Transitional Care Management

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Posts: 45
Joined: Fri Aug 03, 2012 10:22 am

Mon Aug 06, 2018 5:21 pm

Hi. Is Medical Decision Making scored any differently for Transitional Care Management than for any other E/M service? For example, CMS lists the items pasted below as provider non-face to face services that are "components" of the TCM. Does this mean that for TCM we should not score 2 points for review and summarization of old records if the provider reviews the records for the hospital stay and summarizes those, since CMS lists reviewing the discharge summary/continuity of care documents as a "component" of TCM? Also, does this mean we should not score a point in Amount and/or Complexity of Data if the provider reviews and documents a lab value from the hospital stay in his note for the face to face visit post discharge? How about 2 points for discussing the case with another healthcare provider, such as a specialist also treating the patient, since CMS lists "interact with other health care professionals who will assume or reassume care for system-specific problems" as a "component"?

Based on the list below pasted from the CMS TCM MedLearn guide, are these activities "expected" to be performed as part of the TCM service, and if so, does that mean these activities should not be credited in the scoring of the Medical Decision Making for TCM services? Thank you for your help and please include authoritative source references with responses.

You must furnish non-face-to-face services to the beneficiary, unless you determine
that they are not medically indicated or needed. Clinical staff under your direction may
provide certain non-face-to-face services.
Services Furnished by Physicians or NPPs
Physicians or NPPs may furnish these non-face-to-face services:
™ Obtain and review discharge information (for example, discharge summary or
continuity of care documents)
™ Review need for or follow-up on pending diagnostic tests and treatments
™ Interact with other health care professionals who will assume or reassume care of
the beneficiary’s system-specific problems
™ Provide education to the beneficiary, family, guardian, and/or caregiver
™ Establish or re-establish referrals and arrange for needed community resources
™ Assist in scheduling required follow-up with community providers and services
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Mon Aug 20, 2018 9:20 am


It’s best to think of TCH this way. P4er the CPT definition of the CPT codes 99495 and 99496, “The medical decision making over the service period reported [the 30 days after discharge], is used to define the medical decision making of TCM”. It is calculated the same as any other E/M service, and the code is billed at the end of this period.

Pay particular attention to the date of the face-to-face visit. S an example, if a patient is high complexity, but the patient did not have a face-to-face visit within 7 days of inpatient discharge, the TCM will default to the lower code of 99495.

Your question has been answered by J. Paul Spencer, CPC, COC
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