Through the Transitional Care Management (TCM) program, Medicare reimburses healthcare providers for two CPT codes - 99495 and 99496 - that are used to report physician or qualifying non-physician practitioner care management services for a patient following a discharge from a hospital, SNF, or CMHC stay, outpatient observation, or partial hospitalization. The TCM operation intends to assist patients with the transition from the hospital to a community-based setting over a 30-day timeframe from the date of discharge, while reducing the number of unnecessary readmissions that are associated with the discharge diagnosis.
Reimbursement for a successful 30-day transition can range (based on national rates) from $167 (moderate medical decision complexity) to $237 (high medical decision complexity). Please check with your Medicare Administrative Contractor for more information on reimbursement rates within your locality.
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:
While non face-to-face services can be provided by any of the listed healthcare professionals, the face-to-face service must be provided by the physician.
The following are the three key components of TCM services to be provided during the 30 days beginning on the date of patient discharge:
An interactive contact must be made (or attempted) within 2 business days following the patient's discharge to a community setting. Contact can be performed via telephone, email, or in-person communications, and can be performed by the practice's clinical staff
Several non-face-to-face services are to be performed by a combination of clinical staff members in support of the continuity of care operation.
Recommended services are as follows:
The physician responsible for the care transition operation must provide one face-to-face visit with the patient, within a timeframe based on the medical decision complexity determined for the discharge. Timeframes are as follows:
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Unplanned 30-day readmissions can result in financial penalties for your practice, which may negatively affect Medicare payments!
Over 35 million hospital discharges occur annually within the US
These documents outline specific details about the program.