As of January 1st, physicians can be paid for the management of patients who have been discharged from a hospital or skilled nursing facility. Depending on the complexity of care for the patient, Medicare will reimburse $164 and $231 for care provided in an office or clinic setting during a 30 day period after discharge.
The American Medical Association Current Procedural Terminology (CPT) Editorial Panel have created two codes for the transitional care management (TCM) services, 99495 and 99496. The AMA specifies that these services are for established patients whose medical and/or psychosocial problems require moderate or high complexity decision making during transitions from facilities such as hospitals, skilled nursing, rehabilitation hospital, long term acute care hospital, partial hospital, to the patients community setting (home, domiciliary, rest home, or assisted living). TCM begins upon the date of discharge and continues for the next 29 days.
The TCM services are comprised of one face-to-face visit within the 30 day period, in combination with non face-to-face services that may be given by the physician or other qualified and licensed physician staff under the direction of the physician.
The first face-to-face visit after discharge is part of the TCM period as long as it falls within specified time frames. Additional visits after the initial TCM service are reported with the traditional E/M service codes. TCM also requires interactive contact with the patient or caregiver within 2 business days of discharge. The contact can be face-to-face, phone, or other electronic means. However, medication reconciliation and management must occur no later than the date of the scheduled face-to-face visit.
What determines which TCM code is appropriate for care is the medical decision making and the date of the first face-to-face visit. For 99495 the face-to-face visit must occur within 14 days from discharge and contain moderate complexity in decision making. For 99496 the face-to-face visit must occur within 7 days from discharge and contain high complexity in the decision making.
Code Selection Example
Decision Making Face-to-face, 7 days Face-to-face, 8-14 days
Moderate 99495 99495
High 99496 99495
Documentation to be taken includes timing of the initial post discharge communication with patient or caregiver, date of face-to-face visit, and complexity of decision making.
Only one individual within a practice may report TCM services within the 30 day period.
A physician reporting TCM services may not report care plan oversight services, prolonged services without direct patient contact, anticoagulant management, medical team conferences, education and training, telephone services, end stage renal disease services, online medical evaluation services, preparation of special reports, analysis of data, complex chronic care coordination services, medication therapy management services, during the time period covered by the transitional care management services codes.