Understanding The Importance of Billing for Transitional Care Management

Patients that tend to suffer from high complexity or moderate complexity medical issues after being discharged from the hospital have a critical time frame of 30 days. Within this period of time, the chances of getting readmitted to the hospital tend to increase if the right kind of transition is not made. Quality care is also crucial during this part. It is during this period of time that transitional care management (TCM) comes into play.

What Is Medicare Transitional Care Management (TCM)?

What is Medicare Transitional Care Management (TCM)?. Transitional Care Management (TCM) services address the hand-off period between the inpatient

The services rendered between the community setting and inpatient setting refers to Transitional Care Management (TCM). After the patient completes their in-patient (such as in a nursing facility) or hospitalization stay, it might so happen that the patient starts to suffer from another medical crisis. They could also experience a reaction to any of the medication or even have another new diagnosis that must be taken care of. It is the family physicians who tend to manage the transitional care of the patients.

How Much Does Medicare Pay For TCM?

The transitional care management services get covered by Medicare when you are coming back home from any skilled nursing facility or a hospital. Medicare tends to cover the TCM services for a period of 30 days after returning from any medical facility. After meeting the required part from Medicare deductible, 20 percent of the coinsurance (i.e the cost of the services approved by Medicare) must be paid by the patient or the patient party. 

The NLM (United States National Library of Medicine) says that transitional care management services tend to be a requisite for senior citizens that suffer from chronic illnesses such as diabetes, arthritis and cancer. TCM is also quite useful for those patients recovering from any distressing condition such as a stroke. 

Does Medicare Cover Transitional Care Management Services?

Does Medicare Cover Transitional Care Management Services?

Qualifying for transitional care management services requires a patient to stay in:

  1. Rehabilitation facility


  2. Any skilled nursing facility


  3. Hospitals (only for in-patients)


Similar to any of the accessible medicare services, transitional care management must also be a medical requirement in order to be covered. If that is the case then the patient would have to pay the copayment after meeting with the Part B deductible. Medicare part A takes care of the payment for the services during the hospital stay, therefore transitional care cannot be covered by Medicare part A.  

The beneficiaries have the alternative coverage option which is also referred to as the Medicare part C. These medicare plans include both Part A and Part B of the Medicare plan. Therefore, the patient is bound to receive at least a minimum or a similar level of coverage from the original medicare plan. 

Part C of the Medicare plan includes all of the expanded coverage along with the added benefits for a variety of the services that Medicare tends to offer.

Transitional care management lasts for a period of 30 days after being discharged from a medical facility, it, therefore, covers a myriad number of services in order to help the patient adjust to the surroundings of their home. A healthcare provider is bound to help the patient in managing the problems and transition properly with their caretaker or family in order to ensure everything is effective and smooth. 

An in-person visit to the office after returning home within a period of 14 days is also common. The medical provider who oversees the transition of the patient will also be responsible for the treatments and the medications as and when required. This includes an arrangement or scheduling of follow-up services or medical care as and when needed.  

The patient also remains entitled to chronic care management which refers to another kind of service that Medicare tends to cover for all those patients who are suffering from different chronic ailments. 

If transitional care is not mismanaged it can lead to a significant impact on the health of the patient. According to NLM, changing the locations of the patients after receiving medical care can result in miscommunication if the TCM services are disorganized.

Transitional Care Management Procedure Codes

Under the PFS (Physician Fee Schedule) which has been effective since January 1, 2013, medicare pays for two procedure codes. CPT codes 99496 and 99495 are used in qualifying non-physicians or reporting physician practitioner care management services for the patients who are getting discharged from CMHC stay, SNF stays or even a hospital stay.   

  1. 99495 CPT Code takes care of the communication part with the caregiver or patient within a period of two working days after the patient gets discharged from the hospital. This process can be completed either in-person, by email or via phone. This involves decision-making of the medical nature after the patient gets discharged within a period of 14 days. The decision making is of moderate complexity. The location is not written in a specific manner.
  2.  99496 CPT Code takes care of the communication between the caregiver and the patient within a period of two working days after getting discharged. This procedure can either be in-person, e-mail or via phone. This includes decision making of medical nature that is highly complex in nature. It occurs within a period of seven days after getting discharged. 


Coding Guidelines for CPT Codes

CPT codes are maintained and copyrighted by the American Medical Association and are the United States standard for how medical professionals document and report medical services.

When billing for transitional care management is done these are the coding guidelines that must be followed;   

  • Medical management or reconciliation must happen right after the face-to-face visit and not later than that.
  • The CPT codes must not be used alongside a home health care plan (G0181) or hospice care plan (G1082) since the services tend to be duplicable.
  • The billing process must be concluded after the discharge period of 30 days is complete.
  • The bills are payable in nature only per patient during the time of 30 days discharge, therefore if the patient gets readmitted the TCM cannot, therefore, be rebilled.


One individual bill for each patient is allowed, therefore it is crucial to know about all the details from the primary medical caregiver who has been in charge of the coordination process during the TCM time period. The TCM coding applies both for the established and new patients. 

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