Recent CMS Rulings Simplify Payments for Transitional Care Management

In recent years, the use of care management services to provide better patient outcomes has gained momentum. Contributing to this momentum is a desire to generate greater transparency around patient behaviors in Post-Acute Care settings. This setting was the first focus area for the creation of care management services.

Over the last decade, several modalities of care management services have been established for payment by the Centers for Medicaid and Medicare (CMS), but uptake among all has been lower than expected. In response, CMS has issued recent legislation changes aimed at encouraging higher levels of provider participation.

Transitional Care Management (TCM) is a small but priority subset of managed care that focuses strictly on the 30-day period immediately following Post-Acute Care discharge. CMS’s recent ruling greatly impacted this area of managed care. 

Based on provider feedback, billing codes for TCM have been significantly overhauled to remove codes previously restricted as duplicative codes and to improve RVU for certain services. 

Here we review the establishment of managed care services, the defining rules of post-acute managed care, as well as the updates to payment methods set forth by CMS’s ruling for 2020.

Establishment of Care Management Services

Transitional Care Management was the first care management service to be set forth by CMS rules in 2013. It was followed by the establishment of Chronic Care Management, Remote Patient Monitoring, and Principal Care Management, the most recent service added January 2020. A succinct timeline of the service offerings is provided below:

Transactional Care Management Defined

Upon release of CPT Codes 99495 (Moderate Medical Decision Making) and 99496 (High Complexity Medical Decision Making) in 2013, CMS set forth general guidelines for what constitutes TCM. 

Regardless of complexity, an unequivocal requirement is that Interactive Contact be made within two business days of discharge. All unsuccessful attempts to make contact must be documented. The other guidelines are summarized below by the professional providing the care in a non-face-to-face setting:

Practitioner: 

• Obtain & review discharge information
• Review need for diagnostic tests and treatments
• Interact with health care professionals
• Educate
• Referrals
• Scheduling

Clinical Staff (under General Supervision):

• Agency and community service communication
• Educate re self-management, independent living, and daily activities
• Assess and support treatment regimen adherence and medication management
• Identify available community and health services
• Facilitate access to care and services 

While the above can be conducted via remote communications, each of the two codes require face to face encounter, the timing of which depends on the level of complexity.

99495 Moderate Complexity 

This code requires contact within two business days of discharge and documentation of all unsuccessful attempts, and additionally:

• A F2F visit is required within 14 days of discharge
• Medication Reconciliation and Management no later than F2F visit

99496 High Complexity

This code requires contact within two business days of discharge and documentation of all unsuccessful attempts, and additionally:

• F2F visit required within seven days of discharge
• Medication Reconciliation and Management no later than F2F visit

Recent Legislative Impacts on TCM

Upon executing the MPFS 2020 Final Rule, CMS set forth changes across the entire spectrum of care management to address provider feedback around low uptake. The following core changes concerning TCM were effective as of 1/1/2020.

Lifting of Restrictions on Duplicative Billing Codes

CMS has removed 14 Codes previously deemed as non-concurrently billable with Codes 99495 and 99496. 

At the outset of TCM in the 2013 MPFS Final Rule, 57 CPT/HCPCS codes were written into regulation as having significant “overlap” with TCM services and thus were not allowed to be billed alongside TCM.

Upon inputs from provider commentary and review with the AMA’s Chronic Care Coordination (C3W) Workgroup, 14 of those original 57 codes were carved out of the billing restrictions effective 1/1/2020. The codes which are now allowed to be billed alongside TCM are the following:

Increase in Work RVU for 99495 and 99496

Provider commentary has pointed repeatedly to the low valuation of the TCM Codes as a reason for lower than expected uptake. In the MPFS 2020 Final Rule, CMS addressed these concerns by increasing the Work RVUs for each of the two codes. Assuming a Geographic Practice Cost Index of 1.00, the following are the monthly reimbursement rates effective 1/1/2020:

• 99495: $175.76
• 99496: $237.11

Critical Criteria for Successful TCM Billing

There are a few additional key criteria to know in order to successfully bill for TCM:

• Know the Precondition of Care: The codes can be used following “care from an inpatient hospital setting (including acute hospital, rehabilitation hospital, long-term acute care hospital), partial hospitalization, observation status in a hospital, or skilled nursing facility/nursing facility.”
• Have A Single Provider for All Billing: Only one individual can bill per patient, so it is important to establish the primary physician in charge of the coordination of care during this time period. If there is a question, then it might be important to contact the other physician’s office to clarify. The discharging physician should tell the patient which clinician will be providing and billing for the TCM services.
• Applicable for only one 30-Day Period: TCM codes are payable only once per patient in the 30 days following discharge, thus if the patient is readmitted, TCM cannot be billed again.
• Patient Eligibility: The codes apply to both new and established patients.