CMS increases payment and removes billing restrictions for TCM services
In an effort to increase the medically appropriate use of transitional care management (TCM) services, CMS increased payment and removed billing restrictions for TCM services, as outlined in the 2020 Medicare Physician Fee Schedule (MPFS) final rule.
TCM services are provided to patients with medical and/or psychosocial problems requiring moderate or high-complexity medical decision-making following discharge from certain facilities. In the final rule, CMS describes a study conducted by Andrew Bindman, MD, and Donald Cox, PhD, in 2018. The study showed that Medicare beneficiaries who received TCM services demonstrated reduced readmission rates, lower mortality, and decreased healthcare costs. The results also indicated low utilization of TCM services relative to the number of beneficiaries with eligible discharges.
In response to these findings, CMS took steps to increase the use of medically necessary TCM services in 2020 by increasing the payment amount to physicians for these services. CMS increased MPFS payment for the following CPT® codes:
- 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
- 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
Effective January 1, payment for CPT code 99495 increased from $166.50 to $175.76, and payment for CPT code 99596 increased from $234.97 to $237.11.
CMS also removed billing restrictions for TCM services. Starting January 1, providers may bill TCM services with 14 HCPCS codes that were previously restricted from being billed with TCM. These 14 codes include those for end stage renal disease treatment, complex chronic care management, and prolonged services without direct patient contact, and are listed in Table 20 on p. 394 of the final rule.
Notably, CMS has established both a facility and non-facility MPFS payment for TCM services; providers should report TCM services with the place of service code appropriate for the face-to-face visit.
For more information on TCM services, see this CMS fact sheet.