Transitional Care

Are you aware that you can receive reimbursement from Medicare through your MAC for Transitional Care Management?

Some of the components to meet criteria for a Transitional Care Management office visit are provided. We have also provided the web sites you can go to learn additional information.

See the References at the end of this short list of information.

Components of Transitional Care Management:

  • Patient discharged from an inpatient hospital setting
  • Patient has gone “home” to residence, Board and Care or Assisted Living facility.

Timing: Within 30 days from the inpatient discharge, the following must be furnished:

  • Direct contact with the patient within 2 business days of discharge.
  • A face to face visit with physician or NPP within 7 days after discharge OR within 14 days after discharge. (This visit is not to be reported separately.) Include the required Medication Reconciliation and Management portion by the date of the face to face visit.
  • Certain other non-face-to-face services may be provided by either a physician OR other licensed clinical staff. (eg. identify available community and health resources, teach beneficiary and/or caregivers about activities of daily living or self-management, communicate with home health or community services used by beneficiary).

Billing for Transitional Care Management Services:

  • CPT Code 99495 with Face to Face visit with Moderate Complexity Medical Decision Making within 14 day of discharge-paid at approximately $187.00.
  • CPT Code 99496 with High Complexity Medical Decision Making Face to Face visit within 7 days of discharge-paid at approximately $262.00.

Moderate Complexity Medical Decision Making:

  • Multiple diagnoses or management options,
  • Moderate amount and /or complexity of data to be reviewed,
  • Moderate risk of significant complications, morbidity, and/or mortality.

High Complexity Medical Decision Making:

  • Extensive number of diagnoses or management options,
  • Extensive amount and/or complexity of data to be reviewed,
  • High risk of significant complications, morbidity, and/or mortality.

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