1. TRANSITIONAL CARE MANAGEMENT Codes 99495; 99496 CMMI September 2015

2. Transitional Care Management Codes
What are Transitional Care Management Codes and 99496?
What are the Requirements and Services?
What is Necessary to Bill TCM?
September 2015

3. Transitional Care Management
CMS Definition:
“The management of (Medicare) patient’s transition from an inpatient to a community setting. Contact with the patient within 2 business days following discharge, and a face-to-face visit within either 7 or 14 calendar days of discharge depending on the complexity of the medical decision-making involved in the patient’s care.”
Code for moderately complex cases seen within 14 days ~ $160 reimbursement
Code for highly complex cases seen within 7 days ~ $225 reimbursement
20% patient coinsurance and deductible apply .
September 2015

4. Transitional Care Management Requirements
TCM period begins on the date of discharge and continues for 29 days:
There are three required elements:
An interactive contact (telephone, portal, or face-to face) with patient and/or caregiver within 2 business days of discharge, M-F excluding holidays
Prompt interactive communication
Clinical staff under general supervision1
Medication reconciliation and management performed no later than the date of the face-to-face visit
7 or 14 Day follow up office visit (based on medical complexity as determined by Physician or Advance Practice Provider)
1. Effective January 1, 2015 (42 CFR§ (b)(5)
September 2015

5. Transitional Care Management Requirements
7 day visit for highly complex - extensive number of possible diagnoses and/or management of options, extensive complexity of medical data (e.g., tests) to be reviewed, and a high risk for significant complications, morbidity and/or mortality, as well as co-morbidities.
14 day visit for moderately complex – multiple diagnoses and/or management of options, moderate complexity of medical data (e.g. tests) to be reviewed and moderate risk of complications, morbidity or mortality as well as co-morbidities.
September 2015

6. Who Can Provide Services
Intent is to engage the patient with the primary care practices. (can include other specialties)
FQHC and RHC can bill face-to-face
Advance Practice Providers (APP)
Certified Nurse-Midwife
Clinical Nurse Specialists
Nurse Practitioners
Physicians Assistants
Licensed Clinical Staff can perform services under the direction of the Physician or APP
September 2015

7. Physician/APP Services
Generally responsible for overseeing management and coordination of services for all medical conditions, psychosocial needs, and ADL supports.
CMS expects these services unless not medically indicated or needed:
Obtain/review discharge information
Review need for, or follow-up on, pending diagnostic tests and treatments
Interact with other providers involved in patient’s care
Educate patient, family, guardian, and/or caregiver
Arrange for needed community resources
Assist in scheduling any required follow-up with community providers and services
September 2015

8. Licensed Clinical Staff Services
CMS expects services unless not medically needed or indicated
Communicate with home health agencies and other community services utilized by patient
Educate regarding self-management, independent living, and activities of daily living
Assess and support treatment regimen adherence and medication management
Identify available community and health resources
Certain non-face-to-face services may be furnished by licensed clinical staff under general supervision. – No MAs
September 2015

9. Billing TCM Codes When and who can you bill
No sooner than 30 day following discharge
Only one provider can report TCM services and only once in 30 day period
Other specialties can bill, first to bill will be paid!
What must be documented in medical record?
Discharge Date
Date of Communication or two failed attempts within 2 days must be documented to fulfill 2 business day rule
Date of face-to-face visit
Visit that occurs within 2 business days can count as communication and visit
Documentation to support complexity of decision making only
September 2015

10. Billing TCM… E/M visits during the TCM Period Re-admitted to Hospital:
If provider has completed TCM services, the provider can bill an E/M visit with a modifier and restart 30 day period after the second discharge
If provider has completed TCM services, report TCM including the time following the second discharge towards the 30 day period.
E/M visits during the TCM Period
E/M visits including visits for the same condition can be billed with the exception of Coumadin management.
When billing TCM, cannot bill:
Chronic Care Coordination Services ( )
Home Health and Hospice Supervision (G0181,G0182)
End Stage Renal Disease Services ( )
Coumadin patients may not bill an E&M code (99211)
Additional codes refer to CPT Guidelines
September 2015

11. Panel Discussion How did you stratify the work?
What has worked well in your process?
What challenges/barriers did you find when you started TCM? Are they still a barrier?
What impact has it had on readmissions?
September 2015

12. Sources
Transitional Care Management Services Fact Sheet
Frequently Asked Questions about Billing Medicare for Transitional Care Management Services
Frequently Asked Questions: Transitional Care Management
Providing and Billing Medicare for Transitional Care Management Updated November
Transitional Care Management Services: New Codes, New Requirements
“The Future of PC MD Payments” Harvard University, April
September 2015

13. Finger Lakes Health Systems Agency
The triangle represents our agency’s role as a fulcrum—the point on which a lever pivots—boosting the community’s health by leveraging the strengths of all stakeholders. The fulcrum is also a point of equilibrium, reflecting our ability to balance the needs of consumers, providers and payers on complex health matters. The inner triangle also evokes the Greek letter delta—used in medical and mathematical contexts to represent change—with a forward lean as we work with our community to achieve positive changes in health care.
Give me a lever long enough and a fulcrum on which to place it,
and I shall move the world. —Archimedes
1150 University Avenue • Rochester, New York • •
September 2015