What is TCM?

Transitional Care Management (TCM) services include:

● Supporting a patient’s transition to a community setting
● Health care professionals who accept patients at the time of post-facility discharge, without a service
gap
● Health care professionals taking responsibility for a patient’s care
● Moderate or high complexity medical decision making for patients with medical or psychosocial
problems.

Who can perform TCM?

TCM services include both face-to-face visits and non-face-to-face services.
These health care practitioners can provide services associated with face-to-face TCM services and can supervise auxiliary personnel (including clinical staff):

● Physicians (any specialty)

● Non-physician practitioners (NPPs) legally authorized and qualified to provide the services in the state where they practice: ● Certified nurse-midwives (CNMs) ● Clinical nurse specialists (CNSs) ● Nurse practitioners (NPs) ● Physician assistants (PAs) CNMs, CNSs, NPs, and PAs may provide non-face-to-face TCM services “incident to” services of a physician and other CNMs, CNSs, NPs, and PAs.

TCM is a service covered by Medicare Part B – for a patient that is discharged from Inpatient hospital
acute care, Inpatient psychiatric hospital, Inpatient rehabilitation Facility, Long-term care hospital,
Skilled Nursing Facility, Hospital outpatient observation or partial hospitalization, Partial hospitalization
at a community mental health center to go home, domiciliary, nursing facility, assisted living. Skilled
Nursing home is not considered a home.

TCM is a 30-day code. Begins the day of discharge and ends on day 29.

The TCM CPT codes are:

Transitional care management services with the following requirements:
Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2
business days of discharge:

99495 - At least moderate level of medical decision making during the service period. Face – to – face visit: within 14 calendar days of discharge.

99496 - At least high level of medical decision making during the service period. Face – to – face visit: within 7 calendar days of discharge.

Requirements: 2 business days – If the patient is discharged Friday you have until Tuesday.
The 2021 E/M guidelines are used to determine medical decision making. If the patient has a face-to-
face service within 7 days this does not mean 99496 is automatically charged. Code selection is based on Medical Decision Making.

Clinical: Review the discharge summary before calling the patient. What is the status of patient’s
condition? What does the patient need? (i.e., homecare, referral appointment to specialist, DME
supplies) Medication reconciliation can be done at the time on or before the patient contact or when
the patient arrives for the TCM appointment.

Contacts must continue and be documented until the patient has a scheduled appointment within
the 7-to-14-day time frame. Document who was spoken to on the call (I.E. Patient - Daughter – Sally,
Girlfriend - Jane – Homecare nurse – Jenny).

When is TCM not allowed: You can’t bill TCM services within a post-operative global surgery period.
What is not covered during the 30-day TCM codes of 99495 & 99496
0, 10 or 90 Global day services cannot be billed with TCM. (I.E skin tag removal, lesions)
TCM: Concurrent Billing - You can bill certain other care management services concurrently with TCM
services, when medically reasonable and necessary and if time and effort are not counted more than
once. CMS -MLN page 8 has a list of CPT codes that can be submitted in 30 days/documentation of the EM charge has to have key information for separation of to support TCM and an E/M.

Telehealth Services: You can provide CPT codes 99495 and 99496 through telehealth.

Telehealth Services fact sheet has more information.

https://www.cms.gov/files/document/mln901705-telehealth-services.pdf

References:

MLN 908628 May 2023
https://www.cms.gov/files/document/mln908628-transitional-care-management-services.pdf
AMA – Professional Edition - CPT 2023 – page 57

Telehealth Services fact sheet- https://www.cms.gov/files/document/mln901705-telehealth-
services.pdf

December Billing Buzz brought to you by MMBA Saginaw Chapter!!

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