Transitional Care Management Rules and Requirements

Learn how to stay compliant and efficient in managing this valuable program

What is TCM?

Transitional Care Management (TCM), is an initiative started by the Centers for Medicare and Medicaid (CMS) to provide patients with services involving a transition of care during those 30 days after discharge from one of the following settings:

Inpatient acute care hospital
Inpatient psychiatric hospital
Long-term care hospital
Nursing home
Inpatient rehabilitation center
Hospital outpatient observation/partial hospitalization

TCM is designed for primary care doctors and specialists, as well as non-qualifying medical practitioners, to provide care to these types of patients. It’s a vital service that aims to eliminate gaps in patient care and readmission during critical periods.

3 Components of TCM

There are three components of TCM that must be furnished.

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Who Can Provide TCM Services?

TCM services are furnished by a combination of healthcare professionals, including physicians (of any specialty), and other accredited clinical staff under the general supervision of a physician, including:

Physicians (any specialty)
Physician Assistants
Nurse Practitioners
Certified Nurse Assistants
Clinical Nurse Specialists

CNMs, CNSs, NPs, and PAs may furnish non-face-to-face TCM services “incident to” the services of a physician and other CNMs, CNSs, NPs, and PAs.

Interactive Contact

CMS rules require an 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.

A Face-To-Face Visit

Finally, CMS requires you to provide one face-to-face visit within certain timeframes. CMS uses two Current Procedural Terminology (CPT) codes to:

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 that the face-to-face visits are part of the TCM service and should not be reported separately.

Transitional Care Management Features, Benefits, and Getting Started

Non Face-To-Face Services

CMS 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.

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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 care team members
Establish referrals and arrange for community resources (as needed)
Support scheduling activities for required follow-ups with necessary providers/services

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Identify and communicate with necessary agencies, health resources and community services

Educate necessary care team members in areas including self-management, independent living and ADL's
Assess/Support treatment regimen adherence, including medication management
Assist patients and/or non-clinical care team members in accessing care services