Key Elements of Transitional Care Management

Key Elements of Transitional Care Management

What is transitional care management?

Transitional care management is the set of services provided to a patient to help them transition from being in a hospital setting to reintegrating into the community. The period for transitional care management is defined as the 30 days following post-discharge.

The goal of TCM is to prevent hospital readmission. As of 2013, Medicare allows for billing of 30 days of TCM, this is an opportunity for providers to earn additional income from services they may already offer patients.

What is a transitional care unit?

A transitional care unit or TCU is a skilled nursing facility. Most TCUs are located either inside a hospital or a nursing home. Patients in a TCU have been discharged from a higher care level unit or a facility such as an Intensive Care Unit (ICU).

The TCU serves as a bridge between the higher care level unit and going home to a situation where there will likely be less assistance. As part of the TCU services, patients receive a discharge comprehensive plan and at-home follow-up.

What does CMS transitional care management look like?

To bill Medicare (CMS) for transitional care management, it is important to meet all five of their TCM components.

Initial Contact

The first step is for the qualified professional to contact the patient or their caregiver within the first two business days following the hospital discharge. The contact must be documented in detail to include the date and time of contact, the name of the person initiating the contact, how the contact was made, and a summary of the contact.

Medication Management

The qualified professional has the responsibility to document the medication given at discharge and to reconcile it with pre-hospitalization medication.

This medication management activity must be documented in detail to include both lists of medication, the qualifications of the reviewer, and the decisions made, if new medications were prescribed that list must also be included.

In-Person Visit

Within the first 7 days following the discharge, the qualified professional must visit the patient in person. The visit must be documented in detail.

Level of Decision-Making

TCM requires certain levels of decision-making for the 30 days following discharge. The medical decision-making varies from moderate to high complexity depending on the code.

Care Management Services That Do Not Require Face-to-Face Interactions

The requirements of this component are not as strict as the other ones, there is no set number of required interactions or a time requirement for giving these TCM services.

However, Medicare does have a list of services that must either be fulfilled by the qualified professional or clinical staff unless the services are determined not to be medically necessary. Again, this must be documented in detail.

To learn more about TCM, read: A Guide to Transitional Care Management.