Reducing Readmissions through Transitional Care Management


Reducing hospital readmissions has been a focus of the Centers for Medicare and Medicaid Services ("CMS") for some time now and particularly since the enactment of the Hospital Readmission Reduction Program ("HRRP") in 2012. In addition to increased costs, avoidable hospital admissions expose patients to the potential for infections, medication errors, and other hospital acquired conditions. Like other value-based payment mechanisms, the HRRP is intended to help improve healthcare by linking payment to the quality of care.

Among the various approaches employed to reduce hospital readmissions, one that has shown promise is transitional care management ("TCM"). TCM involves a provider taking responsibility for the care of a patient for a 30 day period following discharge from an inpatient stay at an acute care hospital, inpatient psychiatric hospital, long term care hospital, skilled nursing facility, inpatient rehabilitation facility, hospital outpatient observation or partial hospitalization, or partial hospitalization at a community mental health center. TCM patients may be new or established patients whose conditions require moderate or high complexity medical decision-making.

Those who may provide transitional care are physicians of any specialty, nurse practitioners, certified nurse midwives, clinical nurse specialists, and physician assistants. The goal of TCM is to provide the patient with medical follow-up, education about his or her care going forward, and assist in marshalling community resources that the patient may need to successfully transition from the hospital back to the patient's community setting.

The definition of a community setting for TCM includes single family homes, apartments, and assisted living facilities, among others. Although TCM may be provided to patients discharging from a skilled nursing facility, it does not apply to a patient being discharged to a skilled nursing facility.

Under TCM, the provider must make an interactive contact with the patient or the patient's caregiver within two business days of the patient being discharged. The contact, which may be by telephone, email, or face-to-face, addresses the patient's status and needs beyond scheduling follow up care. If two or more unsuccessful attempts to contact the patient or caregiver are made in a timely manner, the attempts should be documented in the patient's medical record and efforts to make contact should continue until successful.

Once the initial interactive contact is made, the provider must make a face-to-face contact with the patient within either seven or 14 days, depending on the medical complexity of the patient. Moderate complexity patients must be seen within 14 days and high complexity patients must be seen within seven days. The patient's medications must be reconciled so that the provider has an accurate list prior to the required face-to-face visit.

In addition to the face-to-face visit, the provider must: obtain and review discharge information; review the need for follow up diagnostic tests and treatment; coordinate with other health care professionals who will care for specific patient issues; educate the patient, family, and caregivers; and assist in scheduling follow-up community services. Some of these services, such as education and arranging for other professional or community services may be performed by the provider's clinical staff under the provider's supervision.

TCM services are billed under CPT codes 99495 and 99496, depending on the complexity of the patient's condition. Each TCM code represents payment for the entire 30 day transitional care period and includes payment for one face-to-face visit. Only one provider may report TCM services during the transitional care period.

Where additional evaluation and management services are required beyond the face-to-face visit bundled with the TCM code, those may be reported separately. The following services may not be reported during the TCM period: care plan oversight services; home health or hospice supervision; end stage renal disease services; chronic care management; and prolonged evaluation and management services without direct patient contact, among others.

TCM helps to insure that patients have continuity of care upon discharge from a hospital or other health care facility. The continuity of care provided under TCM can improve the efficacy of post-discharge care for moderate or high complexity patients and improve their sense of well-being, all of which can help to reduce hospital readmissions.

James Henry is a partner with the law firm of Cabaniss, Johnston, Gardner, Dumas & O'Neal LLP. He represents providers in all aspects of healthcare law, including regulatory, entity formation, purchase and sale of entities, professional discipline, Certificate of Need, reimbursement, physician contracts, and others. He may be reached at 205-716-5257 or


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Dumas & O’Neal LLP; Transitional Care Management; Centers for Medicare and Med, Gardner, James Henry; Cabaniss, Johnston


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