CMS Places $1 Billion Bet On Transitional Care Management

This is the second of our four-part series on the 2013 Medicare Physician Fee Schedule final rule.

For years, the Medicare Physician Fee Schedule final rule has represented the Center for Medicare and Medicaid Services’ (“CMS”) annual attempt to reign in fee-for-service reimbursement by imposing more restrictive billing rules.  This year, however, CMS is taking a step in a different direction.  Beginning on January 1, 2013, Medicare will pay for transitional care management, to the tune of more than $1 billion.

Last year, in the 2012 Medicare Physician Fee Schedule proposed rule, CMS “initiated a public discussion regarding payments for post-discharge care management services” seeking to improve “a beneficiary’s transition from the hospital to the community setting within the existing statutory structure for physician payment and quality reporting.” 

In response, both the American Academy of Family Physicians and the American Medical Association (“AMA”) formed workgroups to consider new options.  Both organizations recommended CMS create new codes and pay separately for post-discharge care transition and care coordination activities. 

CMS has, for the most part, accepted the AMA’s specific recommendation to create two new transitional care management (“TCM”) codes, 99495 and 99496.  Beginning January 1, 2013, CMS will pay physicians and other qualified non-physician professionals for the work needed to successfully transition a patient out of institutional care back into the community setting.  The specific requirements for TCM billing are detailed in the chart below. 

CMS is investing an astonishing amount of money on the promise of TCM generating upstream savings from a reduction in repeated and prolonged hospitalizations.  Based on the 2012 conversion factor, the national average payment rates for TCM would be $142.96 (for 99495) and $231.11 (for 99496).  (Absent Congressional action, the 2013 conversion factor will be 25.5% lower due to the sustainable growth rate adjustment)

For 2013, CMS estimates two-thirds of all discharges will be eligible for TCM, representing approximately 6,667,000 claims.  Using CMS’ assumption that 75% of those claims will be submitted under 99495, the 2013 TCM price tag will be approximately $1.34 billion (again, based on the 2012 conversion factor).  With beneficiaries responsible for the 20% co-payment, CMS expects to pay $1.1 billion for TCM. 

CMS estimates TCM will generate a 4% increase in payments to family medicine physicians, 3% each for internal medicine and pediatrics, and 2% each for gerontologists, NPs, and PAs.  By contrast, CMS estimates several specialists will see a 1% decline in payments due to increased TCM, including cardiologists, oncologists, OB/GYNs, and urologists. 

The following summarizes the requirements for billing TCM services:

Who is eligible to receive TCM services? 

Beneficiaries discharged from inpatient acute care hospitals (inpatient, observation, and outpatient partial hospitalization); skilled nursing facilities; and community mental health center partial hospitalization programs.

What is the time period for TCM services?

30-day period beginning on discharge date.

Who is eligible to bill for TCM services?

Physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse midwives (referred to as “qualified professionals”).  Rural health clinics and federally qualified health centers cannot bill for TCM.

Must the beneficiary be an established patient of the qualified professional ? 

Previously established relationship is not required. 

What are the required elements for TCM services?

(1) Communication with patient or caregiver within two business days of discharge (or two separate, unsuccessful attempts at communication).

(2) Face-to-face visit within fourteen days (99495) or seven days (99496)(cannot be performed on day of discharge; not separately billable; may be performed at any appropriate location; elements of visit not specified).

(3) Medication reconciliation and management performed no later than date of face-to-face visit.

(4) Non-face-to-face care management services (see next section for further explanation).

(5) Medical decision making of moderate complexity (99495) or high complexity (99496) (using E/M code definitions).

What non-face-to-face care management services are required?

The following services must be provided unless the qualified professional determines a particular service is not medically indicated or needed:

Performed by a qualified professional:  obtain and review discharge information; review need for, or follow-up on, pending diagnostic tests and treatments; interact with other providers involved in patient’s care; educate patient, family, guardian, and/or caregiver; arrange for needed community resources.

Performed by clinical staff or case manager under direction of qualified professional:   communicate with home health agencies and other community services utilized by patient; educate patient and/or family/caretaker regarding self-management, independent living, and activities of daily living; assess and support treatment regimen adherence and medication management; identify available community and health resources; facilitate access to necessary care and services.

When can claims for TCM services be submitted?

No sooner than 30 days following discharge.

Can multiple TCM claims be submitted for the same patient?

CMS will pay for only one TCM claim for the 30-day period following discharge.  .  The first claim to be filed will be paid.  CMS will not pay a second TCM claim in connection with a discharge that occurs within 30 days of the original discharge (i.e., if the patient is readmitted and discharged within the 30-day period. 

What are the limits on submitting claims for TCM services?

A qualified professional who reports a global procedure cannot bill for TCM services for the same time period. 

A qualified professional who bills for TCM services cannot bill for the following services during the 30-day period:                       

                Care plan oversight services (99339, 99340, 99374-99380

                Prolonged services without direct patient contact (99358, 99359)

                Anticoagulant management  (99363, 99364)

                Medical team conferences (99366-99368)

                Education and training   (98960-98962, 99071, 99078)

                Telephone services (98966-98968, 99441-99443)

                End stage renal disease services (90951 – 90970)

                Online medical evaluation services (98969, 99444)

                Preparation of special reports (99080)

                Analysis of data (99090, 99091)

                Complex chronic care coordination services (99481X, 99483X)

                Medication therapy management services (99605-99607)

With CMS set to begin paying for TCM in just over five weeks, now is the time for hospitals and physician groups to develop strategies and processes for delivering these critical services.  For example, developing an “extensivist” program to support TCM provides an excellent opportunity for collaboration between a hospital and its medical staff. 

PYA professionals are prepared to assist you in moving forward with your TCM program.  For more information, please contact Martie Ross, Denise Hall, or Rachel Harris.  



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Comments (11) Read through and enter the discussion with the form at the end
Michele Zinoman Baldwin LCSW-R - January 11, 2013 9:21 AM

Can a clinical social worker bill for TCM after their pt has been discharged from the hospital?

Tiffiny Reo - February 14, 2013 1:04 PM

Can a "certified geriatric care manager " Social worker or R.N working with physician practices as an extender of the practice (to better manage the first 30 days post discharge care in the home environment) also bill under these new codes? Or, Can the physician practice bill for the services of the geriatric care manager. The primary function of the C.M is to manage avoidable re-admissions, coordinate care and service providers, provide patient and family education and return the patient back to the PCP.
Can you provide information or where to find it on how these new service codes can work to support the physician practice without the physician making the house call. Consideration should be given to expanding the level of professionals able to utilize these codes. N.P's and P.A's are also becoming very difficult to find. Which does not help in seeing homebound patients timely.

Duane Brookhart - February 21, 2013 3:21 PM

Dear PY&A,

I have a question about our cardiology group's ability to provide TCM services to patients who received a procedure during a hospitalization. For example, suppose that a patient is admitted to the hospital for cardiology problems, and the patient has a pacemaker implanted prior to discharge. There is a global period related to the pacemaker implant. Can another provider in our group, such as a Nurse Practitioner, provide/get reimbursed for the TCM for this discharged patient? Or does the procedure global prevent any provider in our group from providing/being reimbursed for the patient TCM?
Thank you.

bill - March 13, 2013 7:10 AM

Hi, For CMS, do you have to use the 30th day after discharge for the non face to face DOS?

faith - March 21, 2013 8:54 PM

Is there a program to help me with my father who will be goig to assisted living and to help with the transition?

Martie Ross - April 4, 2013 11:54 AM

To Michele and Tiffany:

No, only MDs, DOs, APRNs, PAs, and CNSs may bill for TCM. Other providers may provide certain non-face-to-face services that are component parts of TCM.

Martie Ross - April 4, 2013 11:55 AM

To Duane:

CMS has not addressed this question directly, but it appears another provider in the practice could provide TCM, so long as the services are separate and distinct.

Martie Ross - April 4, 2013 12:03 PM

To Bill:

The service period runs through the 29th day following discharge. The reported date of service should be the 30th day.

Martie Ross - April 4, 2013 12:03 PM


Check with your primary care provider.

Loretta Smith - September 22, 2014 12:30 PM

How are practices handling billing for non-Medicare plans who will not cover TCM codes? For example, we know Tricare will not cover. How are you handling this in the workflow?

Tracy Book - March 2, 2015 11:20 AM

So it sounds like a RN Care Manager can provide the services but it has to be billed under the other providers MDs, DOs, APRNs, PAs, and CNSs? Is that the same for the Chronic Care services. Can an RN provide the telephonic care/consultation but bill under the above?

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