Transitional Care Management Services: Ensuring Smooth Transitions of Care

Transitional Care Management Services

What are Transitional Care Management Services?

Transitional care management (TCM) services refer to the coordination of care and exchange of information as patients transition between different healthcare settings, such as from a hospital to home or to a skilled nursing facility. The goal of TCM services is to prevent medical errors, reduce the risk of re-hospitalization, and ensure continuity of care as patients move between different providers and levels of care.

TCM services involve several important activities and responsibilities to help support patients during care transitions:

Communication between healthcare providers - Key members of the care team communicate effectively  Transitional Care Management Services with each other to coordinate care needs, treatment plans, pending tests or follow-up appointments as patients transition between settings. This helps ensure continuity of care.

Medication reconciliation - A review of the patient's medications is conducted to identify any discrepancies or potential issues that need to be addressed. Medication lists are updated and reconciled across different providers and care settings.

 Care plan development - A comprehensive care plan is collaboratively developed with the patient's input to outline treatment goals, prescribed medications and treatments, scheduled follow-up appointments, expected recovery timeline, warning signs to watch out for, and other important care instructions for managing care at home or in another setting.

Patient education - Patients and caregivers are educated on their diagnosis, care plan, medication instructions, upcoming appointments and follow-up care needs. This education helps them better understand, navigate and participate in their ongoing care.

Access to care team - Contact information is provided so patients can easily reach their care team members with any questions or concerns that arise after discharge from a facility to their next site of care.

Monitoring and follow-up - Patients are contacted within two business days of discharge to their new site of care to ensure they understand their care plan and address any initial concerns or needs. Additional follow-ups per CMS guidelines help monitor patients and prevent avoidable readmissions.

Who Provides Transitional Care Management Services?

TCM services can be provided by various qualified healthcare professionals, including:

- Physicians - A physician practice overseeing a patient's care may take the lead in coordinating TCM activities like communicating with other providers, reconciling medications, developing care plans and monitoring patients post-discharge.

- Nurses - Registered nurses play a key role in areas like patient education, medication teaching, conducting post-discharge follow-ups by phone, and assisting with care plan development and implementation.

- Social Workers - Social workers help coordinate care needs that extend beyond direct medical care, including addressing any psychosocial or discharge planning needs.

- Physician Assistants - PAs can assist physicians by conducting medication reconciliation, participating in care plan development, conducting post-discharge follow-ups, and more.

- Pharmacists - Pharmacists utilize their medication expertise area to aid areas like medication reconciliation and ensuring patients understand new or changed medication regimens.

Ultimately, TCM requires coordinated, team-based efforts from various qualified healthcare professionals to effectively transition patients between care settings.

Benefits of Transitional Care Management Services

Providing structured TCM services for patients moving between care sites has several important benefits:

- Reduced Hospital Readmissions - Strong communication, medication management, care plan oversight and monitoring post-discharge can help address issues early on before they warrant an unnecessary readmission. Studies show TCM reduces 30-day hospital readmission rates significantly.

- Improved Health Outcomes - With better supported care transitions, medication adherence increases and patients are empowered partners in managing their health at home. This continuity results in more positive health outcomes overall.

- Increased Patient Satisfaction - When patients understand expectations moving forward, know who to contact with questions and feel their concerns are addressed, satisfaction with care received improves greatly.

- Cost Savings - Preventing avoidable readmissions through TCM not only leads to better quality of life for patients but also significant healthcare cost savings by reducing utilization of higher-intensity, more expensive settings of care like hospitals.

- Alignment with CMS Goals - Providing documented, billable TCM services helps practices meet CMS requirements for care transitions to reduce readmissions and participate in value-based payment programs emphasizing quality over volume.

Transitional Care Management Billing and Coding

To bill Medicare and other insurance payors for transitional care management services provided to patients, healthcare providers should use the following CPT codes:

- 99495 - TCM services for moderate complexity patients with medical decision making of moderate complexity during the transition period.

- 99496 - TCM services for high complexity patients with medical decision making of high complexity during the transition period.

In addition, diagnosis codes must be documented identifying the principal diagnosis that was treated during the inpatient/outpatient stay. Time spent providing qualifying TCM services must meet the 30-minute minimum for 99495 or 60-minute minimum for 99496. Proper documentation of services in the medical record is also required by payors.

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