What practices need to know about transition care management codes

Two new codes allow for reimbursement for non-face-to-face care when patients transition from an acute care setting back to the community. Learn the fine print of how to properly use these codes.

The new Physician Fee Schedule includes transition care management (TCM) codes that allow for reimbursement of the non-face-to-face care provided when patients transition from an inpatient setting back into the community.

Two new codes will be used to pay for many of the non-face-to-face services that up until now were done but not reimbursed.

Code 99495 covers communication with the patient or caregiver within two business days of discharge. This can be done by phone, e-mail or in person. It involves medical decision making of at least moderate complexity and a face-to-face visit within 14 days of discharge. The work RVU is 2.11.

Code 99496 covers communication with the patient or caregiver within two business days of discharge. This can be done by phone, e-mail or in person. It involves medical decision making of high complexity and a face-to-face visit within seven days of discharge. The work RVU is 3.05.

Although the Centers for Medicare and Medicaid Services may fine-tune the expectations for the services provided during the TCM time period, in addition to the above, the following required non-face-to-face services differ for staff and for the physician.

Clinical staff services (under the supervision of a physician or other qualified clinician) may include:

  • communicate with the patient or caregiver (by phone, e-mail or in person),
  • communicate with a home health agency or other community service that the patient needs,
  • educate the patient and/or caregiver to support self-management and activities of daily living,
  • provide assessment and support for treatment adherence and medication management,
  • identify available community and health resources and
  • facilitate access to services needed by the patient and/or caregivers.

The physician or other qualified clinician services may include:

  • obtain and review discharge information,
  • review need of or follow-up on pending testing or treatment,
  • interact with other clinicians who will assume or resume care of the patient's system-specific conditions,
  • educate the patient and/or caregiver,
  • establish or re-establish referrals for specialized care and
  • assist in scheduling follow-up with other health services.

Since there is some overlap between which services the staff vs. the clinician provide, such as education, it is expected that CMS will clarify the documentation requirements for the use of these codes. Once the requirements are known, ACP will provide additional tools and resources, but since the codes are effective now, we encourage all practices to bill them.

Here are some additional tips regarding use of these new codes:

  • Medication reconciliation and management should happen no later than the face-to-face visit.
  • The codes can be used following hospital inpatient or observation care, inpatient rehabilitation stays, or skilled nursing facility stays.
  • The codes cannot be used with the following services, because the services are duplicative: care plan oversight services (99339, 99340, 99374-99380); prolonged services without direct patient contact (99358, 99359); anticoagulant management (99363, 99364); medical team conferences (99366-99368); education and training (98960-98962, 99071, 99078); telephone services (98966-98968, 99441-99443); end stage renal disease services (90951-90970); online medical evaluation services (98969, 99444); preparation of special reports (99080); analysis of data (99090, 99091); complex chronic care coordination services (99487-99489); and home health care supervision (G0181, G0182).
  • For medication therapy management services (99605-99607), billing should occur at the conclusion of the 30-day post discharge period. An automatic or manual “tickler” system should be set up so that the claim is generated at the 30-day mark.
  • They are payable only once per patient in the 30 days following discharge.
  • Only one individual can bill per patient, so it is important to establish the primary physician in charge of the coordination of care during this time period. If there is a question, then it is be important to contact the other physician's office to clarify. The discharging physician may advise the patient which clinician will be providing and billing for the TCM services, but the patient may choose their TCM physician. Discharging physician will usually notify patient which physician has been identified for follow-up care. The patient/caregiver should confirm this “hand-off” and ask the hospital/rehab facility to facilitate the transition with such documents as D/C summary, medication list, and specialty care appointments already confirmed.
  • The codes apply to both new and established patients.

For more details on the new codes, please refer to the 2013 CPT manual. For coding guidance from CMS on how to use them in the Medicare program, go to ACP's Running a Practice webpage.