Through our intuitive software, we’ve helped many clinicians deliver better quality care to their patients, including through the implementation of TCM. Below, we’ll expound upon the details of TCM and its benefits, and we'll put you on a path to starting your very own TCM program.
3 Required Components of Transitional Care Management
As discussed above, we know that TCM involves services provided to a moderate-to-high complexity patient within 30 days of discharge.
But what are those services?
There are three components of TCM that must be furnished.
1. Interactive Contact
Medicare requires interactive contact to be made with the beneficiary and/or caregiver, as appropriate, within 2 business days after the beneficiary’s discharge.
The contact can be made by telephone, email, or face-to-face.
The provider or clinical staff can make contact with the patient, provided they have the capacity for timely interactive communication in addressing patient status and needs.
Medicare indicates that attempts to communicate should continue after the first two attempts in the required 2 business days until they are successful.
If you are unable to make contact after two or more separate attempts in a timely manner and document them in the medical record, you may report the service (provided that all other TCM criteria are met).
2. Non Face-To-Face Services
Medicare requires the provision of non-face-to-face services to the patient unless you determine that they are not medically indicated or needed. Your clinical staff can also provide certain non-face-to-face services under your direction.
Retrieval and review of patient discharge summaries or other discharge information
Interaction with healthcare professionals and/or care team members who will take responsibility for supporting the care of the patient's problems
Providing education to necessary care team members
Establishing referrals and arranging for community resources (as needed)
Scheduling activities for required follow-ups with necessary providers/services
Identifying and communicating with necessary agencies, health resources, and community services
Educating necessary care team members in areas including self-management, independent living, and ADL's
Assess/support treatment regimen adherence, including medication management
Assisting patients and/or non-clinical care team members in accessing care services
3. A Face-To-Face Visit
Finally, Medicare requires that you provide one face-to-face visit within certain timeframes. Medicare utilizes two Current Procedural Terminology (CPT) codes for billing.
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: Face-to-face visits are part of the TCM service and should not be reported separately.
As you can see in the CPT Codes above, the code you use depends on the level of medical decision-making.
Medical decision-making refers to the complexity of 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 presenting problem(s), the diagnostic procedure(s), and/or the possible management options
The table below shows the elements for each level of medical decision-making.
In order to qualify for a given type of medical decision-making, two of the three elements must either be met or exceeded.
4 Benefits of Transitional Care Management
While TCM is an excellent service that focuses on increasing the quality of health outcomes for patients, providers also stand to see a few benefits from providing such care.
1. Reduced Readmissions
As we mentioned earlier, the goal of TCM is to reduce the rate of readmissions and improve health outcomes for patients.
Additionally, Medicare has implemented value-based penalties for excessive 30-day hospital readmission rates. In 2017, Medicare penalized over 2,500 hospitals at a cost of more than $564 million for such excessive readmission rates.
By reducing readmissions, providers can reduce costs for themselves, Medicare, and their patients.
2. Higher Quality of Care
More and more, readmission rates are being used as a quality of care indicator.
Both commercial payers and consumers (patients) are using these rates to judge the quality of the provider.
A perceived lower value by patients can affect the bottom line of a practice.
3. Financial Reimbursement
As shown above, the national average for moderately complex care is $176.50 per patient per month, while the rate for high complexity is $236.77.
This change allows for dual reimbursement for the same patient when “reasonable and necessary."
Use Software to Offer Transitional Care Management
When you combine TCM’s financial incentives for providers with the health benefits for the patients, implementing a TCM program becomes an easy decision. Assisting with a seamless transition from a hospital, nursing facility, or other qualifying healthcare setting is rewarding for both the patient and the primary care physician.
Knowing these benefits, the decision to implement a TCM program becomes easier.