Billing and Coding Guidelines for Transitional Care Management (TCM)

Transitional Care Management (TCM) is designed to assist patients in the critical 30 days after discharge from an inpatient or facility-based setting. TCM strives to prevent readmissions and ensure continuity of care by providing follow-up visits, coordinating care, and ensuring medication adherence.

Eligible discharge settings include:

• Inpatient acute care hospital
• Inpatient psychiatric hospital
• Inpatient rehabilitation facility
• Long-term care hospital
• Skilled nursing facility
• Hospital outpatient observation or partial hospitalization
• Partial hospitalization at a community mental health center

NOTE: A qualifying facility Evaluation and Management discharge service must be billed in the previous thirty days in order to report a Transitional Care Management service.

There are two CPT codes for TCM services:

• CPT Code 99495: Moderate medical decision complexity.
• Face-to-face follow-up visit within 14 calendar days post-discharge.
• CPT Code 99496: High medical decision complexity.
• Face-to-face follow-up visit within seven calendar days post-discharge.

Essential TCM Billing Guidelines

To ensure accurate billing and reimbursement, TCM services must adhere to specific guidelines and requirements.

1. Provider must initiate contact with the patient or caregiver within two business days of discharge.
2. Only one face-to-face TCM visit is billable per discharge.
3. Provider must perform medication reconciliation.
4. Provider must document and record additional care coordination with other providers.

Billing Restrictions and Considerations

1. Non-Billable with Certain Services: TCM cannot be billed in the same 30-day period as services like chronic care management (CCM), end-stage renal disease (ESRD) services, and certain home health services.
2. Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC) are not paid separately for TCM services via claims submissions for the Highmark Wholecare Medicaid line of business. 

Sources:

1. (2024, July). MLN908628 - Transitional Care Management Services. Retrieved from CMS.gov Centers for Medicare & Medicaid Services: https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/mln-publications-items/icn908628
2. Network, M. L. (2024, July). Transitional Care Management Services. Baltimore, MD, United States.
3. Network, M. L. (2023, January 1). Rural Health Clinic All-Inclusive Rate: CY 2023 Update. Retrieved from CMS.gov Centers for Medicare and Medicaid Network: https://www.cms.gov/files/document/mm12999-rural-health-clinic-all-inclusive-rate-cy-2023-update.pdf