TCM Follow-up

I can bill all discharges with Transitional Care Management codes.  They’re all moderate complexity”

Recently, a client wrote to me about a physician who wants to use the Transitional Care Management (TCM) codes for all discharges.  The physician stated that all patients who were discharged from the hospital had at least moderate complexity on the day of discharge and so should be eligible for TCM.   (If you are still wondering about the requirements for reporting TCM, you can read the article I wrote about it, the comments and download Medicare’s FAQ  at  Wondering about TCM codes?

I don’t like to disagree with doctors, but I had to disagree in this case.  While it is true that most patients admitted to the hospital will still be moderately or highly complex on the date of discharge that is only one requirement for reporting TCM.  (If you read the article, you will remember that one key difference between the two TCM codes is complexity, moderate or high, selected by whether the patient has moderate or high complexity any time during the TCM period.  The TCM period starts the day of discharge and continues for 29 days. This is determined using the medical decision making criteria in the Documentation Guidelines).  The codes also require that the patient have medical or psychosocial problems that require extra work during a transition from inpatient, observation, partial hospitalization or nursing facility to home, domiciliary care, assisted living or rest home.  There must be a need for both a face-to-face service and non-face-to-face care coordination for the patient.

The CPT book lists the types of care that might be needed.  These include:

• Communication with patient and/or caregivers
• Communication with home health or other community services
• Education to support self-management
• Assessment and support for following the treatment regimen
• Identifying resources the patient will need to maintain independence and follow the treatment plan
• Facilitating access to care and services

This is in addition to reviewing the discharge summary and follow up diagnostic tests.  The physician or staff may also need to interact with other healthcare professionals, make referrals, educate the patient and/or family and assist in scheduling community and healthcare follow up.  It is insufficient review the discharge summary and see the patient in follow up and then to report TCM services unless additional non-face-to-face services are required. 

Examples of cases that will not require TCM:

• Patient admitted to observation for chest pain, ruled out, home without any community resources or additional referrals
• Patient admitted with pneumonia, treated, discharged on oral meds.  Follow up with PCP arranged, but no other referrals, home care, community care or health care arranged.  No need for non-face-to-face education.  Patient able to return to independent living at home.
• Patient with fracture, surgical treatment, discharged home.  Outpatient PT arranged at time of discharge.  No other follow up or referrals needed.

Transitional Care Management codes are not for every discharge.  They are for patients who have complex medical and psychosocial problems who need community resources, education and extra care to help in the transition from a facility to home.