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Monetary Incentives of Transitional Care Management


Since the beginning of 2013, primary care physicians have, for the first time, been able to get paid by Medicare for the time spent coordinating care for patients who are transitioning back to their homes.

Since the beginning of 2013, primary care physicians have, for the first time, been able to get paid by Medicare for transitional care management (TCM) — the time spent coordinating care for patients who are transitioning back to their homes from either hospitals, nursing or skilled nursing facilities.

While the move by Medicare is aimed largely at reducing problems in care coordination that all too often lead to re-hospitalization, it also puts newfound money in primary care physicians’ pockets. Nevertheless, PCPs, according to postings on the American Academy of Family Physicians’ website, have decidedly mixed feelings about the monetary opportunity.

“Too complicated and too much paper work to be worth the extra $60,” writes one physician. Another agrees, noting that, “$60 does not cover the costs of the excessive documentation.”

But others, who say they had already been documenting the transitional care they provide, point out that they are, “…now getting paid an extra $60 to do the same work. Sounds like a good deal to me.”

Breaking down the codes

To be exact, Medicare covers transitional care management under two CPT codes: 99495 for conditions requiring moderate medical decision-making; and 99496 for conditions of a high-complexity nature. The former, according to physicians, reimburses physicians approximately $60, the latter approximately $120.

Mark Oshnock, chief executive officer of Visiting Nurse Health System, a leading provider of home health care and hospice care in Atlanta, understands physician skepticism over the payments. He relates the TCM situation to his own experience with home health care supervision.

A physician who worked with Visiting Nurse Health Systems could bill Medicare about $105 a month as long as he kept a log that documented he had worked with the company, the patient and the patient’s family for at least half an hour during that month. However, just like the TCM situation, the documentation requirements were so strict that it might not be worth the $105.

“Now, the transition care management payments are a bit higher, but I think what physicians are always attempting to do is balance the return on their investment, right?” says Oshnock. “And is that return of $105 in the home health supervision, for example, worth their investment of keeping logs and documenting, and then having Medicare second-guessing them a portion of the time, and all that kind of stuff? And I think they pretty much concluded it wasn’t worth my time.”

Oshnock acknowledges that he has no idea whether physicians will come to a different answer where the TCM codes are concerned, but he points out, “The dollar amounts are not that much higher.”

Like chasing patients?

According to the AAFP’s website, “Payment allowances will vary by payer, and Medicare’s allowance will vary geographically. Also, Medicare’s allowance will depend on the conversion factor in force at the time claims are paid.”

To Oshnock, that sounds a lot like attempting to bill a patient who owes the medical practice $100.

“You’re going to spend, you know, $200 to actually get staff mobilized to bill, collect, follow-up and everything on a hundred dollar bill,” he says. “It’s much the same [with the TCM codes]. How much time does it take?”

Oshnock does acknowledge, however, that several studies have revealed that one of the biggest reasons for a hospital re-admission after a hospital discharge is the lack of linkage between patients and their primary care physician.

“I think one study showed that more than half the time, when patients are discharged, neither the hospital nor the patient closes the loop with the patient’s primary care physician,” Oshnock says. “The primary care physicians are not even aware that their involvement can be a plus in keeping that patient from bouncing back into the hospital.”

To participate or not

Oshnock believes that it’s going to be difficult for a small, single-physician practice to benefit from payment for transitional care management.

“It’s going to be tough for them to figure all this out, put the infrastructure in place, track it and put a plan in place to actually identify the patients who would benefit,” he says. “But if you’re a group of 50 physicians, you may have the infrastructure to get it launched, and you may see some decent results.”

He also points out that reimbursement for TCM is right in line with other related initiatives, demonstrations and pilots Medicare has launched.

“It certainly ties into what an accountable care organization may do with a primary care physician — properly rewarding a physician for care to keep a patient from hospitalization,” Oshnock says. “Transitional care management is one more mechanism attempting to reward for that work.”

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