The information provided here applies to Medicare coding. Be sure to check with your Medicare Administrative Contractor (MAC) for additional information and clarification on these and other items. You should also contact your local insurance carriers to determine if private insurers follow Medicare's lead on all coding matters.
Transitional Care Management
Transitional Care Management (TCM) is a care concept initiated by Medicare in 2014. The two Current Procedural Terminology (CPT) codes for these services are 99495 and 99496 for the 30 days of care provided by a physician or other qualified healthcare provider. CPT codes 99495 and 99496 are used when billing for care services for patients transitioning from an inpatient hospital setting, skilled nursing / nursing facility, partial hospitalization or observation setting into the community (home, domiciliary, rest home, assisted living). The TCM codes encompass providing or overseeing the management and coordination of services, as needed, for all the patient’s medical conditions, psychosocial needs and work with activities of daily living support systems.
There are specific face-to-face and non-face-to-face duties for the licensed clinical staff and physician. These include contact with the patient within two days of discharge, medication reconciliation and a face-to-face visit with either moderate or complex medical decision making. The latter, along with the timing of the visit, determines which of the two codes are submitted. In the transition for the patient, a review of the discharge information to initiate or re-instate care with other providers and review and order testing as appropriate occurs. The provider is responsible for 30 days of TCM from the date of discharge. Only one face-to-face visit is required and bundled into the TCM codes. Additional medically-necessary visits are billable as separate services. Payment for this care management is made to only one provider. However, since CPT codes 99495 and 99496 are valued at about 4.8 and 6.8 relative value units (RVUs), respectively, their use can well be worth the work for this select set of patients. Additional information is available through the Medicare Learning Network’s (MLN) publication, “Transition Care Management Services” (ICN 908628), available at www.cms.gov.