Transitional Care Management, Part 1: Why it’s Important

Background

Close to 20% of the Medicare population has a readmission within the first 30 days of being discharged from an acute care facility¹.  This is costly to the healthcare system and leads to poorer outcomes for patients.  The Transitional Care Management (TCM) program was created by the Centers for Medicare and Medicaid Services (CMS) to improve coordination of care and reduce hospital readmission rates for patients transitioning out of an acute care setting.

In the 30 day period following discharge, the chances of readmission are increased if proper follow up and care are not provided.  To address this, in 2013, CMS established a reimbursement structure to incentivize healthcare providers to establish immediate contact with patients after their departure from the acute care setting. Two CPT codes, 99495 and 99496, can be utilized by providers who successfully meet the TCM requirements.

Components

The TCM program begins on the day of the patient’s discharge, continues for the next 29 days, and has three primary components:

1. Interactive contact: within two business days following the patient’s discharge, the provider, or their clinical staff, must make contact with the patient and/or the patients’ caregiver via email, phone, or face-to-face.  The person must have the capacity for timely interactive communication in addressing patient status and needs.
2. Non-face-to-face services: unless they are determined to be unnecessary, non-face-to-face services, such as reviewing discharge instructions and helping patients and caregivers access community health resources.
3. Face-to-face visit: for patients requiring medical decision making of moderate complexity, a face-to-face visit must be provided within 14 days of discharge.  The 99495 CPT code can be billed for this visit.  For patients with high medical decision complexity, the visit should be scheduled within seven days, and, accordingly, the 99496 CPT code can be used to bill this encounter.  It’s important to note that providers can only bill for TCM services once within the 30 day window, but other E&M codes, such as additional office visits, as needed, can be billed during this timeframe.

Reimbursement

The national average reimbursement rate in 2021 for CPT code 99495 was $175, and for 99496, the amount was $237².  Providing TCM services for just ten patients per month could bring in more than $20,000 in additional revenue to a practice per year, and for higher volume groups, that number could be significantly larger.

The Transitional Care Management program can be challenging to navigate and implement, but putting a successful TCM process in place leads to reduced readmissions, better health outcomes for patients, and, importantly, increased financial reimbursement for practices.

In part two of this series we’ll discuss the common mistakes practices make when implementing TCM.

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