Transitional Management Codes Linked to Better Outcomes, Lower Costs

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ACP urges more members to start using these codes for Medicare patients

Sept. 21, 2018 (ACP) – The Transitional Care Management services that the American College of Physicians helped champion make dollars and sense, but usage remains low, according to a new study in JAMA Internal Medicine.

Transitional Care Management (TCM) codes, implemented by the Centers for Medicare and Medicaid Services in 2013, allow for reimbursement for specific types of care, within 30 days, for patients who are transitioning from an acute care setting back into the community.

The study found that patients who got TCM services had better outcomes and lower health care costs than patients who did not. Specifically, patients were less likely to be readmitted and less likely to die within 60 days of their discharge, and their health care costs were lower, too.

The study included roughly 18 million Medicare beneficiaries who would have been eligible for these services from 2013 through 2015.

Still, “despite the apparent benefits of TCM services, the use of this service remains very low and it is growing slowly,” the study authors wrote. Their analysis found that just 3.1 percent of eligible patients received TCM services in 2014 and 7 percent did in 2015.

“ACP was involved in getting these codes developed, valued, and paid for through Medicare, and having this study indicate that they are working is a really positive and exciting sign and something that we hope will encourage others to use these codes,” said Shari Erickson, ACP's vice president for governmental affairs and medical practice.

Internists tended to use the codes more than other eligible practitioners, Erickson said. For instance:

  • For TCM code 99495, which reimburses doctors for face-to-face visits within 14 days of the patient's discharge, the CMS data show that the agency was billed for 576,158 visits in 2017, and internists accounted for 45.25 percent (260,711).
  • For TCM code 99496, intended for face-to-face visits within seven days of discharge, the CMS data show it was billed for 546,526 visits in 2017. Of that number, Erickson said, internists accounted for 45.59 percent (249,161).

Still, she said, these services are not being used to the extent that the ACP had hoped.

Increasing usage starts with greater awareness about these services, she said.

“Some members may not even be aware of these codes, but others may be aware of the codes and just hadn't known their value,” Erickson said. “The new study shows that there is a lot of value in using these codes.”

Other factors may also contribute to the low usage rates, including an administrative burden associated with submitting claims. The study authors suggest that relaxing some of the paperwork requirements may help increase participation.

Currently, billing is supposed to occur 30 days after the patient's discharge, but the study suggested that allowing a physician to bill for TCM services at the time of an office visit might encourage wider use.

The study suggested that other obstacles include the requirement that a doctor contact a patient within two days of discharge but that discharge summaries can take up to three days to be disseminated. An outpatient physician may not even know about a patient's hospitalization or be able to reach the patient during this two-day time frame.

Another deterrent could be the reimbursement rate, which could be too low given the logistical challenges and administrative burdens, according to an editorial that accompanied publication of the study.

Reimbursement averages $145 per post-discharge episode, and “clinicians may not deem it enough to warrant the workload changes required to routinely deliver TCM services,” the editorial said.

To help troubleshoot some of the logistical challenges for its members, ACP offers a wealth of resources on its website pertaining to the TCM codes, how to use them and what to do in the face of a claims denial. This includes a sample document that practices can use to bill for TCM.

More Information

ACP's resources on TCM are available on the College's website.

The study, “Changes in Health Care Costs and Mortality Associated With Transitional Care Management Services After a Discharge Among Medicare Beneficiaries,” is available on the JAMA Internal Medicine website.

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Back to the September 21, 2018 issue of ACP Advocate