medical complexity.
  • The provider must conduct face-to-face visits with the patient within specified time frames.
  • The provider must document all TCM services provided.

Meeting these requirements ensures the patient receives appropriate and timely care during this critical transition period.

Is transitional care management only for medicare patients?

While CMS initially created TCM for Medicare patients, it can also be used for non-Medicare patients meeting the requirements.

Additionally, some private insurance companies have begun to cover TCM services as well. It is essential to check with each individual insurance provider to determine coverage and billing procedures.

Transitional care management workflow

The workflow for TCM involves the following steps:

  1. Identify eligible patients - This includes reviewing discharge records and identifying patients who meet the requirements for TCM.
  2. Contact the patient - The provider or their team will contact the patient within two business days of discharge to schedule a face-to-face visit.
  3. Conduct initial visit - During this visit, the provider will assess the patient's health status, reconcile medications, and create a comprehensive care plan.
  4. Coordinate follow-up appointments and services - The provider will assist in scheduling necessary follow-up appointments and coordinating any additional services or resources needed.
  5. Conduct ongoing visits - Additional face-to-face visits with the patient may be conducted within 7-14 days after discharge and again at 30 days post-discharge.
  6. Document all TCM services provided - It is essential for providers to accurately document all TCM services provided to bill for these services.

Transitional care management examples

Some examples of TCM services that the CPT codes may cover include:

  • Medication management, including reconciliation and education on how to properly take medications
  • Assistance with scheduling follow-up appointments and coordinating transportation if needed
  • Connecting patients with community resources, such as home health services or support groups
  • Addressing any issues or concerns that arise after discharge, such as pain management or wound care
  • Providing education on self-care and warning signs of potential complications

By utilizing TCM services, healthcare providers can help improve patient outcomes and reduce the likelihood of costly readmissions.

It also allows for a smoother transition from one healthcare setting to another, providing patients with the support they need during this vulnerable time.

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