Dating back to 2013, transitional care management (TCM) is one of the first medical billing code structures to incorporate remote patient monitoring (RPM). But what is transitional care management, exactly? And what does TCM mean in medical billing terms? Here’s a brief definition of transitional care management, and what providers should know about this model of patient care.

What is transitional care management (TCM)?

So, what is TCM, and how is it used? Transitional care management is a medical billing option that reimburses billing practitioners for treating patients with a complex medical condition during their 30-day post-discharge period. The primary goal of TCM is to avoid patient readmissions to an acute-care hospital or facility during the time while they transition to at-home care.

According to the official wording for the CPT® Codes for transitional care management, TCM reimbursement is restricted to the treatment of patients “whose medical and/or psychosocial problems require moderate or high complexity medical decision making during transitions in care.”

Those transitions are specified as “an inpatient hospital setting (including acute hospital, rehabilitation hospital, long-term acute care hospital), partial hospital, observation status in a hospital, or skilled nursing facility to the patient’s community setting (home, domiciliary, rest home, or assisted living).”

Just one healthcare provider may act as billing practitioner during this 30-day period. These are usually physicians or qualified health professionals (QHPs) such as nurse practitioners (NPs) or physician assistants (PAs). The billing party is often a primary care doctor or practitioner, but not always, depending on the needs associated with the patient’s condition.

What is TCM in medical billing?

So, what is TCM in medical billing terms? As of January 1, 2022, transitional care management can be reimbursed under two different CPT® Codes: CPT Code 99495, covering patients with “moderate medical complexity,” and CPT Code 99496, covering those with a “high medical decision complexity.” (Stay tuned to the CareSimple blog in the weeks to come for a deeper dive on each of these CPT codes.)

Because they “span a period of time versus a single snapshot date of service,” as Elizabeth Hylton puts it at the AAPC Knowledge Center, TCM services can be delivered in-person/face-to-face, and remotely/non-face-to-face, as needed.

The allowance for remote care is particularly important, as it lets providers bill for time spent in interactive contact with patients outside of the traditional office visit. This can include communication by phone or email, and can cover such aspects of patient care as educating patients on self-care, supporting them in medication adherence, helping them identify and access community resources, and more.

Remote communication among the care team is also reimbursed, which can be a significant advantage given the range of needs associated with caring for patients with complex conditions. Reimbursed services can include time spent discussing the patient’s condition with other parties, reviewing discharge information, working with other staff members to create an educational plan, and establishing referrals and follow-ups.

How is transitional care management different from principal care management, chronic care management and remote patient monitoring?

For purposes of medical billing, TCM is often used in conjunction with principal care management (PCM) to provide care for patients with a single complex/chronic condition. When linked together in this way, TCM is used for the reimbursement of care during the patient’s first month post-discharge — a period usually requiring intensive communications and planning and occasional intervention.

After that period, principal care management may then be used for the remainder of a calendar year to provide continuing treatment — particularly in the case of patients with chronic diseases who are at high risk of comorbidity. You can get more details on principal care management here, and a guide to PCM codes here.

Because they treat patients at specific and different points in their journey, TCM cannot be reimbursed during the same month as PCM. It can, however, be billed simultaneously with RPM or chronic care management (CCM), which are two different programs offering different ways to treat patients with chronic conditions:

  • CCM is a model of care that reimburses for the care of patients with two or more chronic conditions (as opposed to PCM, which is just one).
  • RPM codes reimburse physicians and qualified non-physician practitioners for the use of remote devices that are used to collect important patient data, including the time needed to set up the patient, as well as ongoing consultations.

It’s important to note that certain CPT codes cannot be reimbursed during the same 30-day period by the same provider or caregiver who billed for transitional care management services because the services provided are considered redundant. These include certain codes for home health and hospice plan oversight, medical team conferences, medication management and more. You can find a more comprehensive list of restrictions here.

Looking to leverage transitional care management for your practice or organization?

Whether they use TCM, PCM, CCM, or another form of virtual care, there’s no doubt that doctors and caregivers today have more options than ever when it comes to reimbursable claims for complex patient care.

“In the past, providing care for a chronically ill patient with multiple comorbidities and frequent jumps between an acute care setting and their community often meant a great deal of behind-the-scenes work for healthcare professionals, with very little revenue reimbursement potential,” as Hylton writes.

Today more than ever before, practitioners can reclaim the value of time spent managing their most complex patients. And if your organization is interested in leveraging remote care technology to implement transitional care management or other models of care, we may be able to help. Contact us today to connect with a CareSimple specialist.

For a closer look at current reimbursement codes for transitional care management, principal care management, remote patient monitoring and more, check out our handy Reimbursement Tree.