Updates to TCM Services Coverage for 2020

March 2020

In the last edition of From the Field, we discussed the basics of Transitional Care Management (TCM). This edition will take a close look at this year’s new changes to TCM service coverage as well as a couple of TCM service frequently asked questions. In the 2020 CMS Physician Fee Schedule Final Rule published to the Federal Register, the Centers for Medicare & Medicaid Services (CMS), and US Department of Health and Human Services sites, a recent study of 2018 TCM claims data demonstrated that beneficiaries who received TCM services had reduced readmission rates and lowered mortality in addition to decreased healthcare costs. Additionally, the study showed that recent utilization of TCM services was low compared with the number of patients who would have qualified to receive TCM services. Based on this information, a move was made by CMS to increase utilization of TCM services.

During the first six years that TCM services were a billable, covered service, Medicare would not allow providers to bill for TCM services in conjunction with the services listed below during the TCM service period.

  • Care plan oversight services
  • Home health or hospice supervision
  • End-stage renal disease (ESRD) services
  • Chronic care management services
  • Prolonged evaluation and management services without direct patient contact
  • Other services excluded by Current Procedural Terminology Codes reporting rules

In their efforts to increase utilization of TCM services, CMS has loosened the restrictions on the codes that can be billed concurrently with TCM services by the same provider by allowing providers to bill concurrently for the services listed below, effective January 1, 2020.

  • ESRD services (for patients ≥20 years of age)
  • Complex chronic care services
  • Care plan oversight services
  • Prolonged services without direct patient contact
  • Home and outpatient international normalized ratio monitoring services
  • Analysis of Data

CMS has also increased the allowed reimbursement for TCM services. These changes are great news for nephrologists, as Medicare now allows an ESRD patient’s nephrologist to be reimbursed for both the Medicare Capitation Payment and TCM services during the same month.

While it is fantastic that CMS has made these changes, there has been little communication with the provider community regarding these specific changes. One significant factor that has caused confusion for providers and billing staff is the CMS TCM fact sheet. During my research for this article, I found that the most recently available CMS TCM fact sheet had a release date of January 2019.

Despite my best internet sleuthing efforts, I have come up empty handed on any details regarding billing specifics from CMS or the Medicare Administrative Contractors for providers billing concurrently for TCM services and the six services that are no longer excluded. As there is little documentation available regarding the billing and reimbursement specifics when providers bill concurrently for TCM services and ESRD services, providers may receive Medicare denials in error. Billing staff may find it helpful to familiarize themselves with the pertinent pages of the CMS 2020 PFS Final Rule. Being well versed in the 2020 updates may come in handy in the event erroneous denials are received for TCM services billed during the same month as ESRD services for the same Medicare beneficiary.


CMS TCM FAQs: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/FAQ-TCMS.pdf

CMS TCM Fact Sheet: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Transitional-Care-Management-Services-Fact-Sheet-ICN908628.pdf

CMS 2020 Final Rule: https://s3.amazonaws.com/public-inspection.federalregister.gov/2019-24086.pdf

TCM Services FAQs

In recent months, I’ve received many questions about the specifics of TCM services regarding two basic questions below.

Q: TCM services are only reimbursable by Medicare to one provider, per patient, per 30-day period following a discharge. How does Medicare determine who to pay if more than one provider submits a claim for TCM services for the same beneficiary?

A: The first eligible claim received by Medicare for TCM services will be reimbursed. As only the first claim is reimbursed, it is critical that TCM claims are submitted in a timely manner.

Q: In the event the patient passes away before the 30th day following discharge, can the provider still report TCM Services?

A: As the TCM services codes include 30 days of care, providers would not report TCM services in the event the patient passes away less than 30 days after discharge. However, providers may report any face to face visits that occurred under the appropriate evaluation and management code.