EDUCATIONAL SERIES: TRANSITIONAL CARE MANAGEMENT (TCM)

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EDUCATIONAL SERIES: TRANSITIONAL CARE MANAGEMENT (TCM)
In 2013, two new Evaluation & Management (E&M) codes for Transitional Care Management (TCM) services
were introduced. Centers for Medicare and Medicaid Services (CMS) (as well as other carriers) continue to clarify
the billing requirements. Below we have outlined some additional guidelines providers should be aware of related
to billing of these TCM codes.
Transition Care Management (TCM) Services (99495-99496) are billed 30 days after discharge from a
facility, the codes are billed when the patient is not present. TCM services are for new or established patients
whose medical and/or psychosocial problems require moderate or high complexity medical decision making
(MDM) during transitions in care:
From: inpatient acute care hospital, inpatient psychiatric hospital, long term care hospital, skilled nursing
facility, inpatient rehabilitation facility, hospital outpatient observation or partial hospitalization, partial
hospitalization at a community mental health center
To:
patient’s community setting, i.e., home, domiciliary, rest home or assisted living
TCM Codes/Billing:
* = LA Area 99 PAR 2014
99495 Transitional Care Management Services (MDM of Moderate Complexity):
• Communication (direct contact, telephone, electronic) with the patient and/or caregiver
within 2 business days post-discharge.
• Medical decision making of at least moderate complexity during the service period.
• First face-to-face visit, within 14 calendar days post-discharge; included in TCM codes.
• Medicare Fee Schedule: $154.06*
99496 Transitional Care Management Services (MDM of High Complexity):
• Communication (direct contact, telephone, electronic) with the patient and/or caregiver
within 2 business days post-discharge.
• Medical decision making of high complexity during the service period.
• First face-to-face visit, within 7 calendar days post-discharge, included in TCM codes.
• Medicare Fee Schedule: $217.95*
MSI suggests that providers use a Telephone Note (MEDEHR) once a TCM patient candidate is identified to
capture discharge (D/C) date and to record required attempts made in the first 48 hours post D/C and update
Charge Ticket, Transaction Master, and EHR templates with special ‘transaction codes’ to assist in capturing the
correct services for TCM codes to be billed.
Charge Ticket:
Provider should indicate the actual E&M level of service, i.e., complete (992__) for the $0 charge first face-to-face
(F2F) visit (included in the TCM code) so that in the event the TCM code is denied, the provider can go back and
rebill the face-to-face visit with actual level of service with a charge amount.
TCM SERVICES/BILLING
TRANS CODE
DX#
Discharge Date:_____________________________
FEE
st
1 Face-to-Face (F2F) Visit (992＿ ＿) w/in 7 days
TCM07
0.00 Potential TCM Bill Date:
1 Face-to-Face (F2F) Visit (992＿ ＿) w/in 14 days
TCM14
0.00
TCM, if above 1ST F2F w/in 7 days & High MDM
496
TCM, if above 1ST F2F w/in 14 days &/or Mod. MDM
495
OR
st
OR
st
_______________________________________________
(i.e., D/C Date + 29 days)
Make appt to bill TCM 99496 / 99495
NOTE: If 1 face-to-face within 7 days but only Moderate medical decision making (MDM),
user must use TCM code 99495 at 30 days after D/C.
Educational Blast: TCM Billing
Page 2 of 5
Transaction Master:
Setup transaction code TCM07 used at first F2F $0 charge visit to prompt staff to bill TCM code: 99496, and
code TCM14 used at first F2F $0 charge visit to prompt staff to bill TCM code: 99495 at the conclusion of the
transition, i.e., 30 day mark.
When billing TCM07/TCM14, provider should add comment to indicate discharge date (D/C) and true level of service
provided and schedule an appointment as a reminder to bill the appropriate TCM code, i.e., D/C plus 29 days.
EHR Templates:
For MEDEHR instructions, see News Blast: 031413 Educational Series: Transition Care Management (TCM).
MSI is moving this information (Telephone Note/workflow to template maintenance) into an EHR TCM User
Guide.
Select the correct code:
Documented contact/attempts within 2 business days
First Face-to-Face (F2F) Visit is Within:
MDM:
Date TCM Code is Billed:
7 Days of D/C
8-14 Days of D/C
Trans Code: TCM07 Trans Code: TCM14
Moderate Complexity
99495
99495
Discharge date + 29 days
High Complexity
99496
99495
Discharge date + 29 days
Billed with Place of Service (POS) of First F2F
NOTE: Subsequent face-to-face visits are not included in the TCM code and are billed in routine fashion.
NOTE: If first face-to-face visit is within 7 days but only Moderate medical decision making (MDM),
user must use TCM code 99495 at 30 days after D/C.
Select the correct date:
The TCM 30-day period begins on the day of discharge and continues for the next 29 calendar days and includes
the first face-to-face visit. The reported date of service (DOS) for the TCM should be the 30th day using the place
of service where the first face-to-face visit occurred. Use the below chart to confirm billing on the correct date and
to identify the ‘TCM 30 day period’.
OR
OR
Example using above date chart:
Discharge date (month with 30 days):
First face-to-face visit by (within 7 days):
First face-to-face visit by (within 14 days):
TCM Billed:
14
21
28
13
 Patient discharged from hospital on September 14th
 First face-to-face visit must have occurred by September 21st
OR
 First face-to-face visit must have occurred by September 28th
 TCM should be billed on October 13th (generally in the following month)
Educational Blast: TCM Billing
Page 3 of 5
TCM Facts:
When providing the first face-to-face visit (after D/C), providers should indicate the level of service on the charge
ticket as well as discharge date and include same in a comment added to the patient account, so that in the event
that the TCM code is denied, i.e., if another provider was already paid for the TCM code, then the first face-toface visit then can be rebilled with actual level of service CPT code.
Providers who administer services (procedures) with a 10* or 90 day GSP, i.e., services that are within a postoperative global period, within the TCM 30-day period may not bill both the GSP procedure and the TCM code.
TCM codes cannot be paid if any of the 30-day TCM period falls within a global period for a procedure code billed
by the same provider.
TCM code billing requires an interactive contact with the patient (or caregiver) within 2 business days of a discharge
from the previously identified facility type, interactive contact may be direct, phone, or by electronic means and
requires medication reconciliation which must occur no later than the date of the first face-to-face visit.
Business days are defined as Monday-Friday except holidays without respect to normal practice hours or date of
notification of discharge. Date of discharge is not included in the 2 business days, i.e., starts on next business day.
To meet the 2 business day contact requirement, providers should initiate and/or improve relationships with
nearby hospitals and hospitalists to coordinate a method/protocol of admission/discharge notifications.
Providers should promote their practice as being a solution to preventable readmissions.
Medical Decision Making (MDM) as well as the date of the first face-to-face visit is used to select and bill the
appropriate TCM code at day 30. Providers must review the services that are included in the TCM codes as these
services cannot be billed separately during the time period covered by the TCM code billed at day 30.
NOTE: Do not report Care Plan Oversight (G0181-G0182) or End Stage Renal Disease services
(90951-90970) on same day as TCM codes.
Only one provider (any specialty) may bill the TCM code and only once per patient at 30 calendar days after
discharge.
If multiple providers submit a claim for the TCM services provided to a patient at the 30th calendar day following
discharge, Medicare will pay the first claim that it receives that commences with the day of discharge and
otherwise meets the coverage requirements.
The discharging (D/C) physician can bill the TCM code at day 30 and his discharge day management (99238/9),
however, the D/C day cannot count as the first F2F. The first F2F must be on a different date of service;
> 24 hours but < 15 days post D/C.
If the patient is discharged then readmitted before 30 days have passed, or if the patient is admitted to a hospice
facility during the 30 calendar day period, the provider can only bill one TCM code.
If patient is readmitted and is in the hospital on the 30th day when TCM code should be billed, many carriers have
an edit in place that will deny services as TCM code typically uses Place of Service 11 and other facility charge
will show inpatient on the same date of service.
If the beneficiary dies prior to the 30th day following discharge, TCM services cannot be billed as TCM codes
describe 30 days of care. Providers should rebill the first face-to-face $0 visit that occurred using the appropriate
level of service CPT code and charge.
Some patient Medicare Managed Care/Part C plans may be ‘referral driven’, i.e., some Humana MA plans, in
these instances, a PCP referral is required for TCM services to be considered for payment.
Educational Blast: TCM Billing
Page 4 of 5
Resources:
• 2014 AMA CPT book, pages 48-49
•
CMS Medlearn Matters, TCM Services:
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Transitional-Care-ManagementServices-Fact-Sheet-ICN908628.pdf
•
CMS Medlearn Matters, MM8553, Expansion of Medicare Telehealth Services for CY2014
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8553.pdf
•
CMS TCM FAQs:
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/FAQ-tcms.pdf
•
American College of Physicians (ACP) articles:
www.acponline.org/running_practice/payment_coding/medicare/
http://www.acpinternist.org/archives/2013/03/coding.htm
•
American College of Physicians (ACP) Sample Documentation and Flow Sheet:
http://www.acponline.org/running_practice/payment_coding/coding/sample_tcm.pdf
•
AAFP Frequently Asked Questions on TCM:
http://www.aafp.org/online/etc/medialib/aafp_org/documents/prac_mgt/codingresources/tcmfaq.Par.0001.File.dat/TCMFAQ.pdf
•
AAFP Sample TCM Worksheet:
http://www.aafp.org/online/etc/medialib/aafp_org/documents/prac_mgt/codingresources/tcmworksheet.Par.0001.File.dat/TCM30day.pdf
•
Federal Register - Proposed Payment for Post-Discharge Transitional Care Management Service:
https://www.federalregister.gov/articles/2012/11/16/2012-26900/medicare-program-revisions-to-payment-policies-under-the-physician-feeschedule-dme-face-to-face#p-1088
*Subject to interpretation (Q&A pending to Novitas):
 10 day GSP vs 90 day GSP
 TCM code within 30 days (one per patient)
 Goal is preventing hospital readmissions, therefore only 1 TCM code billable per 30 days
 Date of service for TCM code on claims, exactly the 30th day, or thereafter
Per call to Humana Gold, “follow Medicare guidelines”; interprets as TCM code must be billed on
30th day; if patient has referral type plan, a referral is needed from PCP for TCM code to be
considered for payment
Per Call to Peoples Health, “follow Medicare guidelines”.
Help is available via ACP: http://www.acponline.org/running_practice/payment_coding/coding/tcm_denials.pdf
- According to the CPT code descriptors, the patient should be seen by the physician within 7 or 14 days after
discharge. The choice of codes is determined by the date of the first face-to-face visit after hospital/facility
discharge and the level of medical decision making at that first visit. If there is a subsequent face-to-face
visit within the same service period (30 days), that visit may be billed separately.
- In its Physician Fee Schedule final rule for 2013, CMS indicates that it expects to see the billing occur at or
near the 30-day point, but the agency has not stated whether earlier billing would result in a claim rejection
or denial. ACP will continue to work with CMS toward a resolution of this question.
Contact Software Support for assistance or any questions via:
Email: Double click on ‘[email protected]’ from sign-on screen
-ORPhone: (985) 234-0599 (local), (800) 978-0599 (toll free)
-ORFax:
(985) 234-0609
Educational Blast: TCM Billing
Page 5 of 5
TCM flowchart to assist in selecting correct codes and meeting all requirements:
Patient with hospital stay, discharged (date): _______________
Discharged by:
PCP
Other Provider
(Notification sent to PCP via
hospital census, phone, etc.)
Patient contacted (or attempted) within 2 business days of discharge
st
nd
1 Attempt:
Method:
Phone / Email / In Person
Date/Time: ____________________
Spoke to: ____________________
2 Attempt:
Method:
Phone / Email / In Person
Date/Time: ____________________
Spoke to:
____________________
No
STOP
TCM code
cannot be billed
First F2F visit within ≤ 7 (TCM07) or 8-14 (TCM14) days after discharge
Appt Date/Time: _______________ Level of Service: _________
EHR Action: Schedule ‘billing’ appointment 30 days from discharge date,
should be same as ‘Bill date’ (noted below)
No
STOP
TCM code
cannot be billed
Yes
Medication reconciliation
and management performed
EHR Action:
Date of first F2F
‘zero bill’ visit,
complete as per
standard office visit
encounter template
STOP
TCM code
cannot be billed
No
Yes
Obtained and reviewed
discharge information
STOP
TCM code
cannot be billed
No
Yes
MDM of moderate or high complexity
Refer to E&M Resources
Yes
High MDM
No
STOP
TCM code
cannot be billed
Yes
Moderate MDM
7 days after
discharge
14 days after
discharge
7 days after
discharge
14 days after
discharge
Bill 99496
Bill 99495
Bill 99495
Bill 99495
CAUTION*:
TCM services should be billed on 30th day (*or thereafter) post-discharge
Bill Date: ________________ TCM code:  99495  99496
Discharge date + 29 days = TCM Bill date
(Bill date = date of service used for TCM code)
EHR Action: Add notes to Facesheet tab, Notes tab, Telephone Notes section
Yes
EHR Action:
Date of first F2F (post-discharge),
use E&M scoreboard and select
Trans Code TCM07/TCM14,
‘zero bill’ visit, update day 30
appointment note with qualifying
TCM code and diagnosis codes
EHR Action:
At 30 day appointment, complete
TCM non-F2F template, approve
charges for billing with correct
TCM code and diagnosis codes