Understanding Transitional Care Management

Sarah Tolson

In recent years, the theme in healthcare reimbursement has been to find ways to pay for quality rather than quantity. Medicare has introduced several new programs with direct impact on the renal community, designed with the intent of producing better patient outcomes while driving cost savings. These programs can be complex, and some may argue they increase administrative burden. Effective January 1, 2013, Medicare began reimbursing providers for Transitional Care Management (TCM) services—a service that many nephrologists have been providing, to some extent, for patients with end-stage renal disease (ESRD) for many years. In this article we will discuss the basic components of TCM services, and in a subsequent article we will discuss several frequently asked questions about TCM services and the codes associated with TCM services.

TCM services were designed to reduce hospital readmissions of patients whose medical and/or psychosocial problems require moderate or high complexity medical decision making during the transition from the inpatient hospital setting to the patient’s home setting. TCM services are only billable once per patient within 30 days of discharge. Additionally, the physician that bills for TCM services may not report care plan oversight services, medical team conferences, education and training, ESRD services, or complex chronic care coordination services, not to mention several other types of non–face-to-face and care coordination services during the time period covered by the TCM services. As nephrologists commonly see their ESRD patients in the hospital and continue to oversee the patient’s care after discharge, TCM services are not billable by the same physician in the same time period as ESRD monthly capitation payment services.

There are several components that make up TCM services: initial, interactive patient contact, face-to-face visits, medication reconciliation and non–face-to-face services. Initial patient contact consists of some form of interactive contact with the patient and/or their caregiver within two[JF1]  business days following the patient’s discharge. I have received several questions about the timing of the initial, interactive patient contact. To clarify, if a patient is discharged on Wednesday, the initial, interactive patient contact should take place by the end of the day Friday.

The initial, interactive contact can occur via telephone, email, or face-to-face. In the event you make two or more unsuccessful separate attempts to contact the patient and those attempts are documented in the patient’s medical record, TCM services may still be billable. However, much of the Medicare documentation regarding TCM services indicates the expectation is that providers continue their attempts to communicate with the patient until the patient has been reached.

The complexity of medical decision making involved in a patient’s TCM services determines when the face-to-face visit must take place. If a patient’s condition requires medical decision making of at least moderate complexity, then the face-to-face visit should occur within 14 calendar days of the patient’s discharge. In the event the patient’s condition requires medical decision making of high complexity, the face-to-face visit should take place within seven calendar days of the patient’s discharge. Billing staff should be advised that the TCM face-to-face visit should not be billed separately, as it is included in the TCM service bundle, and it may not take place on the date of discharge.

Medication reconciliation is the next component of TCM services and should occur no later than the date of the face-to-face visit. The last piece of the TCM package is the non–face-to-face services. Here are a few examples:

  • Communication with the patient or family regarding the patient’s care
  • Communication with home health agencies and other community services utilized by the patient
  • Patient and/or caretaker education to support self-management and independent living
  • Reviewing need for or follow-up on pending diagnostic tests and treatments
  • Interaction with other qualified health care professionals who will assume care of the patient’s system-specific conditions

One important thing to remember about the non–face-to-face services is that some of the services must be performed by a physician, while others may be performed under the direction of a physician by clinical staff as long as the services are performed within the scope of license.

Sarah Tolson is the director of operations for Sceptre Management Solutions, Inc., a company specializing in billing for outpatient ESRD dialysis programs, nephrology practices, and vascular access. Your questions are welcome and she can be reached at stolson@sceptremanagement.com, 801.775.8010, or via Sceptre’s website, www.sceptremanagement.com.