Transitional care management codes: What physicians should know

July 10, 2013

Primary care physicians can, for the first time, get paid for transitional care management (TCM) - the time they spend coordinating care for patients transitioning from hospitals, nursing, or skilled nursing facilities back to the community.

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Primary care physicians (PCPs) can, for the first time, get paid for transitional care management (TCM)-the time they spend coordinating care for patients transitioning from hospitals, nursing, or skilled nursing facilities back to the community.

Medicare began paying for TCM at the start of 2013, with the goal of encouraging PCPs to contact patients immediately after they are discharged from an inpatient facility, thereby reducing the mistakes in care coordination that frequently lead to rehospitalization. A 2007 Medicare Payment Commission Advisory Report to Congress found that 18% of Medicare patients discharged from the hospital were readmitted within 30 days of discharge, at a cost of $15 billion.

TCM is covered under the Current Procedural Terminology (CPT) codes 99495 and 99496. Required elements for CPT code 99495 are:

  • communication (direct contact, telephone, or electronic) with the patient and/or caregiver within 2 business days of discharge;

  • medical decision-making of high complexity during the service period; and

  • a face-to-face visit within 14 calendar days of discharge.

For CPT code 99496 the requirements are:

  • communication (direct contact, telephone, or electronic) with the patient and/or caregiver within 2 business days of discharge;

  • medical decision-making of high complexity during the service period; and

  • a face-to-face visit within 7 days of discharge. Both codes permit the face-to-face visit to take place in the patient’s residence or somewhere other than the doctor’s office.

Medicare requires that services performed under the codes be billed on the 30th day following discharge or later, although the rules for private payers may be different.

In addition to the codes covering transitional care management, the 2013 CPT list includes three new codes-CPT 99487, 99488, and 99489-for complex chronic care coordination (CCCC) services. CMS considers CCCC services to be bundled services covered by existing codes and thus does not pay for them separately, but is studying the new codes for future implementation. Its decision on whether to do so is expected later this summer.