Transitional Care Management

What is transitional care management?

Transitional care management is a Medicare-covered service, billed with CPT 99495 or 99496, for a patient's 30 days after discharge from a hospital or facility to a community setting. It requires an interactive contact within 2 business days, non-face-to-face care coordination, medication reconciliation and a face-to-face visit within 7 or 14 days.

The 30-day period begins on the day of discharge and continues for the next 29 days. One practitioner takes responsibility for the patient's care during that period, and the service is reported once.

CMS describes the required parts of TCM as supporting the patient's move back to a community setting, accepting the patient at discharge without a gap in service, taking responsibility for their care, and making moderate or high complexity medical decisions. Payment follows from doing that work on time and recording it, which is why TCM is as much a workflow problem as a coding one.

Which discharges qualify for TCM?

TCM applies after discharge from an inpatient or partial hospitalization setting to the patient's community setting. CMS's TCM booklet lists the qualifying settings on both sides.

• Discharged from: Inpatient acute care hospital, inpatient psychiatric hospital, inpatient rehabilitation facility, long-term care hospital, skilled nursing facility, hospital outpatient observation or partial hospitalization, or partial hospitalization at a community mental health center.
• Discharged to: The patient's home, a domiciliary such as a group home or boarding house, a nursing facility, or an assisted living facility.
• Complexity: The patient's medical or psychosocial problems must need moderate or high complexity medical decision making.

Software should store the discharge setting and destination as coded values, because both decide eligibility. A discharge from an emergency department without observation status, for example, does not appear on the list.

What are the TCM deadlines?

TCM has three deadlines: an interactive contact within 2 business days of discharge, a face-to-face visit within 7 or 14 calendar days depending on the code, and medication reconciliation on or before the date of that visit.

• Interactive contact: Direct, telephone or electronic communication with the patient or caregiver within 2 business days of discharge.
• Unsuccessful attempts: CMS allows the service to be reported after 2 or more unsuccessful, separate, timely contact attempts, if they are documented and the other requirements are met.
• CPT 99495: Moderate complexity medical decision making, with a face-to-face visit within 14 calendar days of discharge.
• CPT 99496: High complexity medical decision making, with a face-to-face visit within 7 calendar days of discharge.
• Medication reconciliation: Completed on or before the face-to-face visit date.

Note the mix of business days and calendar days. A discharge on a Friday afternoon gives the practice until Tuesday for contact, and the software must know the practice's holidays to count correctly.

What services does TCM include beyond the visit?

TCM includes non-face-to-face services through the 30 days, some furnished by the physician or non-physician practitioner and some by clinical staff under general supervision. These are the care coordination tasks that keep the patient out of the hospital.

• Practitioner tasks: Review discharge information, follow up on diagnostic tests and treatments, talk with other clinicians taking on parts of the patient's care, educate the patient and caregivers, set up referrals and community resources, and help schedule follow-up.
• Clinical staff tasks: Communicate with the patient and the agencies and community services they use, support self-management and daily living, assess and support treatment adherence including medication management, and help the patient find and access resources.

Each task should be a checklist item in the TCM record with a date and the person who completed it, so the chart shows the work was done and nothing was missed.

Pending results deserve special attention. Tests ordered in the hospital often come back after discharge, addressed to a clinician the patient will never see again. The TCM checklist should list each pending result from the discharge summary and track it until someone in the practice has reviewed it.

What must the record show?

The record must show the date of discharge, the date of the interactive contact, the date of the face-to-face visit and the complexity of medical decision making. Missing any of these is the most common reason a TCM claim cannot be defended.

• Discharge date: Taken from the discharge notice or summary, not from the patient's memory.
• Contact date and method: Including each unsuccessful attempt, with time and method.
• Visit date: The face-to-face visit, in person or by telehealth.
• Medical decision making: Moderate or high, supported by the note.
• Medication reconciliation: Date and the clinician who completed it.
• Non-face-to-face services: The coordination tasks completed during the period.

Most of these fields can be filled automatically. The discharge date comes from the ADT message, contact attempts come from the phone or messaging log, and the visit date comes from the schedule. The clinician then only has to confirm the complexity level and sign, which removes most of the gaps auditors find.

Which billing rules trip practices up?

The rules that trip practices up are about who bills, when the claim date falls and which other services can overlap. Build each into the software so staff are warned before the claim goes out.

• One practitioner: Only one physician or non-physician practitioner may report TCM for a patient's 30-day period.
• Global surgery: Medicare does not pay TCM if any part of the 30-day period falls within a global surgery period for a procedure billed by the same practitioner.
• Date of service: CMS's 2016 TCM FAQs say to report the date of the face-to-face visit as the date of service, and the claim may be submitted once that visit is furnished.
• Visit not billed separately: The face-to-face visit is part of TCM and is not reported on its own.
• Telehealth: CPT 99495 and 99496 can be furnished through telehealth.
• Concurrent services: CMS allows certain care management services, such as chronic care management, to be billed in the same period when medically necessary and time is not counted twice.

How can software find discharges in time?

Software finds discharges in time by receiving discharge events electronically, usually as HL7 ADT messages or event notifications from hospitals and health information exchanges, and turning each one into a TCM case with its deadlines already set.

• ADT feeds: Discharge messages from partner hospitals and facilities, matched to the practice's attributed patients.
• HIE notifications: Encounter alerts from regional health information exchanges that cover many hospitals.
• Payer and ACO alerts: Discharge lists from health plans and accountable care organizations.
• Manual entry: A quick form for discharges learned by phone or fax, so they enter the same workflow.
• Patient matching: Reliable matching on name, date of birth and identifiers, with a review queue for uncertain matches.

Speed matters more than completeness at this step. A discharge alert that arrives on day three has already used the 2-business-day window, so feeds should be near real time and staff should see new cases at the start of each day.

What should a TCM worklist show?

A TCM worklist should show each open case with its discharge date, the countdown to each deadline, what has been done and what is next, sorted so the most urgent cases sit at the top.

• Contact countdown: Business days left for the interactive contact, with attempts logged.
• Visit deadline: The 7-day or 14-day date, with open appointment slots offered from the schedule.
• Medication status: Whether reconciliation is done, with the discharge medication list attached.
• Coordination tasks: Pending results, referrals and home health orders from the discharge summary.
• Billing readiness: A check that all required dates and the complexity level are recorded.
• Readmissions: A flag when a patient in an open TCM period is admitted again, so the team can review what went wrong.

Good worklists also feed a simple monthly report: discharges received, contacts made on time, visits within the deadline, claims submitted and readmissions within 30 days. Those five numbers tell a practice whether its TCM program is working and where it is losing patients along the way.

Where do TCM programs lose revenue?

TCM programs lose revenue when discharges go unnoticed, when visits slip past the deadline, or when documentation is incomplete at billing time.

• Unknown discharges: The patient was in a hospital the practice receives no feed from.
• Late contact: The first call goes out on day three, and attempts are not recorded.
• No visit slots: The schedule has no room inside 7 or 14 days, so the visit becomes a regular follow-up.
• Missing dates: The note lacks the discharge or contact date, so the claim cannot be supported.
• Duplicate billing: Another practitioner reports TCM for the same discharge first.

The fixes are mostly operational. Widen the discharge feeds to every hospital your patients use, reserve a few visit slots each week for post-discharge patients, script the first call so clinical staff cover medications and warning signs, and agree with specialists and hospitalist groups who will take TCM responsibility for shared patients.

How Agnotic can help

Agnotic Technologies builds TCM workflows for the client's care management platform or EHR: discharge intake from ADT and HIE feeds, case creation with business-day deadlines, worklists, contact logging, medication reconciliation tasks and billing readiness checks.

Agnotic also connects TCM to chronic care management and other programs, so time is tracked once and patients move from transition support into ongoing care without new paperwork.

Sources

• CMS: Transitional Care Management Services
• CMS: Frequently Asked Questions about Billing Medicare for Transitional Care Management Services (2016)