Transitional Care Management (TCM) Guidelines

The CPT Codes 99495 and 99496 are used to report transitional care management services (TCM).

These services are covered for a new patient or established patient and the code selection will be considered based on the MDM and the problems require either "Moderate Complexity or High Complexity".

To qualify for Transitional Care Management (TCM) services, the patient must be discharged from one of the following facility settings,

•  Acute Care Hospital
•  Psychiatric Hospital
•  Rehabilitation Facility
•  Long-term Care Hospital
•  Skilled Nursing Facility
•  Partial hospitalization
•  Hospital outpatient observation
•  Partial hospitalization at a community mental health center

Additionally, the patient must be returned to one of the following community settings,

•  Home
•  Domiciliary (e.g., group home or boarding house)
•  Nursing Facility (e.g., boarding home or adult care home)
•  Assisted Living Facility

Guidelines

• TCM is included in one face-to-face visit within the specified time-frames, in combination with non-face-to-face services that may be performed by the physician or other qualified health care professional.

• Only one individual may report these services and only once per patient within 30 days of discharge.

• Another TCM may not be reported by the same individual or group for any subsequent discharge(s) within 30 days.

• The same individual should not report TCM services provided in the postoperative period of a service that the individual reported.

Non-Face To Face Service

Non-face-to-face services provided by the physician or other qualified health care provider may include,

• Obtaining and reviewing the discharge information (eg, discharge summary, as available, or continuity of care documents).

• Reviewing the need for or follow-up on pending diagnostic tests and treatments.

• Interaction with other qualified health care professionals who will assume or reassume care of the patient's system-specific problems.

• Education of patient, family, guardian, and/or caregiver.

• Establishment or reestablishment of referrals and arranging for needed community resources.

• Assistance in scheduling any required follow-up with community providers and services.

The first face-to-face visit is part of the TCM service and not reported separately. 

Additional E/M services provided on subsequent dates after the first face-to-face visit may be reported separately. 

Interactive Communication

For TCM requires interactive contact with the patient or caregiver, as appropriate, within two business days of discharge and the communication typically involves following,

1. In-person visits: Face-to-face visits with the healthcare provider allow for a more comprehensive assessment of the patient's health status and the ability to address any issues that may arise. 
2. Telephone calls: Providers may call patients or caregivers to discuss the patient's condition, medications, follow-up appointments, and any other necessary information.
3. Secure messaging: Some healthcare providers use secure messaging platforms to communicate with patients, allowing for quick and convenient exchange of information.
4. Video visits: Telehealth visits via video conferencing can be used to conduct follow-up visits, assess the patient's progress, and address any concerns.

CPT Codes

• CPT 99496 -The face-to-face visit must occur within 7 calendar days of the date discharge and MDM must be of "High complexity". 

• CPT 99495 -  The face-to-face visit must occur within 14 calendar days of the date of discharge and MDM must be "Moderate complexity".

Documentation

For Transitional Care Management (TCM) services, the following elements must be documented in the patient's record:

1. Date of discharge from acute care
2. Date of provider contact with the patient (two days post-discharge)
3. Date of face-to-face visit with the provider (either 7 days or 14 days post-discharge)
4. Complexity of the Medical Decision Making (MDM), documented as either moderate or high

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