To achieve patient-centered care, providers need a number of critical components working together. These include respect for patients’ principles, physical comfort, and emotional support. Another component that can contribute to patient-centered care is transitional care management.
Transitional Care Management (TCM) used to describe the process of coordinating the transition of a patient from one healthcare setting to another in a community setting. It involves the collaboration of healthcare providers, patients, and their families to ensure the smooth transfer of care, reducing the risk of adverse events while improving health outcomes.
Transitional care management is vital for patients discharged from the hospital, especially those who are at a higher risk of complications, such as those with chronic conditions or complex medical needs. The goal of TCM is to provide patients with a seamless transition from the hospital to another care setting, such as a:
- Personal home
- Domiciliary (such as a group home or boarding house)
- Nursing facility
- Assisted living facility (long-term care facility)
This service is greatly needed, as research shows that 20% of patients are readmitted to the hospital within a 30-day period following their discharge and a substantial 79% of these readmissions could have been prevented. To make matters worse, the cost of hospital readmission in the United States is alarmingly high, with estimates of over $52.4 billion annually.
With proper transitional care management, patients can receive the proper care at the right time, reducing the risk of complications, readmissions, and other adverse outcomes. In turn, this leads to a better quality of care and significant cost savings for facilities, patients, and their families.
TCM Coding Explained
TCM coding is a system used by healthcare providers to bill for services related to transitional care management. The TCM codes were introduced by the Centers for Medicare & Medicaid Services (CMS) in 2013 to provide increased compensation to healthcare providers who offer care to patients post-hospital discharge.
There are two main Current Procedural Terminology (CPT) codes used in Transitional Care Management:
- CPT Code 99495: This code represents a level of moderate medical complexity that necessitates an in-person appointment within 14 days of discharge from the hospital.
- CPT Code 99496: This represents a level of high medical complexity that requires a face-to-face examination to be conducted within seven days of being discharged from the hospital.
It is important to remember that both CPT codes related to transitional care management services require communication with the patient or their caregiver through direct contact, telephone, or electronic means, which must take place within two working days of discharge from the hospital.
Other requirements and components for the above transitional care management codes that healthcare staff should be aware of include:
- Scheduling a follow-up visit within seven to 14 days after discharge, depending on the medical complexity level
- An in-person examination as part of the transitional care management service and reported along with it
- Complete medicine reconciliation and management prior to the date of the face-to-face visit
- Reviewing the discharge information
- Assessing the requirement for any diagnostic tests or treatments and tracking of any pending results
- Providing education to the patient, their family, caregiver, or guardian
- Re-establishing or establishing connections with community providers and services when necessary
- Scheduling future visits with providers and services, if required.
Some of the key components of transitional care include the following:
- Patient engagement: This involves actively involving the patient in their own care and making sure they are informed and aware of the care they are receiving. Doing so helps to ensure they are more invested in their recovery and better equipped to manage their health.
- Caregiver engagement: This is about involving the patient’s caregiver (nurses in a facility or relative providing care at home) in the care process. This ensures that the caregiver is equipped to provide the necessary support to the patient, both during and after the transition from hospital to home or a long-term care facility.
- Complexity management: This includes assessing the patient’s medical history, current medications, and other factors that may impact their recovery.
- Patient education: Patients should be provided with clear and concise information about their condition, treatments, and any other relevant information. This empowers them to take control of their health and reduce the risk of readmission.
- Caregiver education: Caregivers play a vital role in the recovery process, and it is important that they are provided with the necessary information and education to support and engage with their patients. This can help to reduce the stress and anxiety of caring for a loved one and improve the quality of care provided.
- Patient and caregiver well-being: Considering the patient’s or caregiver’s psychological and emotional state helps ensure that they receive the necessary support and care.
- Care continuity: This can help reduce the readmission risk and ensure that the patient receives the right care at the right time.
- Accountability: This means clearly understanding who is responsible for each aspect of the patient’s care and ensuring that everyone involved in the care process is aware of their role and responsibilities.
Having discussed TCM codes, requirements, and the key components of transitional care, we can now move on to the benefits of transitional care management.
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TCM Codes and 4 Benefits of Transitional Care Management
Long-term care staff needs to be familiar with TCM codes in order to ensure effective transitional care management in a facility. In addition, it is also best for them to understand the benefits of transitional care management, as this will result in better transitional care management billing practices by MDS coordinators.
Some of the benefits of transitional care management in long-term care facilities include the following:
- A decrease in the number of hospital readmissions: This is achieved through a seamless transition of care, patient and caregiver education, and ongoing monitoring and support. By reducing the number of hospital readmissions, patients are able to receive the care they need in a more cost-effective and efficient manner, while facilities avoid being penalized and save on costs as well.
- An increase in the quality of care provided to patients: By ensuring that patients receive the proper care at the right time, transitional care management can help improve the quality of care provided. This can lead to better health outcomes, improved patient satisfaction, and fewer health complications. For example, transitional care management ensures the continuity of care from a hospital to a nursing facility, decreasing the chances of hospital readmissions.
- Financial reimbursements that improve the bottom line of long-term care facilities: Long-term care facilities can benefit from financial reimbursements associated with billing using TCM coding. By providing a higher quality of care, reducing the number of hospital readmissions, and understanding the Medicare TCM guidelines, facilities can improve their bottom line and increase their revenue. For instance, the average cost per patient per month for care of moderate complexity is $176.50 nationally, whereas the cost for care of high complexity is $236.77. If providers ensure fewer hospital readmissions, they stand to benefit from these financial reimbursements.
- Chronic Care Management (CCM) is billable with transitional care management: Previously, the Medicare policy prohibited simultaneous reimbursement for Chronic Care Management (CCM) and transitional care management services in the same month for a single patient. However, this has recently changed, and now Medicare allows dual reimbursements when the services are deemed “reasonable and necessary” for the patient’s care.
Before we conclude on the topic of transitional care management, it is worth mentioning some billing tips that can prove helpful for long-term care facilities accepting patients from hospitals.
Billing Tips for Transitional Care Management Services
When billing for transitional care management services, it’s important to keep the following billing tips in mind:
- Only one physician or Non-Physician Practitioner (NPP) may report TCM services for a single patient.
- TCM services can only be reported once per patient during the designated TCM period.
- The same healthcare professional who discharged the patient from the hospital can also report hospital or observation discharge services and bill TCM services. However, the required face-to-face visit must not take place on the same day as the discharge day management services.
- Document Evaluation and Management (E/M) services that are reasonable and necessary (excluding the mandatory in-person examination) in separate records for effective patient care.
- TCM services cannot be billed within a post-operative global surgery period; if any part of the 30-day TCM period falls within the global surgery period for a procedure code billed by the same practitioner, TCM services will not be reimbursed.
- As a minimum requirement, the patient’s medical record must contain documentation of:
- The patient’s discharge date
- The first interactive contact date with the patient or caregiver
- The face-to-face visit date
- Medical complexity decision-making (moderate or high)
By following the above, nurses and administrators can be sure they are appropriately reimbursed for services provided to their transitional care patients.
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