- Transitional care management CPT codes.
At first glance they can be confusing
and intimidating,
as well as the program itself,
but once we break it down
they are relatively easy to understand.
In this video we'll give you everything
you need to know regarding the Transitional Care Management
or TCM CPT codes,
and what you'll need to properly bill and code,
as well as maximize your reimbursement opportunities.
(gentle music)
Hi, this is Loran with ThoroughCare.
Here at ThoroughCare,
we help practices just like yours every day
manage, bill and streamline popular care management programs
like Transitional Care Management.
Knowing the billing codes for TCM
will give you a better idea
of what's expected by your staff,
and by Medicare to properly bill for these programs.
There are two CPT codes for transitional care management,
and those are based on the complexity
of medical decision making.
But before we go over the codes,
let's take a look at
how transitional care management actually works.
Transitional care management
manages the patient's first 30 days
after some sort of discharge.
The goal is that the patient avoids readmission,
and makes for a smooth transition
back to their everyday life.
The patient's discharge must be
from one of the following settings.
Inpatient acute care, inpatient psychiatric care,
longterm care hospitals,
nursing homes, inpatient rehabilitation centers,
or hospital outpatient observation,
or a partial hospitalization.
So, who can offer TCM services?
TCM services can be done by primary care doctors,
specialists or non-qualifying medical practitioners.
TCM consists of tree segments,
interactive contact,
non-face-to-face interactions,
and finally an in-person office visit.
Now let's talk a little more
about the interactive contact.
The interactive contact for TCM
must be done within two business days,
so that pivotal 48 hours after discharge.
This can be done by a clinical staff member,
and also can be performed via telephone, telehealth
or an in-person visit.
For the non-face-to-face services,
this can also be done by a clinical staff member
or the provider team.
These services may vary based on who is providing
this type of care.
The non-face-to-face services
usually consists of documenting in some sort or fashion.
This document can be reviewing medications,
can be reviewing the hospital discharge,
or any other important information
that needs to be reviewed by the patient's care team.
And, finally, the last portion of the transition
is the office visit.
Now the office visit must be performed
by the physician who is responsible
for the patient's transitional care management.
Now, this portion of the TCM must be done
within a certain period of days
based on the complexity of decision making.
We'll talk a little bit more about that later.
One other important note,
that office visit done as part
of the transition,
that is part of TCM,
and should not be billed as a separate ENM visit.
So that's something to consider
when providing the TCM service.
Once all three segments of the TCM have been completed,
and the patient was not readmitted
within a 30-day period,
billing can commence.
Now there are two CPT codes that you can bill
for transitional care management,
including 99495 for moderate complexity
of decision making,
and 99496 for high complexity of decision making.
Now, you may be wondering
what goes into determining that complexity.
Well here are some things to consider.
How many possible diagnoses
or the amount of care management options
needed to be considered,
the breadth or complexity
of medical records, tests
or other information that needs to be analyzed,
or the risk of significant complications
with the patient's presenting problems,
diagnostic procedures,
or the possible management options.
Both CPT code options account for
medical decision making,
but it's ultimately up to the provider
to determine the level of the decision making.
At the provider's discretion one of the following
can be used for transitional care management.
For moderate complexity of decision making,
billing code 99495.
So no matter the complexity,
you'll still need to outreach your patient
within those crucial 48 hours,
but you have up to 14 days after the discharge
to see your patient in office.
The national average reimbursement of a 99495 claim
is about $176.
The other option is to bill for high complexity
of decision making using CPT code 99496.
You'll still need to contact your patient
within 48 hours for that non-face-to-face interaction,
but with high complexity your face-to-face visit
has to be within seven days of the patient's discharge.
This code pays at about $236 nationally.
One thing we didn't mention yet
is the low complexity of decision making.
Now, for TCM you cannot bill for low.
However, here at ThoroughCare,
we strongly recommend that you still complete transitions
for these low complexity of decision making patients,
but you can't bill.
Having a completed TCM will still ensure
that the patient has a smooth transition home,
and also add to your value-based offerings at your practice.
So now that you have a better understanding
of transitional care management
and its CPT codes,
what should you do next?
There's a link in the description below
to our learning center.
Our learning center is the best place
to find out rules and regulations of TCM,
as well as the other value-based
care management services we provide.
You can also find tips
and tricks on how to run a successful program.
Ready to talk more about how ThoroughCare
can take your organization to the next level
by providing TCM services?
Contact me or an account representative
for more information, to set up a discovery call,
or even a live demonstration.
You can see a link right here below.
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and thanks for watching.
(gentle music)