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Transitional Care Management Billing Challenges and Solutions

June 12, 2018

transition care management billing

Transitional care management (TCM) is concerned with providing continuing at least moderately complex care for a patient transitioning from a facility, such as a hospital or rehab, back into their community. While not limited to a particular “type” of provider, the codes were created for primary care. Below we will look at some of the more common billing and coding problems with TCM and offer solutions. The focus will be on CMS guidelines and their coding criteria for this important but often under-billed provider service.

Primary Medicare requirements when billing for TCM

  • The healthcare provider accepts care of the post-discharge beneficiary without any gaps.
  • The provider accepts responsibility for the beneficiary’s care.
  • One thing to remember is that only one provider can bill a TCM service for the hospitalization or facility stay regardless of the number of providers caring for the patient during the reporting time-frame.

Other TCM qualifications for CMS

Medicare requires that both providers and patients meet their reimbursement criteria:

Physicians of all specialties as well as qualified non-physician practitioners (NPPs) may provide TCM services. To do so, they must furnish the proper documentation and other billing information – including the proper CPT codes 99495 and 99496.

Patients must be moving from the following locations:

  • Long-term care hospital
  • Inpatient rehabilitation facility
  • Skilled nursing facility
  • Inpatient psychiatric hospital
  • Inpatient acute-care hospital
  • Partial hospitalization or hospital outpatient observation
  • Partial hospitalization in a (community) mental health center

The patient is being moved into one of the following:

  • The patient’s domiciliary
  • The patient’s home
  • Assisted living
  • A rest home

What billable services are included in TCM?

CMS mandates that the physician must furnish non face-to-face services unless such services are not deemed by you to be medically needed or indicated. CMS permits qualified clinical staff to perform non-face-to-face (NFF) services at the provider’s discretion.

Non face-to-face (NFF) performed by clinical staff:

  • Patient/ family caretaker education promoting self-management in independent living and daily living activities
  • Communication with patient and/or caregiver within two business days of discharge (may be through phone, email or direct)
  • Supporting access to patient or caregiver services
  • Identification of community and other health resources

Read More : Specialty-Specific Medical Billing Service Advantage 

  • Communication with community services or health agencies
  • Treatment assessment and support for medicine and regimen adherence

Non-face-to-face reimbursable services performed by a physician or a mid-level provider:

  • Reviewing any need for follow-up diagnostic tests or treatment
  • Reviewing the patient’s discharge summary as available or continuity of care
  • Educating the patient, guardian, family or caregiver
  • Interactions with other healthcare providers who will assume (or re-assume) care of the patient with any system-specific issues.
  • Help with scheduling required follow-up for needed community resources
  • Establishing or re-establishing referrals arranging for necessary community resources

Medication reconciliation management is required for billing TCM, involving the comparison of patient medication orders to all medication the patient has been taking, to detect errors, medication omissions, duplications, interactions or dosage errors. This should take place by the date of the face-to-face visit.

What do you need to properly document TCM?

According to CMS policy, documentation should include:

  • The time of the initial post-discharge
  • Any communication with patient or caregivers
  • Date of the face-to-face visit
  • Complexity levels of medical decision-making
  • Documentation of completion of medication reconciliation
  • Performance of all applicable non-face-to-face services during the reporting period

Note that complexity levels as defined by CMS in medical decision-making may be impacted by any of the following factors:

  • The number of possible diagnoses as well as management options
  • The complexity medical records and other information to be reviewed
  • The risk of complications and other issues presenting patient management problems

Billing tip: If you provide TCM services, having a template designed to act as a guide can help your office make sure that all necessary documenting and billing criteria are met. Be sure that the template includes the following:

  • Date of discharge
  • Date of face-to-face visit (date to bill)
  • All coordination of care that was performed for that patient

When is it inappropriate to bill for TCM?

CMS forbids billing for TCM in addition to any oversight-care provided (G0181 and G0182) or end-stage renal disease care (90951-90970). In addition, most chronic care management (CCM) services are not billable as TCM, except in the following cases: when at least 20 minutes of clinical staff time as directed by a physician or qualified health care professional in a calendar month, during the same Calendar month as TCM, if the TCM service period if the TCM service period ends before the calendar month is over and a minimum or 20 minutes of qualifying CCM services are provided subsequent during that month.

It’s important to remember that CMS expects that for most of the time, CCM and TCM will not be billed within the same calendar month.

What time period or dates of service are billable for TCM?

Medicare-reimbursable TCM spans a 30-day period, beginning on the hospital discharge day, continuing through the next 29 days. Beginning on January 1, 2016, Medicare allows billing for TCM on the date of the face-to-face visit, once that has taken place. There is no need to withhold billing until the end of the service period.

How often can a provider or group bill for a TCM?

CMS rules permit only one TCM billing per patient by the physician or group for TCM service within 30 days of the patient’s discharge.

How can a billings and claims management service help with transitional care management billing?

Billing for TCM is challenging and carries the potential for errors or worse, may be ignored by providers when it could be reimbursable. Partnering with a trusted billing and practice management service such as M-Scribe can take much of the worry out of correctly coding and billing for your TCM services. Since 2002, M-Scribe has worked with practices of all specialties and sizes to maximize reimbursements and ensure compliance with the latest regulations. For more information, contact our experienced analysists at 888-727-4234 or by email.


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