Transitional Care Management: Reimbursement of Non-Face-To-Face Services

As of January 1, 2013, the Medicare Physician Fee Schedule includes reimbursement for transitional care management (TCM) services from the hospital to the community setting.  The two relevant codes are 99495 and 99496 and apply to physicians and other qualified non-physician professionals.  The goal of this investment is to generate savings from a reduction in the number of re-admissions.

While this new approach to reimbursing for care is truly welcome, the inclusion of non-face-to-face care management services is an opportunity to leverage enterprise portals and social technologies to facilitate these processes.  The following services are required be provided unless they have been determined to not be medically necessary:

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.

Now is the time for innovative providers to develop new processes and create strategies for leveraging technologies to support delivery of these important and reimbursable services.

For a detailed summary of the billing requirements for TCM, visit the PYA Healthcare Blog and CMS FAQs.