August 12, 2018

Getting Paid for Transitional Care Management (TCM)

by Continuum Health

Medicare adopted transitional care management (TCM) payment codes in 2013 to encourage clinicians to provide TCM services after beneficiaries were discharged to the community from medical facilities. As a result, Medicare spending on TCM services increased over 200 percent between 2013 and 2016, and studies show that these services significantly reduced cost and mortality in the month after the service was provided.1

To recap the requirements, a care team member must communicate with the beneficiary or the caregiver within two business days after the discharge, and the clinician must provide an office visit within 14 days, to bill for the 30-day TCM service.

Documentation is key when filing a claim with CMS for reimbursement. Providers that perform TCM services (i.e. 99495-99496) should work with their inpatient facilities, such as a hospital or skilled nursing facility, to ensure the patient discharge date is correctly documented. A comparative billing report performed last year found that an average of 24% of TCM claims did not have a patient discharge date documented in the medical file.2 When the date on the TCM claim does not agree with the discharge date from the facility, the validity of the claim is in question.

Practices should also check that the patient was discharged from one of the following settings: inpatient acute care hospital; inpatient psychiatrist hospital; long-term care hospital; skilled nursing facility; inpatient rehabilitation; outpatient observation; partial hospitalization in a hospital or a community mental health center. A patient must be discharged to his or her home, which may be a domicile, rest home or assisted living facility.

Make sure that your clinicians are adhering to these requirements to ensure that your patients and your practice are reaping the full benefit of this service.



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