What's new in 2023 for Transitional Care Management, or TCM.
In this video, we'll discuss everything you need to know about the CPT codes
for TCM, so that you can properly bill and code
for this program.
Hey there.
This is Loran from Thorough Care.
Here at Thorough Care, we specialize in helping practices manage,
bill and streamline reimbursements for CMS programs
like Transitional Care Management with our care coordination software.
If you'd like a reference guide for the TCM CPT codes
that we’ll cover in this video, you can download one from our website.
There's a link in the description below.
So what are the 2023 updates for Transitional Care Management?
There were no major changes to TCM
rules and regulations in CMS’ 2023 Final Rule.
But good news is there is a substantial increase
in the reimbursement rates for the CPT codes.
We'll cover that in just a bit.
Keep in mind that the codes are based on a national average,
which may vary in your area. For the exact current rate
based on your location, visit the Physician Fee Schedule website.
TCM provides for patients in the first 30 days after a discharge.
The goal is that the patient avoids readmission and has a successful transition home.
If a patient is not readmitted after 30 days and the three segments of TCM
have been completed, including the interactive contact,
the non-face-to-face services and an office visit, billing can commence.
There are
two CPT codes for Transitional Care Management
and they are based on the complexity of medical decision making.
Only one code can be billed per patient
per program based on that complexity.
So, what exactly goes into determining
the complexity in medical decision making?
Complexity can be determined by how many possible diagnoses
and or the amount of care management options needed to be considered.
The complexity of medical records, tests,
and other information that needs to be acquired and analyzed,
or the risk of significant complications with the patient's conditions.
It's ultimately up to the provider to determine the level
of medical decision making. At the provider's discretion
one of the following codes can be used for billing.
The first is CPT code 994954.
for moderate complexity in medical decision making.
The patient will need to be outreached within the first 48 hours of discharge
and the face-to-face office visit must occur within 14 days of discharge.
The current national average reimbursement for a 99495 claim is $205.
The other option is to bill for high complexity
in medical decision making with code 99496.
The patient will still need to be outreached within the first 48 hours of discharge,
but the face-to-face office visit will need to occur within seven days.
The national average reimbursement is about $278.
One thing we didn't mention is low complexity
in decision making. For transitional care management
You cannot bill for lower complexity.
However, we at Thorough Care strongly recommend that you still complete
a TCM for low complexity, but you cannot bill for them.
Otherwise you can bill for an E&M visit.
Having completed a TCM will help make sure your patient has a smooth
transition home and also add to the value based offerings at your practice.
So now that you have a better understanding of TCM
and its CPT codes for this year, what should you do next?
If you'd like to learn more, there's a link in the description below
to our Learning Center,
where you can read and learn more about TCM as well as other value based programs.
And don't forget to download your free reference guide for the billing codes
we discussed in the video.
Like we mentioned, they're pretty high in 2023.
Please like and subscribe this video and thank you for watching.
We'll talk to you soon.