(Last Updated On: August 18, 2017)

Transitional Care Management (TCM), which includes both CPT 99495 for moderately complex patients and CPT 99496 for higher complexity patients, can be used in tandem with a Chronic Care Management (CCM), CPT 99490, program to enhance the revenue generated from the overall CCM program. When CCM (99490) was originally introduced in January 2015 there were certain restrictions around billing 99490 alongside TCM codes 99495/99496 in the same month. CMS had specifically ruled that 99490 could not be billed with 99496/99496 in the same calendar month. However, changes to this restriction as well as other operational synergies between CCM and TCM make these a perfect paring. Below are three important ways that CCM and TCM program play well together:

1.    One Call, Two Options for Coding

Keep in mind that the service level requirements between TCM and CCM are highly similar. TCM core scope of service requirements has 3 key components:

  • Interactive Contact
  • Non-Face-To-Face Services
  • Face-To-Face Visit

Interactive Contact
The interactive contact can be a phone call or secure e-mail from the care coordinator. The key is that the outreach must be made within 2 business days of discharge. As care coordinators from a CCM program are always reaching out to the patient on a monthly basis for CCM, they are in the best position to meet this scope of service requirement.

Non-Face-To-Face Services
Many of the TCM non-face-to-face requirements can also be performed by licensed clinical staff (e.g., care coordinators) and are all items that are normally included as part of the CCM scope of services. Below is a high-level overview of these TCM non-face-to-face requirements:

  • Communicate with agencies and community services used by the beneficiary
  • Provide education to the beneficiary, family, guardian, and/or caretaker to support self-management, independent living, and activities of daily living
  • Assess and support treatment regimen adherence and medication management
  • Identify available community and health resources
  • Assist the beneficiary and/or family in accessing needed care and services

These TCM requirements overlap with CCM to such an extent that it is only natural that the same coordinator provide both CCM and TCM services to each patient.

Face-to-Face Visit
The real differentiator between TCM and CCM is the face-to-face visit requirement. This requires that either the patient come into the physician’s office/facility or that the physician visits the patient wherever they reside. This physical encounter (including the associated requirements) is the only real TCM scope of service component that is not already being delivered by CCM.

So what does this all mean? Physicians should always enroll their patients in CCM. By default, plan to bill CCM (99490) in any given month. If the patient ends up in the hospital and is discharged that month, try to get the patient into the office for a face-to-face visit. If the coordinator reaches out to the patient within 2 days of discharge and is able to bring the patient into the office for the face-to-face visit, bill TCM (99496/99496). In the event that the patient refuses or is unable to come into an office for the face-to-face visit, all the time spent towards the attempted TCM billing will count as CCM time, and the physician should bill for CCM! A win-win either way with a guaranteed CCM upside and an even greater TCM potential upside of the patient comes into the office.

2.    Transitional Care Management to Initiate CCM

CMS was explicit in the fact that initiation into Chronic Care Management (CCM) must occur during to a face-to-face visit. This visit is the opportunity for the provider to explain the CCM program to the patient (e.g., only a single provider can render services, copay may be applicable, opt-out at any time) and obtain written consent. Typically this initial visit can come in the form of an Annual Wellness Visit (AWV), Initial Preventive Physical Examination (IPPE), or comprehensive scheduled evaluation and management (E&M) visit. However, CMS has specifically outlined another face-to-face encounter that can be used to kick-off CCM: the TCM face-to-face visit. This means any new Medicare patient meeting the CCM criteria that is brought into the office due to TCM can be signed up for CCM during that TCM visit. Through this method TCM becomes a funnel for new CCM enrollment!

3.    Bill for CCM (99490) in the Same Month as the TCM Service Period

As of March 2016, CMS issued clarifications around billing CCM and TCM in the same month.

“CCM could be billed to the MPFS during the same calendar month as TCM only if the TCM service period ends before the end of a given calendar month, at least 20 minutes of qualifying CCM services are subsequently provided during that month, and all other CCM billing requirements are met.”

This means in some cases, a provider can take advantage of CCM immediately after the TCM service periods end. For example, take a patient that is discharged from the hospital in the middle of Month 1. The TCM 30 day period would end in the middle of Month 2. As long as the 20 minutes are provided after the end of the TCM 30 day period, CCM can be then billed immediately after the TCM period in Month 2!

To recap, TCM and CCM go hand in hand. Both codes reimburse for similar care coordination services that are especially critical for chronically ill patients post-discharge. Due to synergy between the two and to maintain consistent, continuous care for the patient, it is advisable to consolidate the TCM/CCM function into a single staff member or vendor.