Transitional Care Management (TCM) helps patients in the first 30 days following a hospital discharge. Covered by Medicare Part B, providers should learn what CPT billing codes are used for TCM in order to optimize care delivery and avoid denied claims.
TCM is covered for Medicare Part B patients with a small co-pay. This service helps educate patients and care teams, supports medication and treatment regimens, and improves access to care resources.
TCM is reimbursable under Medicare’s Physician Fee Schedule, paying various rates.
TCM CPT Codes: 99495 and 99496
There are two CPT codes for TCM reimbursement: 99495 and 99496.
Only one code can be billed per patient per TCM completion. The most appropriate code is based on the complexity presented within the medical decision-making for the patient. Billing happens after all three TCM service segments are provided and a 30-day timeframe has passed from the date of discharge, as long as the patient was not readmitted.
Medical decision-making refers to the difficulty of establishing a diagnosis and/or selecting a care management option. Its complexity is determined by the following factors:
- Number of possible diagnoses and/or amount of care management options to be considered
- Breadth and/or complexity of medical records, diagnostic tests, and/or other information that needs to be acquired and analyzed
- Risks of significant complications, morbidity, and/or mortality, as well as comorbidities associated with the patient’s presenting problem(s), the diagnostic procedure(s), and/or the possible management option(s)
Both CPT codes, 99495 and 99496, account for medical decision-making. The differential is within the complexity, moderate or high, of medical decision-making required.
- CPT code 99495: TCM services with moderate medical decision complexity and includes a face-to-face office visit within 14 days of discharge. National average reimbursement: $203.34.
- CPT Code 99496: TCM services with high medical decision complexity and includes a face-to-face office visit within 7 days of discharge. National average reimbursement: $275.05.
It is important to note that office visits are considered part of TCM services and do not get billed individually or separately.
About TCM and Its Billing Requirements
Providers can use TCM to engage patients at a critical time following hospital discharge.
Delivered through remote interactions, as well as in-person assessments, TCM is billable when all three service segments are completed. These are:
TCM helps patients transition from a hospital to a community-based setting over a 30-day timeframe from the date of discharge. The purpose is to reduce the number of unnecessary patient readmissions and prepare for a successful patient transition back into their place of residence in the community.
Hospital settings can include:
- Inpatient acute care hospital
- A skilled nursing facility
- A community mental health center
- Inpatient psychiatric hospital
- Long-term care hospital
- Nursing home
- Inpatient rehabilitation center
- Hospital outpatient observation
- Partial hospitalizations
Who Can Provide TCM?
Services can be provided by:
- Primary care physicians
- Specialists
- Physician assistants
- Nurse practitioners
- Certified nurse assistants
- Certified nurse specialists
While non-face-to-face services can be provided by any of the above-listed healthcare professionals, face-to-face services must be provided by a provider.
Submitting Claims to Medicare
Five items are required when submitting a Medicare claim:
- CPT codes for each program you are managing for the patient
- ICD-10 codes tied to each of the conditions you are managing within that program
- Date of service
- Place of service (most often in-office or telehealth)
- National Provider Identifier (NPI) number
It is helpful to know the staff care coordinator assigned to a patient in case of an audit.
Four Steps to Bill for TCM
- Verify CMS requirements were met for each patient
- Submit claims to CMS after the 30-day TCM timeframe
- Send an invoice to patients receiving TCM services
- Determine there are no conflicting codes that have been billed
TCM with Chronic Care Management
Providers can use TCM to enroll patients in Chronic Care Management (CCM) programs.
Providers can use CCM to engage patients on a monthly basis between regular appointments. Delivered through remote interactions, either by phone or a telehealth platform, CCM is billable when at least 20 minutes are spent with the patient performing appropriate tasks.
CCM supports its own CPT billing codes, and these can be billed concurrently with TCM, supporting dual reimbursements. However, all CCM services and time requirements must be met separately from RPM.
Learn more about CCM billing codes here.
Revenue Potential of TCM
For healthcare organizations, care management programs can drive revenue and support cost savings. Below is a general example of how reimbursement for a TCM program could add up.
The figures shown do not account for staff wages; however, your organization is likely already providing some TCM services upon a patient’s hospital discharge.
TCM Promotes Value-based Care
TCM offers additional benefits to providers, beyond reimbursement.
It enables a coordinated care approach to reduce hospital readmissions and enroll patients in care management programs. TCM can be optimized to report data, engage and motivate patients, and meet specific quality metrics key to value-based care.
Patients benefit from enhanced engagement, as well as access to a care manager. They have a point of contact to ask questions, discuss their conditions, and access resources.
TCM can generate significant revenue just by billing certain CPT codes. However, elements of the program, especially within a larger healthcare system, can also promote a value-based care model.
ThoroughCare Simplifies Transitional Care Management
ThoroughCare offers end-to-end workflow for Transitional Care Management.
We simplify the process, so providers can focus on engaging patients. ThoroughCare offers tools to:
- Track and report hospital discharges
- Coordinate time-sensitive transitional care services
- Simplify reimbursement with automated CPT code assignment and an audit-proof record of care
*Reimbursement rates are based on a national average and may vary depending on your location.
Check the Physician Fee Schedule for the latest information.