Transitional Care Management (CMS) Program helps Providers Earn more Revenue

30 DAYS! That's the critical phase for patients with moderate or high-complex medical conditions after getting discharged from hospitals. Lack of consistent monitoring and quality care during this period could increase the chance of hospital readmission.

To reduce the patient readmission rate and eliminate the gap in patient care, the Centers for Medicare and Medicaid Services (CMS) started a preventive wellness program named Transitional Care Management (TCM).

As Transitional Care Management is reimbursable by CMS, it encourages physicians to manage their patients outside the hospital from the time they get discharged.

Through our comprehensive hiCare Chronic solution, we’ve helped providers earn more revenue through TCM implementation.

So, here’s your turn. Read this article to understand TCM requirements, codes, benefits, and the steps to start your own TCM program.

Who can offer Transitional Care Management (TCM) services?

The list of healthcare professionals who can offer and bill for Transitional Care Management (TCM) services include:

Physicians from any specialty
Non-Physician Practitioners (NPPs)
Clinical Nurse Specialist (CNS)
Nurse Practitioner (NP)
Certified Nurse Midwife CNM)
Physician Assistant (PA)

What are the settings eligible for transitional care management?

The 30-day TCM phase starts on the patient’s discharge date from the partial or inpatient hospitalization settings and continues for 29 days. The partial or inpatient hospitalization settings include:

Inpatient Acute Care Hospital
Inpatient Psychiatric Hospital
Inpatient Rehabilitation Facility
Long-Term Care Hospital
Skilled Nursing Facility
Partial hospitalization at a Community Mental Health Center
Hospital outpatient observation or partial hospitalization

After getting discharged, the patient should return to their community setting, which includes:

Home
Nursing home
Domiciliary
Assisted living facility

What are the services provided by healthcare professionals during the TCM program?

Both physicians and NPPs can provide the following services:

Review discharge summary and continuity-of-care documents
Review patients’ follow-ups, pending diagnostic tests, and treatments
Communicate with other care professionals regarding patient’s system-specific issues
Educate patients, families, or caregivers
Establish or re-establish referrals
Arrange community resources
Help schedule community providers’ services and follow-up

What are the components of TCM?

The patient should be Medicare-based
To qualify for TCM reimbursements, you should use a certified EHR (Electronic Health Records) module.
TCM covers communication with the patient or caregiver within two business days of discharge from the hospital.
This communication can be non-face-to-face (email/phone) or face-to-face.
Medication reconciliation and prescription assistance were performed no later than the date of the face-to-face visit.
Face-to-face visit within fourteen days (99495) or seven days (99496) (cannot be billed separately)
The face-to-face visit cannot be performed on the day of discharge
Transitional Care Management (TCM) can be performed at any appropriate location
Medical decision making of moderate complexity (99495) or high complexity (99496)

What codes are used to bill CMS for the Transitional Care Management program?

CPT Code

Time (min)

Monthly reimbursement per patient

Description

Key points

99495

$216

A face-to-face visit with moderately complex patients within 14 calendar days of discharge.

- TCM becomes a funnel for new CCM enrolment via face-to-face visit

- Any new Medicare patients meeting the CCM criteria that come to the office for TCM can be signed up for CCM as well during the same visit

- You can bill TCM in the same month as CCM & RPM

99496

$282

A face-to-face visit with highly complex patients, within seven calendar days of discharge

What are the tips for billing Transitional Care Management codes for CMS reimbursements?

Here is the list of billing tips for TCM services:

Only one physician or NPP can bill TCM service who discharge the patient from this hospital or report discharge services
Report services only one time per patient during the TCM phase
The face-to-face visit cannot take place on the same date of discharge
Report only necessary Evaluation and Management (E/M) services except for a face-to-face visit
You can’t bill TCM services if its 30-day period falls within the global surgery period for a procedure code billed by the same care practitioner
Make sure to enter the following information in the patient’s medical record:
Patient discharge date
Patient or caregiver first interactive contact date
Face-to-face visit date
Medical complexity decision making (moderate or high)

When can you submit the reimbursement to the CMS for Transitional Care Management (TCM) services?

You can submit reimbursement to the CMS for TCM services 30-days after the discharge date.

Is it possible to submit claims for any other CPT code during the 30-day TCM billing period?

A qualified healthcare practitioner who opts for billing TCM services during the 30 days cannot bill for the following services:

Medication therapy management services (99605-99607)
Prolonged services without direct patient contact (99358, 99359)
Plan oversight services (99339, 99340, 99374-99380)
Education and training (98960-98962, 99071, 99078)
Telephone services (98966-98968, 99441-99443)
Anticoagulant management (99363, 99364)
Medical team conferences (99366-99368)
End-stage renal disease services (90951 – 90970)
Online medical evaluation services (98969, 99444)
Preparation of special reports (99080)
Analysis of data (99090, 99091)

What challenges are involved in running a CMS - Transitional Care Management program (TCM)?

The challenges experienced by a qualified care provider include:

Outreach the patients within two days of discharge and see them again within 7 or 14 days according to the respective TCM reimbursement code
Consuming more time in developing an individualized care plan for each patient to get TCM reimbursements
Consuming more time to bill the proper TCM codes could be a burden for physicians

How to run a CMS - Transitional Care Management program?

Running a TCM program involves three steps:

Identify patients discharged from hospitals
Prioritize high-risk patients and outreach easily
Help physicians schedule TCM visits with their patients
Monitor and update TCM visit performance
Measure patient health outcomes

Following the above three steps could significantly reduce medical costs and hospital readmissions through continuity of care.

What are the benefits of CMS Transitional Care Management Services for providers?

While TCM can improve patient's quality of health outcomes, practitioners also reap many benefits from offering TCM services. The list of benefits include:

Reduced hospital readmission rate

Hospital readmissions cost Medicare nearly 26 billion USD per year. About 17 billion USD was spent on avoidable hospital visits after getting discharged from this value.

Furthermore, Medicare has implemented penalties for excess 30-day hospital readmission rates. In 2017, nearly 2500 hospitals were penalized by Medicare at the cost of more than 564 million USD for excessive readmissions.

With TCM, physicians can reduce overall costs for themselves, patients, and Medicare. Furthermore, they can save the hospitals from getting penalized.

Did you know? A 2018 research article reported more than 86 percent reduction in readmission rates by receiving TCM services compared to those who didn't receive them.

2. High quality of care

The lesser the readmission rate, the higher the quality of care. Both patients and payers follow this indicator to ascertain the quality of the provider.

3. More revenue through TCM reimbursements

While improving the health outcomes of patients and overall costs of payers, physicians can earn more revenue using TCM codes.

Here's the case study on the annual revenue calculation of a single physician:

Suppose 20 moderately complex Medicare patients get discharged from your setting; the estimated annual TCM reimbursement will be $51,840 if the average TCM reimbursement per patient is $216

20*216*12 = 51,840

Similarly, 20 highly complex Medicare patients get discharged from your setting, the estimated annual TCM reimbursement will be $67,680 if the average TCM reimbursement per patient is $282

20*282*12 = 67,680

Chronic Care Management (CCM) is billable with TCM

Previously, CMS (Centers for Medicare & Medicaid Services) would not reimburse both TCM and Chronic Care Management (CCM) services in the same month. Now, it is not so. You can opt for dual reimbursement (CCM and TCM) for the same patient in the same month.

Here’s the case study on annual revenue calculation of a single physician (CCM + RPM + TCM) from a single patient:

TypeCCM+RPM Duration (minutes)YearCPT codes usedMinimum Revenue Per Patient Per MonthMinimum Annual Revenue Per Patient ($) Moderate 60+40FirstTCM (99495) + CCM (99487) + RPM (99453 + 99454 + 99457 + 99458)[$216] + [$134] + [$21 + $56 + $51 + $42] = $520$520*12 =$6240SecondTCM (99495) + CCM (99487) + RPM (99454 + 99457+ 99458)[$216] + [$134] + [$56 + $51 + $42] =$499$499*12 =$5988 High 60+30+60FirstTCM (99496) + CCM (99487 + 99489) + RPM (99453 + 99454 + 99457 + 99458 + 99458)[$282] + [$134 + $71] + [$21 + $56 + $51 + $42 + $42] = $699$699*12 =$8388SecondTCM (99496) + CCM (99487 + 99489) + RPM (99454 + 99457 + 99458 + 99458)[$282] + [$134 + $71] + [$56 + $51 + $42 + $42] =$678$678*12 =$8136

Note: There is no cap to the upper reimbursement limit, as one can add as many 20/30-minute installments as required for the patient

Why Hifinite’s hiCare Chronic?

With Hifinite’s hiCare Chronic Disease Management Solution, you get:

Simplified risk-stratified patient dashboards
Real-time tracking of vitals and medication adherence
Individualized care plan built from the provider’s assessment
Automated time tracking for every patient interaction
Secure HIPAA compliant patient engagement, including calls, texts, chats, and secure mail
Easy care transition among providers and care circle
Billing analytics and report generation, including reimbursement codes
Seamless integration with your existing certified EHR
Electronic consent forms for patient enrollment

And many more.

Our most comprehensive feature set is available on all modalities (web, mobile, wearables, voice, TV) and can be configured to meet your specific needs.

Putting it all together with care management software

If it’s possible to combine better health outcomes for patients, reduce healthcare costs for payers, and increase TCM reimbursements for providers, adopting a TCM program is the right decision.

Transitional care management (TCM) is a significant piece of the puzzle for managing chronic conditions.

Hence, implementing care management software tailored to TCM and other reimbursement services like CCM, RPM, etc., into your practice could help you manage your patients efficiently.

With Hifinite’s hiCare Chronic Disease Management Solution, you can effectively improve the bottom line through our simple and intuitive features.

Does this sound interesting to you? Is this something you would like to implement in your practice? Contact us right away to schedule a demo!

Learn how Hifinite Health can bring a massive difference to your practice by increasing your revenue and improving your patients' health outcomes through TCM services.

References

Ballard J, Rankin W, Roper KL, Weatherford S, Cardarelli R. Effect of Ambulatory Transitional Care Management on 30-Day Readmission Rates. Am J Med Qual. 2018;33(6):583-589. doi:10.1177/1062860618775528 (Link)