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Transitional Care Management

03-21-18Neeta Goel MD

Transitional Care Management (TCM) refers to the service provided to patients during transitions in care from a hospital or other health care facility to a community setting. Hospital setting may include Inpatient acute care hospital, Inpatient psychiatric care hospital, Long term care hospital, Skilled nursing facility, Inpatient rehab, Hospital outpatient observation or Partial hospitalization. Home setting may include Home, Domiciliary (residential facility with treatment programs for a variety of issues, such as disabled veterans), Rest home (residential institution) or Assisted living facility.

Why is this important?

When leaving the hospital:

  • Almost one in five elderly patients return to hospital for care within 30 days
  • One third can’t explain their medications (means they do not know to take medication correctly)
  • 50% patients can’t state their diagnoses
  • 75% of chronically ill patients won’t need to make a return trip to the hospital if they had a plan for follow-up care

Extra support provided during transition of care from hospital setting to home setting improves care, enhances quality of life for our patients, and reduces hospital readmission.

Required Components of Transitional Care Management:

  1. Interactive Contact with the patient or caregiver within 2 business days (Mon – Fri except holidays) following a discharge. This contact is intended to:
  • Obtain and review discharge information
  • Review need for and or follow up on pending test/treatments
  • Education of the patient, family member or caregiver
  • Establish or re-establish with community providers and services
  • Assist in scheduling follow up visits with providers and services

Contact may be made via telephone, email, or face-to-face. Attempts to communicate should continue after the first two attempts within the required two business days until a contact is successful. If two or more separate attempts are made in a timely manner, and documented in the medical record, but are unsuccessful and all other TCM criteria are met, TCM service can still be reported/billed.

  • Face-to-face visit within 7 or 14 days
  • Medication reconciliation must be performed at this visit if not already done so during earlier contact
  • Medical Decision Making of Moderate or High Complexity

Moderate Complexity – e.g.

  • Multiple number of diagnoses or management options
  • Complexity of data to be reviewed is considered moderate
  • Risk of significant complications, morbidity or mortality is considered moderate

High Complexity – e.g.

  • Extensive number of diagnoses or management options
  • Complexity of data to be reviewed is considered extensive
  • Risk of significant complications, morbidity or mortality is considered extensive

Billing for Transitional Care Management:

Use the following CPT codes to appropriately code for TCM services –

  • 99495 – Medical decision making of moderate complexity during the service period; office visit with the Provider within 14 days of discharge
  • 99496 – Medical decision making of high complexity during the service period AND office visit with the Provider within 7 days of discharge
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