Transitional Care Management
Rules and Requirements

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

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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.

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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

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