Numerous studies reflect that, when done properly, Transitional Care Management (TCM) decreases readmissions and mortality; as well as healthcare costs overall. Not surprisingly, our clients are, to varying degrees, all striving to refine their processes around TCM to realize these benefits and positively impact the communities which they serve. Unfortunately, building a program around TCM (and the utilization of these codes) requires alignment of several variables and has proven to be a challenge for our clients. Interestingly, this struggle is shared nationally, and in response, CMS has increased reimbursement for TCM services per the 2020 Medicare Physician Fee Schedule (MPFS).

99495, TCM services with the following required elements:

• Communication (direct contact, telephone, electronic) with the patient and/or caregiver within two business days of discharge
• Face-to-face visit, within 14 calendar days of discharge
• Medical decision-making of at least moderate complexity during the service period
• Now reimbursed at $175.76 (á 5%) for 2020

99496, TCM services with the following required elements:

• Communication (direct contact, telephone, electronic) with the patient and/or caregiver within two business days of discharge
• Face-to-face visit, within seven calendar days of discharge
• Medical decision-making of high complexity during the service period
• Now reimbursed at $237.11 (á 1%) for 2020

A client story;

HealthInsight.org tells us that 20% of discharged Medicare patients are readmitted within 30 days, and 76% of those are determined to be the result of poor Care Transitions. The client in this story is a large system that discharges 120,000 patients annually, of which, roughly 50% are Medicare. If we assume that 80% of our client’s discharged Medicare patients were seen appropriately for TCM, and that the distribution for 99495 and 99496 is split evenly, then we target TCM reimbursement at $9.8M. However, our client received approximately $2M in reimbursement for 99495 and 99496 last year. While these are rough estimates, the discrepancy is highly suggestive that opportunity exists.

We believe our client is performing appropriate Transitions of Care efforts to lower readmissions and improve patient outcomes. The gap, we suspect, is driven by the provider’s confidence using TCM codes. To support this notion, we’ve heard from providers that using these codes requires additional chart searching and time consuming evaluation to determine if TCM criteria have been met.

Does this sound familiar? This is where The Wilshire Group can help with our Clin-to-Fin methodology. We combine Revenue Cycle leaders with experts in customizing Epic’s clinical modules to close these gaps. Send us an email, and we’ll be happy to explain our approach for helping this client improve TCM utilization and reimbursement.