The Transitional Care Management Opportunity

When and how do you find out your patient was hospitalized?  When they are admitted?  Discharged?  Only if you remember to log into a hospital portal?  Or when your patient shows up and tells you? And what does your practice do when they find out?  The number-one predictor as to whether that patient ends up readmitted to the hospital within 30 days is the number of chronic conditions a patient has.   And both the PCP and the hospital have big incentives to get this post-acute care follow-up right for all higher risk patients.

Medicare has made a number of programs and codes available to help physicians deal with the added time, cost and effort of keeping this risky and expensive population out of the hospital and addressing their chronic illnesses.  They are designed to focus on the riskiest period of transition--the first ten days after discharge, when 60 percent of the readmitted patients end up back in the hospital.

Transitional Care Management (TCM) is an infrequently used Medicare charge  (CPT 99495 and 99496) that incents the physician to follow up in a timely fashion and recognizes that it is considerable work to do so.  That’s why the average reimbursement for such a visit is $166, almost double the average extended care office visit.  And TCM visits also help improve quality metrics for both physicians and hospitals, that affect Value-Based Purchasing and the Physician Value-Based Modifier that will affect 2016 payments for 85% of physician and hospital billing.  Finally, timely check-ups including medication review with patients post-hospitalization has proven to reduce 30 day readmissions.

Using some broad averages, this can mean potentially $27,000 a year to the average family medicine practitioner per annum for something that physicians want to make time to do. That is roughly the same amount that is available through the new CCM code, 99490, but doesn’t require patients to sign off and have separate billing and compliance, and is well within the scope of all certified EHR’s.

Patient Panel

% Medicare patient

Average Hospitalizations of Medicare Panel*

Transitional Care Reimbursement

Total Potential Dollars



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Medicare payment records for 2014 show only 20% of patients discharged from acute hospitalization subsequently showed Transitional Care Management visits post hospitalization (Not all Medicare patients discharged from hospitals are eligible for TCM, but there is a 92% correlation between high risk patients and hospitalizations, according to Medicare.). As with all averages, the broad average hides a wide variance in what is happening behind the scenes.


The promising news is that Medicare data shows that the highest risk patients (those with 6 or more chronic conditions) are getting at least one-post acute care visit  50% of the time (not necessarily TCM), but there is a much bigger gap for other groups of patients.  The size of this gap becomes even more meaningful when you look at the absolute number of Medicare patients that fall in each risk category.

A different view shows this gap more clearly.  There are many more patients with 2-5 chronic conditions than >6, and only 19% of them are receiving post acute care.

So why don’t physicians take advantage of the Transitional Care Management Code if it helps not only their patients, but adds revenue and helps with physician and hospital risk scores? Some of the reasons include:

  • Not having a full understanding of code
  • Not having timely notification of when patients are released from hospital
  • Not having the staff to make follow up calls
  • Not having the workflow tools to ensure compliance

In the future we will explore these barriers in more depth and suggest ways to take more full advantage of this code.