Healthcare providers to be reimbursed for transitional care management (TCM) services

Healthcare providers are justifiably worried about cuts in reimbursement, but some are finding other services they already perform that can add legitimate revenue to the business if they are coded properly. As the healthcare industry coding system evolves, it is critical to understand code changes along with the relative reimbursement value of each change.

The Centers for Medicare and Medicaid Services (CMS) has finalized reimbursement rates for the new Transitional Care Management Services (TCM). Beginning Jan. 1, 2013, physicians who perform these services on or within 29 days after the date of discharge (30 calendar days) may be able to be reimbursed for the service rendered.

TCM is comprised of one face-to-face visit within 7 or 14 days (respectively), in combination with non-face-to-face services that may be performed by the physician or other qualified healthcare professional and/or licensed clinical staff under his/her direction.

Physicians and other qualified health care professionals may bill one of two codes, based on the complexity of the service provided:

99495 – Transitional Care Management Services with the following required elements:

  • Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge
  • Medical decision making of at least moderate complexity during the service period
  • Face-to-face visit, within 14 calendar days of discharge

99496 – Transitional Care Management Services with the following required elements:

  • Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge
  • Medical decision making of high complexity during the service period
  • Face-to-face visit, within 7 calendar days of discharge

Non-face-to-face services provided by clinical staff, under the direction of the physician or other qualified health care professional, may include:

  • Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge
  • Communication with home health agencies and other community services utilized by the patient
  • Patient and/or family/caretaker education to support self-management, independent living, and activities of daily living
  • Assessment and support for treatment regimen adherence and medication management
  • Identification of available community and health resources
  • Facilitating access to care and services needed by the patient and/or family

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

  • Obtaining and reviewing the discharge information (for example, discharge summary, as available, or continuity of care documents)
  • Reviewing 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

Medicare reimbursement for the two new CPT codes for Transitional Care Management services is calculated based on the following relative values:

99495 (moderate complexity):

  • Work RVU: 2.11
  • Malpractice RVU: 0.14
  • Practice expense RVU: 2.57 (non-facility) and 1.71 (facility)

99496 (high complexity):

  • Work RVU: 3.05
  • Malpractice RVU: 0.20
  • Practice expense RVU: 3.54 (non-facility) and 2.56 (facility)

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