Transition of Care Management FAQs

Physicians of any specialty and non-physician practitioners (NPPs) including:

• Certified nurse-midwives (CNMs)

• Clinical nurse specialists (CNSs)

• Nurse practitioners (NPs)

• Physician assistants (Pas)

• Obtain and review discharge documents (for example, the discharge summary or continuity of care documents)

• Review need for a follow-up on pending diagnostic tests or treatments and assist in scheduling the required follow-up with healthcare and community services providers

• Interact with other health care professionals who will assume or reassume care of the patients’ specific needs

• Provide education to the patient, family, guardian, and/or caregiver

• Establish or re-establish referrals and arrange for necessary community services

Yes, providers may use licensed clinical staff outside of their practice to provide TCM services subject to the Medicare “incident to” rules and all other applicable Medicare rules. For payment of TCM services under the Physician Fee Schedule, CMS requires direct supervision for the face-to-face visit, but all other TCM services may be provided under general supervision.

• Identify available care resources and communicate with the agencies and community services the patient will use

• Assist the patient and/or family in accessing necessary care and services

• Provide education to the patient, family, guardian, and/or caretaker

• Assess and support treatment regimen adherence and medication management

Beneficiaries discharged from:

• Inpatient Acute Care Hospitals

• Inpatient Psychiatric Hospitals

• Inpatient Rehabilitation Facilities

• Hospital outpatient observation or partial hospitalization

• Long-Term Care Hospitals

• Skilled Nursing Facilities

• Partial hospitalization programs at a Community Mental Health Center

• Care coordination for the 30 days following patient discharge from hospital

• Patient contact within two business days of discharge (can be non-face to face)

• Creation of a care plan that can be shared electronically with patient and other providers

• Other non-face-to-face services (review discharge instructions, medicine reconciliation, care coordination with other providers and community services, patient/caregiver communication and education)

• Follow up appointment/face to face visit within 7 days (high medical decision complexity) or 14 days (moderate medical complexity) of discharge

No, CMS has established both a facility and non-facility MPFS payment for this service. Practitioners should report TCM services with the place of service appropriate for the face-to-face visit.

• Initial contact within two business days of discharge - may be by direct contact, telephone, or electronic means

• Must include capacity for prompt interactive communication addressing patient status and needs beyond scheduling follow-up care

• May be performed by clinical staff under the general supervision of a qualified professional

• Date of communication (or two failed attempts) must be documented

• Moderate complexity: multiple possible diagnoses and/or management of options; moderate complexity of medical data (e.g., tests) to be reviewed; and moderate risk of significant complications, morbidity, and/or mortality, as well as co-morbidities.

• High complexity: extensive number of possible diagnoses and/or management of options; extensive complexity of medical data (e.g., tests) to be reviewed; and high risk of significant complications, morbidity, and/or mortality, as well as co-morbidities.

Average reimbursement ranges from $165 (14-day follow up visit) to $233 (7-day follow up visit) per 30 day episode.

The date of service you report should be the date of the required face-to-face visit. You may submit the claim once the face-to-face visit is completed and need not hold the claim until the end of the service period.

There are two CPT codes for TCM. The code you will bill will depend on the timing of the face-to-face visit and the degree of medical complexity:

•CPT Code 99495 – Transitional care management services with moderate medical decision complexity that requires a face-to-face visit within 14 days of discharge.

•CPT Code 99496 – Transitional care management services with high medical decision complexity requiring a face-to-face visit within 7 days of discharge.

Yes, TCM services can still be reported as long as the services described by the code are provided by the practitioner during the 30-day period. Alternatively, the practitioner can bill for TCM services following the second discharge for a full 30-day period as long as no other provider bills the service for the first discharge.

TCM services can only be billed by one individual during the 30-day period after discharge. If more than one physician or NPP submits a claim for TCM services provided to a patient in a given 30-day period following discharge, Medicare will pay the first claim that it receives that otherwise meets its coverage requirements.

Other reasonable and necessary Medicare services may be reported during the 30 day period, with the exception of those services that cannot be reported according to CPT guidance and Medicare HCPCS codes G0181 and G0182. CCM could be billed during the same calendar month as TCM only if the TCM service period ends before the end of a given calendar month, and at least 20 minutes of qualifying CCM services are subsequently provided during that month, and all other CCM billing requirements are met. However, the majority of the time, CCM and TCM will not be billed during the same calendar month.

AviTracks-TC helps to automate the management of patients in care transitions to improve outcomes and reduce hospital readmissions. With AviTracks-TC you can automate and customize your workflow, optimize your staff’s efficiency and maximize your TCM reimbursements.

• Enables team-based care and care coordination across providers

• Creates electronic care plans, assigns teams and separates the tasks among physicians, nurses and coach coordinators

• Creates custom questionnaires for patient follow up

• Records and logs time for every interaction with the patient

• Assigns a risk level to each patient and adjusts tracking based on the risk profile

• Flags patients by condition, risk or program for easy identification and monitoring

• Can be implemented across multiple care provider teams, letting each group focus on their work while sharing critical information

• Reports statistics by user so that administrators may view staff workload as well as identify highly efficient nurses, coaches and care coordinators

• Creates documentation for billing purposes including CMS CPT codes 99495 and 99496

No, because AviTracks-TC is a cloud-based web application, no new software or hardware is required.

AviTracks-TC contains a comprehensive suite of security technologies, including encrypted technology that protects patient data in transit and at rest. Our software is HIPPA compliant and hosted on Microsoft Azure’s cloud environment. In addition to these features, AviTracks-TC contains fully redundant data centers in the United States and has a full chain of Business Associate Agreements.