Posted and filed under Coding, Compliance, Healthcare.

Transitional Care Management (TCM) codes are used to report patients who are transitioning from inpatient hospital, observation, skilled nursing/nursing facility, or rehabilitation to the patients’ normal community settings such as their home, domiciliary, rest home or assisted living settings.

The patient’s transition to a normal community setting is not the only requirement of the TCM Services. The health care professional must accept care of the patient, without any gap and post discharge.  Furthermore, they need to take responsibility for the patients care, and the patient’s condition (medical /or psychosocial) must be of moderate or high complexity medical decision making.

TCM begins when the patient is discharged from an inpatient facility setting, and continues for the next 29 days.

The services include a face-to-face visit within the time frame required (as specified by CPT), as well as a non-face-to-face service as appropriate for the condition of the patient. The non-face-to-face services are provided either by the physician, other qualified health care professional and/or licensed clinical staff under the direction of the physician overseeing the patient.

Interactive contact must be made between the patient and caregiver within the two business days following discharge. As noted in the CPT codes, the contact may be in the following form: direct contact, telephone, or electronic. This communication must be an exchange of information and appropriate medical direction between the parties to be considered successful. If unsuccessful attempts are made, TCM codes may NOT be billed.

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

  • Communication by direct contact with the patient, family members, guardian, or care taker, surrogate decision makers, and/or other professionals regarding aspects of the patients care
  • Communication with home health agencies and other community services utilized by the patient
  • Provide education to support self-management, independent living, and activities if 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 (ex. 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 care giver
  • Establishment or reestablishment of referrals and arranging for needed community resources
  • Assistance in scheduling any required follow-up with community providers and services

One face-to-face visit is required. During the face-to-face visit, the provider will perform a medication reconciliation, and plan for or coordinate care for services that the patient may need.  They can utilize community agencies such as: Home Health nursing visits.

TCM codes are determined largely by medical decision making and the date of the first face-to-face visit. As described in the TCM codes the patient’s problem must be of Moderate or High Medical Decision Making. You can find more info on MDM in the Documentation Guidelines (1995 or 1997).

You may look at the CPT requirements for performing these TCM services and find yourself overwhelmed. We suggest you break it down step by step and create an office policy and procedure. Performing these services is vitally important to improving Quality in your patient’s life, improving their ability to safely stay out of the hospital in a more comfortable home environment.