• CPT code 99495 (TCM with moderate medical decision complexity and a face-to-face visit within 14 days of discharge)
• CPT code 99496 (TCM with high medical decision complexity and a face-to-face visit within 7 days of discharge)
Payment information: CMS began paying for TCM in 2013, and many commercial payers began doing so shortly thereafter. The 2017 national average Medicare payment for TCM with moderate medical decision making is $165.45. For TCM with high medical decision complexity, Medicare pays a national average of $233.99.
Transitional care management (TCM) includes the services that physicians provide to new or established patients whose medical and/or psychosocial problems require moderate- or high-complexity medical decision making during transitions in care. These transitions occur when patients move from an inpatient hospital setting, partial hospital, observation status in a hospital or skilled nursing facility/nursing facility to the patient’s home or another community setting (e.g., rest home, domicile, or assisted living).
Even though CMS and most commercial payers began to pay for TCM in 2013, physicians continue to see denials when billing these services. Experts believe there could be several reasons why.
Physicians shouldn’t report TCM every time a patient is discharged, says Raemarie Jimenez, CPC, CPC-I, vice president of membership and certification solutions at AAPC. The patient’s level of severity must support the code assignment, she adds.
In particular, TCM requires either moderate- or high-complexity medical decision-making. A patient admitted due to a dehydration, for example, wouldn’t require TCM services post-discharge. Patients who are admitted for exacerbation of a chronic illness such as chronic obstructive pulmonary disease, diabetes or congestive heart failure would likely qualify.
Not fully understanding TCM requirements could be another reason why denials occur, says Kim Huey, MJ, CHC, CPC, an independent coding and reimbursement consultant. Many physicians don’t fully understand the breadth of their responsibilities when they bill TCM, she adds. “It’s about managing all of their medical and psychosocial needs for 30 days.”