Know the Ins and Outs of Transitional Care Management
Find billing tips for providing this crucial service for patients. Transitional care management (TCM) plays a vital role in healthcare by ensuring patients have a smooth transition from different care settings, including from a hospital to the patient’s home. Primary care physicians (PCPs) are often at the forefront of TCM for patients. For instance, patients may need TCM after having surgery and transitioning to their home, where certain parameters must fall into place. This could include medications, therapy, and other assistive services. TCM services are used to bridge the gaps for consistent and coordinated care, which can reduce readmission to the hospital. Understand the Requirements The initial 48 hours post-discharge are crucial. In this time, the provider or provider practice should contact the patient or caregiver either by phone or other electronic communication. This first conversation is intended to gather information about the setting and medications, as well as provide an opportunity to address any questions or concerns from the patient or caregiver. After surgery this could mean understanding postoperative pain, assisting in daily activities, and ensuring they follow any other postoperative instruction. The first seven to 14 days is essential to billing these services. For patients with high-risk complexity, they should be scheduled for a face-to-face visit within the first seven days. For patients with moderate complexity, the face-to-face service should be within 14 days. This is a detailed comprehensive visit reviewing all necessary components for that patient’s healing and recovering process. Use These Codes to Report Face-to-Face Visit No separate evaluation and management (E/M) service should be billed on this date of service face-to-face appointment. There must be documentation of the date the patient was discharged, date of first contact with the patient or caregiver, date of the face-to-face visit, and the patient complexity. Here are some relevant codes: In the first 30 days close monitoring will be performed, including additional testing, changes to medications, and referring to specialists or any other components as the provider sees fit. Only one provider can bill for TCM services. These are only billable once during that patient’s TCM period of time. These services are not separately billable during the 90-day global period for the provider or provider group specialty that performed the surgery. For patients with Medicare, do not report G0181 (Physician or allowed practitioner supervision of a patient receiving Medicare-covered services provided by a participating home health agency (patient not present) requiring complex and multidisciplinary care modalities involving regular physician or allowed practitioner development and/or revision of care plans) and G0182 (Physician supervision of a patient under a Medicare-approved hospice (patient not present) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, review of subsequent reports of patient status, review of laboratory and other studies, communication (including telephone calls) with other health care professionals involved in the patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month, 30 minutes or more) for care plan oversight (CPO) or end-stage renal service codes 90951 (End-stage renal disease (ESRD) related services monthly, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 4 or more face-to-face visits by a physician or other qualified health care professional per month) to 90970 (End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients 20 years of age and older). The following healthcare settings are applicable to TCM: After discharge, the patient must return home, to a domiciliary facility like a group home or boarding house, or to a nursing or assisted living facility. Providers who can perform TCM services include: Incident-to services are allowed for this code set and supervision requirements must still be met. Non-face-to-face services by clinical staff under the direction of the provider are billable as appropriate for the patient’s needs. Telehealth services are also payable for TCM coding. TCM also promotes value-based care by coordinating care and reducing hospitalizations by supplying data that can be optimized, interacting with the patient, and allowing for specific metrics to be met. Consider These Billing Tips, Too The 30-day period begins the day of discharge and then continues for 29 days; the reported date of service should be the date of the visit. Place of service should reflect the location of the face-to-face visit. Providers at federally qualified health centers and rural health clinics are also eligible for billing TCM services. If a patient gets readmitted within the 30-day period, the initial provider can still bill for the TCM services from the first discharge. No other provider can bill for the subsequent discharge for 30 days. Remember, TCM is only billable by one provider and is not allowed by another provider during this period. If a patient dies prior to the end of the 30-day period, then the provider should not bill for TCM services, but should bill for any other face-to-face services during that period. TCM services are not eligible for the primary care exception or other teaching physician services. Other necessary services are billable within the TCM period with the exception of the excluded services mentioned above. TCM services are billable for both facility and nonfacility services. As a reminder, providers should bill for the place of service where the face-to-face encounter is performed. Cristin Robinson, CPC, CPMA, CCC, CRC, CEMC, AAPC Approved Instructor,
Education Coding Consultant, Bristol, Tennessee
