Medicare Compliance & Reimbursement

Question: What types of discharge fall under the transitional care management codes?

California Subscriber

Answer: The evaluation and management transitional care management (TCM) codes you mention are:

• 99495 (Transitional Care Management services with the following required elements: communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge medical decision making of at least moderate complexity during the service period face-to-face visit, within 14 calendar days of discharge)
• 99496 (... medical decision making of high complexity during the service period face-to-face visit, within 7 calendar days of discharge).

With TCM, the provider delivers services during the patient's transition back home following particular kinds of discharge, according to Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, AAPC Fellow, AHIMA-approved ICD-10 CM/PCS trainer, and president of Maggie Mac-Medical Practice Consulting in Clearwater, Florida.

The eligible inpatient hospital discharge settings include the following, according to the CMS TCM Services Guide:

• Inpatient acute care hospital
• Inpatient psychiatric hospital
• Long-term care hospital
• Skilled nursing facility
• Inpatient rehabilitation facility
• Hospital outpatient observation or partial hospitalization
• Partial hospitalization at a community mental health center.

After discharge from an inpatient setting, the patient must return to his community setting (where he will reside), which includes the following, according to the CMS TCM Services Guide:

• His or her home
• His or her domiciliary
• A rest home
• Assisted living.

Caution: The requirements are specific to the patient being discharged from the inpatient hospital setting to his community setting, not to another facility. You cannot bill a TCM code if the patient is discharged from one inpatient facility to another such as from inpatient to a skilled nursing facility.