Primary care doctors and specialists, as well as non-qualifying medical practitioners, may offer TCM services.
These services consist of three segments.
They are interactive contact, non-face-to-face services, and office visit.
All are mandatory within a specific timeframe, as required by Medicare to fulfill TCM. Unless they are determined to not be medically necessary.
This is simple, initial outreach to the patient or their caregiver. It is required to be performed within two business days following the patient’s hospital discharge.
Contact may be made by telephone, email, or face-to-face.
It may be made by the provider or clinical staff. The conversation will touch upon the patient’s general well-being, as well as the next steps in the TCM process.
Non-Face-to-Face services may be performed by either the physician or clinical staff.
Services vary depending on who is providing them.
For the physician, services include:
Retrieval and review of patient discharge summaries or other discharge information
Interact with healthcare professionals and/or care team members who will take responsibility for supporting care of the patient's problems
Provide education to necessary team members
Establish referrals and arrange for community resources (as needed)
Support scheduling activities for required follow-ups with necessary providers/services
For clinical staff, services include:
Identify and communicate with necessary agencies, health resources, and community services
Educate necessary care team members in areas including self-management, independent living, and ADLs
Assess/support treatment regimen adherence, including medication management
Assist patients and/or non-clinical care team members in accessing care services
An in-person office visit is a final step. It should occur within either seven or 14 days of the patient’s hospital discharge.
This time frame depends on the complexity of medical decision-making inherent to caring for the patient.
Medical decision-making refers to establishing a diagnosis and/or selecting a care management option, which is determined by the following factors:
How many possible diagnoses and/or the amount of care management options need to be considered
The breadth and/or complexity of medical records, diagnostic tests, and/or other information that needs to be acquired and analyzed
The risk of significant complications, morbidity, and/or mortality as well as comorbidities associated with the patient’s problem(s), the diagnostic procedure(s), and/or the possible management options
Medicare utilizes two different CPT codes to distinguish between office visit types. These are separated and labeled as involving either moderate or high complexity decision-making.
CPT Code 99495 – Transitional care management services with moderate medical decision complexity (face-to-face visit within 14 days of discharge)
CPT Code 99496 – Transitional care management services with high medical decision complexity (face-to-face visit within 7 days of discharge)
Please note: Office visits are part of the overall TCM service. They should not be reported separately.
How Care Coordination Software Can Streamline the Process for Transitional Care Management
To deliver the three service segments covered above, you’ll want a system in place to track and manage TCM.
A practical resource, such as care coordination software, will keep key details from being lost or overlooked. For you and your staff, this will promote a more efficient process.
Below, we cover three of the benefits this software solution can provide to aid with TCM management.
1. Time Management / Scheduling
As covered above, TCM revolves around a 30-day timeframe. Two of its three service segments require action by predetermined deadlines.
Care coordination software will help meet these requirements.
Simple features, such as built-in scheduling and time management tools, will assist clinical staff with patient outreach and office visits.
It’s crucial to consider the timing when providing TCM services to patients, and software will keep your practice on time.
Care coordination software is a great way to create a paper trail of patient data and services.
This can help you hedge against a possible audit by Medicare, as well as provide exceptional medical care.
Such software will vary in what exactly it can document, but some common examples are:
Notes on previous medical care and/or office visits
Summaries of patient care transition activities, such as what TCM services were provided
Details that pertain to the patient’s hospital discharge, such as diagnoses and type of hospital care provided