What is Transitional Care Management?

Doctor with a patient

Seniors and other patients who need to go from the inpatient to a community setting after hospitalization or time in an inpatient facility benefit from transitional care management. Transitional care management, which is also referred to as TCM, takes care of the hand-off period between these two facilities and changes in the level of care the patient receives. It's important to note that many patients have new diagnoses, medical conditions, medical crises, or medications that they must adapt to when in transitional care. 

Generally speaking, it's possible for family clinicians to manage patients' transitional care, but others can as well. 

What Is Transitional Care Management? 

Transitional care management (TCM) helps make sure that patients with high-risk medical conditions receive appropriate care after they're discharged from an inpatient facility, such as a hospital, to a community setting such as their home. 

The Centers for Medicare and Medicaid Services (CMS) state that Medicare will cover transitional care services for 30 days starting the day of discharge from the inpatient facility.  The services CMS requires with TCM care include:

  • Patient intake by health care professionals who accept the patient at the time of the discharge without any service gap.
  • The ability to make moderate or high-complexity medical decisions on the behalf of patients who are dealing with psychosocial or medical conditions.
  • Supporting patients as they transition back to a normal community setting.
  • Assigning care to health care providers who will monitor the patient's care.

For the purpose of the CMS's regulations, community settings refer to places such as:

  • Patients' homes
  • Group homes or boarding houses
  • Assisted living facilities
  • Nursing facilities

Who Provides Transitional Care Management (TCM) Services?

Once it's established that a patient will need transitional care management, a team has to be assembled to help. Normally, the clinical staff working with the patient may include:

  • Nurse practitioners (NPs)
  • Physician assistants (PAs)
  • Certified nurse-midwives (CNMs)
  • Clinical nurse specialists (CNSs)

These individuals all fall into the category of "non-physician practitioners," or NPPs. 

Depending on the patient's needs, they may also work with clinicians of any specialty. 

What Kinds of Transitional Care Services Are There? 

The medical staff that works with a patient will be expected to provide two kinds of services:

  1. Face-to-face services
  2. Non-face-to-face services

During the 30-day period of CMS TCM, there are requirements that have to be met. The staff has to contact the caregiver or patient in person, by phone, or via email within two business days of the inpatient discharge. At that time, the meeting must be performed by someone who can not only schedule follow-up care but also address any health issues the patient is dealing with that that time. 

For non-face-to-face services, it's necessary for the staff to provide as many necessary non-face-to-face services as needed within the 30-day period. Common non-face-to-face services include the following:

  1. Patient reviews, which look at the need for further testing, treatments, and follow-up services
  2. Patient or caregiver education
  3. Patient scheduling
  4. Patient transfers to new health care professionals
  5. Discharge documentation reviews

Essentially, patients must be both interacted with in person and in non-face-to-face scenarios throughout the 30 days after their discharge. 

What Is the Importance of Transitional Care Management? 

It's important for clinicians to become familiar with TCM codes as well as why TCM is so vital for patients leaving inpatient settings. 

It is known that transitional care management helps prevent readmissions to the hospital by having patients monitored at home or within other community settings. When medical providers can treat them at the first sign of a problem and make medical decisions in those settings, they often prevent costly readmissions. 

Another reason TCM is so important is because it helps bring long-term care facilities and other community settings more income in the form of CMS reimbursements. In addition to that, it's possible to combine TCM with chronic care management, or CCM, to double bill the CMS. Dual reimbursements further boost communities' income and help them benefit from performing the reasonable and necessary care patients in their care need to stay comfortable and recover.

How Is Transitional Care Management Billed? 

Now that you have an understanding of transitional care management and what it is, it's necessary to look at how you bill for it. 

First, know that only one non-physician practitioner (NPP) or clinician can report TCM services for each of the patients they see. Additionally, only one report is allowed per patient within the 30-day period. 

It is allowed for the healthcare professional who treated the patient at the hospital to do follow-up care through the TCM. However, these services can't take place on the same day.

There are two Current Procedural Terminology (CPT) codes that you'll use to bill for face-to-face visits. These codes are:

  • 99495, which refers to interactions such as communication within two days of discharge and moderate decision-making within 14 days of the patient's discharge.
  • 99496, which refers to communication within two days of discharge and a high level of decision-making within the first week following the patient's discharge.

Both of these codes can also be used for telehealth services. To learn more about the specific codes you can use to bill for TCM, you can visit the Centers for Medicare and Medicaid Services

Transitional Care Management and Your EHR

To make TCM claims, it's necessary to keep documentation on your patients. That documentation has to include information such as the patients' discharge date, the date of your first face-to-face visit, data on all contact between the caregiver/patient and the medical team, and details on the medical complexity of all decisions made on the behalf of the patient. 

An electronic health record can help by keeping data on every interaction. Additionally, the billing features of a good EHR (such as ChartPath) help ensure that you use the right CPT codes when you make a claim for reimbursement through the Centers for Medicare and Medicaid Services. Choosing an efficient EHR is the right move when you're getting ready to move into transitional care management and want to be sure you're staying in regulation to get fair, and appropriate, reimbursement. 

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