Obtaining PCP Reimbursement for Post-Discharge Transitional Care Management

If you are a primary care provider, you may be pleased to learn that Medicare will begin providing reimbursement for post-discharge transitional care management (TCM).  In particular, Medicare will pay providers between $163.91 and $230.90 for care provided in a non-facility setting (assuming that Congress acts to prevent the 26.5% cut).

Other authors in this forum have provided a great high-level overview of the TCM reimbursements (i.e., 99495 and 99496) and the rationale that undergirds them, so we will not retread that ground in this blog.  Instead, we’ll focus on the three simple components that must be satisfied to obtain reimbursement.

  1. In the case of 99495, the decision-making required during the 30-day post-discharge transition period must be of moderate complexity and for 99496, the decision-making required during the 30-day transition period must be of high complexity
  2. An initial telephonic, electronic or in-person communication must occur with the patient or caregiver within 2 calendar days of discharge
  3. A face-to-face visit must occur within either 7 days (for 99495) or 14 days (for 99496)
  4. Only one provider may obtain TCM reimbursement per discharge, so you need to be the first provider to have a claim submitted and processed