Coding tips: Transitional care management

Published on: 
Medical Economics Journal, July 25, 2018 edition, Volume 95, Issue 14

Here are four common transitional care management denials and how to avoid them.

Transitional care management (TCM) is also a payer target for auditing, which means practices need to focus on following the rules when billing this service. Consider the following common TCM denials and how to avoid them:

Reason for denial: The practice doesn’t call the patient within two business days of discharge.

How to avoid it: Join a health information exchange to receive daily admission discharge transfer (ADT) feeds and discharge summaries, says Samantha Sizemore, chief operating officer at Holston Medical Group PC in Kingsport, Tenn. Then work with the EHR vendor to incorporate this information into the system so staff can view it easily. Consider hiring a patient navigator who can monitor these discharges and reach out to patients in a timely manner to schedule a post-discharge appointment. In small practices with few TCM billings, nurses, medical assistants, or even administrative staff can also perform this task, she adds.

“The idea is to get the patient engaged in the outpatient setting as quickly as possible,” says Shelton Hager, MD, CPC, a primary care physician at Holston who bills TCM approximately five times a month.

Reason for denial: The practice doesn’t document the initial call to the patient.

How to avoid it: Develop an EHR template for the follow-up telephone call to the patient, says Sizemore. This template should include the date of discharge, time, and date of the follow-up phone call, and a summary of the conversation. Work with the EHR vendor to automatically pull information from this template into the template for the transition of care (TOC) office note, she adds.


The TOC office note should also include checkboxes to remind physicians of the key components of the TCM code (e.g., review the discharge summary, establish or re-establish referrals to community services, and provide patient education). “These are the components that auditors will be looking for,” says Hager.

Reason for denial: The patient is not seen within seven or 14 days of discharge.

How to avoid it: Save one or more appointment slots per week for hospital follow-up appointments, says Sizemore. Another option is to double book or have the patient see a different provider in the practice, she adds.

Reason for denial: The patient is readmitted or dies within 30 days of discharge.

How to avoid it: One option is to hold the TCM claim for 30 days and manually review ADT data before billing to ensure the patient hasn’t died or been readmitted. Another option is to bill TCM at the time of service under the assumption that the patient won’t die or be readmitted. If the patient is readmitted or dies within 30 days of discharge, Medicare will automatically recoup the TCM payment; however, practices can refile the claim using an E/M code based on the documentation. “If you don’t refile it, then you forfeit the payment for the TCM service altogether,” says Sizemore.


CPT codeDescription2018 national average Medicare payment
99495TCM with moderate medical decision complexity and a face-to-face visit within 14 days of discharge$167.04
99496TCM with high-complexity medical decision making and a face-to-face visit within 7 days of discharge$236.52