Overcoming Transition of Care Management (TCM) Visit Challenges

While there is a lot of literature written about the benefits of a transition of care management visit (TCM) for patients, practices, and ACOs, why aren’t more providers billing for these visits? Unfortunately, there are a number of challenges related to completing a successful TCM. Let’s explore the Top 5 challenges, followed by some key solutions to help address this highly beneficial visit.

  1. The physician is not notified, or not notified in a timely manner, that their patient was discharged from the hospital or skilled nursing facility.

    While you may have the best intentions to complete the TCM visit for your patients, your practice is unable to do so if you’re unaware that the patient has recently been discharged from the hospital or SNF. While an Admit, Discharge, and Transfer (ADT) feed may help you to become more aware of the hospital discharges, and capture a large majority of the patients, you may still run into issues if notifications are delayed. There’s also the possibility that the facility from which your patient has been discharged isn’t connected to a state-wide Health Information Exchange (HIE). There are a few things that you can do to mitigate these issues.

    First, create a process to monitor your hospital discharge notifications daily. You should be reaching out to discharged patients on a daily basis for TCM follow ups. You will immediately notice a drop in your volume if the notification process is delayed, and you can alert your HIE of the issue immediately. Most HIEs are able to mitigate these issues quickly if they are alerted to the problem. This way, while you may not reach out to the patient within the first day after discharge, you will still be within the 2-day window for TCM outreach.

    Let’s assume that your patient was discharged from the hospital (and you received the ADT notification in a timely manner), but they were discharged to a Skilled Nursing Facility (SNF). Many SNFs aren’t connected to an HIE feed. In this instance, you may want to create a process whereby you begin to form relationships with the SNFs for increased visibility. When a patient is discharged from the hospital to the SNF, the SNF will reach out to the practice to alert them of the transition. The practice will send a patient summary sheet that includes the patient demographics, patient medication list (for medication reconciliation), patient health history, patient social history (such as whether the patient has caregiver support). This will help the SNF identify an accurate (and sometimes quicker) discharge date. The SNF and practice will stay in close communication, and the SNF will schedule the patient TCM appointment before the patient is discharged from the facility. The increased communication will help to improve patient care and close care gaps. Upon discharge, the practice will complete the required TCM outreach, and confirm the TCM appointment date. The information that is exchanged between the SNF and practice is tracked by the practice, including: patient SNF admission date, patient potential discharge date, patient actual discharge date, diagnosis, etc.
  2. Your practice attempted to reach the patient, but unfortunately, they were unable to reach them within the 2-day timeframe.

    Remember, while you might not be able to reach the patients within the 2-day timeframe, it’s good practice to leave a message (make sure it’s HIPAA compliant) and document your outreach in your electronic health record. Many high-risk patients are too sick to pick up the phone, so it’s really important that you continue to reach out to them. You may want to try calling at different times each day. Perhaps the patient takes an afternoon nap and doesn’t hear the phone, or they have plans during the day. If you have the contact number of a family or caregiver, you may try calling them as a safety precaution.
  3. The patient is unable to travel to the office for their TCM appointment due to lack of transportation or too ill to travel.

    These are high risk patients are precisely the patients that are most likely to be readmitted to the hospital. These patients don’t usually have a lot of caregiver support, and because they lack transportation services to get help before their health rapidly declines, they are highly likely to call for an ambulance ride back to the hospital as their conditions worsen. Many practices have implemented home visits, and some have even hired Nurse Practitioners to lead the effort (usually done once per week). If your practice is not able to do home visits, you may consider partnering with a home health agency to be the eyes and ears in the home. Home health visits, especially following a discharge, can prevent readmissions if done effectively and in coordination with the primary care physician.
  4. The patient missed/no-showed their TCM appointment.

    In many cases, these patients are likely a subset of the patients that I described in challenge #3! While these patients scheduled their appointment, they are high risk patients that either lack transportation services or got too sick to come in for their TCM visit (a very small number of them simply forgot their visit). Your practice can consider flagging patients that missed their TCM appointment and create a new process where a clinician reaches out to these patients.
  5. Your practice completed the TCM, but an Evaluation & Management (E&M) visit was billed instead of the TCM.

    I’ve heard many practices say that they spent a lot of time with their patients that were recently hospitalized, and while they completed all of the TCM requirements, they choose to bill for a level 5 E&M rather than the TCM billing codes because of higher reimbursement. The reimbursement for the TCM is approximately 2 times higher than a level 5 E&M visit. The reason many practices don’t bill the TCM is because of the documentation and billing burden. Historically, practices held their claims during post-discharge period since the TCM covers 30 days of management services with one evaluation service bundled into the code. The date of service on the claim would be the 30th day post-discharge. Starting January 2016, the practice can bill for the TCM much sooner- the date of service on the claim is the date of service for the face-to-face visit. However, the practice is still responsible for tracking whether the patient is readmitted within 30 days because if the patient is readmitted, they can’t bill for the TCM when the patient is discharged for the second time. Secondly, practices cannot bill for a TCM and CCM (chronic care management) services within the same month. However, many high-risk patients enrolled in CCM are precisely the same patients that are hospitalized. This creates some confusion from an operational perspective.

    While there will always be administrative and operational challenges with TCM billing, there are certainly significant benefits to patients, practices, and ACOs. The TCM helps the patient by closing gaps in care during transition, keeps the patient out of the hospital, and enhanced the patient-physician relationship. The physicians also benefit from the strengthening of the patient-physician partnership, but the TCM creates a sustainable revenue stream for the practice. As an ACO, it’s important to encourage practices to complete at least 70% of TCM visits to reduce readmissions.

What challenges does your practice face with rendering TCMs? How have you tackled these challenges? We would love to hear your input!

Maria Nikol

About the Author


Maria Nikol

Maria Nikol is a senior business consultant with 10 years of experience in healthcare operations and healthcare strategy. Her specialization includes process improvement and the application of emerging models of healthcare delivery such as Patient-Centered Medical Homes and Accountable Care Organizations. She holds a Master of Jurisprudence in Health Law from Widener University and a Bachelor of Science in Pharmaceutical Marketing and Management from the University of the Sciences in Philadelphia.

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