Care Model Eligibility – CMS Transitional Care Management Model

Patients who have been discharged with moderate or high complexity levels from an inpatient hospital setting to their community setting.

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Patient Segment Eligibility Description Data Source
Patients discharged from inpatient facility Patients who have been discharged with moderate or high complexity levels from inpatient care at a hospital to their community setting Claims:

  • Claim type code to determine if discharged from inpatient stay
  • Procedure HCPCS code to determine if moderate or high complexity
  • Stay discharge status code to deter
Patients discharged from skilled nursing facility (SNF) Patients who have been discharged with moderate or high complexity levels from a SNF to their community setting Claims:

  • Claim type code to determine if discharged from SNF
  • Procedure HCPCS code to determine if moderate or high complexity
  • Stay discharge status code to determine if discharged to community setting (e.g., home or home care)
Patients discharged from outpatient observation Patients who have been discharged with moderate or high complexity levels from an outpatient observation to their community setting Claims:

  • Claim type code to determine if discharged from outpatient observation
  • Procedure HCPCS code to determine if moderate or high complexity
  • Stay discharge status code to determine if discharged to community setting (ex. home or home care)

Care Model Implementation – CMS Transitional Care Management Model

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Time Frame Action
Trigger event Beneficiary discharged from an inpatient hospital setting to his or her community setting
Within 2 business days of trigger event Contact made via telephone, email or face-to-face

  • If two or more separate attempts are made and documented in the medical record but are unsuccessful, and if all other TCM criteria are met, TCM may still be billed
Within 7 days of trigger event For beneficiaries with high medical decision complexity:

  • Face-to-face visit
  • Medicine reconciliation and management (before or during face-to-face visit)
Within 14 days of trigger event For beneficiaries with with moderate medical decision complexity:

  • Face-to-face visit
  • Medicine reconciliation and management (before or during face-to-face visit)
Within 30 days of trigger event Physicians or non-physician providers (NPPs) must furnish the following non-face-to-face services, unless they are not medically indicated or needed:

  • Obtain and review discharge information
  • Review need for or follow-up on pending diagnostic tests and treatments
  • Interact with other health care professionals who will assume or reassume care of the beneficiary’s system-specific problems
  • Provide education to the beneficiary, family, guardian, and/or caregiver
  • Establish or re-establish referrals and arrange for needed community resources
  • Assist in scheduling required follow-up with community providers and services

Physicians, NPPs, or licensed clinical staff under the direction of the physician or NPP, must furnish the following non-face-to-face services, unless they are not medically indicated or needed:

  • Communicate with agencies and community services the beneficiary uses
  • Provide education to the beneficiary, family, guardian, and/or caretaker to support self-management, independent living, and activities of daily living
  • Assess and support treatment regimen adherence and medication management
  • Identify available community and health resources
  • Assist the beneficiary and/or family in accessing needed care and services

Care Model Compliance – CMS Transitional Care Management Model

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Intervention Intervention Description Data Source
TCM billed by attributed TIN An interactive contact, face-to-face visit, and certain non face-to-face services are furnished by the patient’s TIN.

See detailed information on these services on the previous slide for Care Model: Transitional Care Management – Implementation.

 Claims:

  • Procedure HCPCS codes to identify TCM billing
  • Rendering Provider TIN and Facility ID to determine if TCM was billed by attributed TIN
TCM billed by other TIN An interactive contact, face-to-face visit, and certain non face-to-face services are furnished by a different TIN than the patient’s TIN.

See detailed information on these services on the previous slide for Care Model: Transitional Care Management – Implementation.

 Claims:

  • Procedure HCPCS codes to identify TCM billing
  • Rendering Provider TIN and Facility ID to determine if TCM was billed by non-attributed TIN
Follow-up visit within 14 days with attributed TIN Any activity within 14 days of the discharge date furnished by the patient’s TIN that was not billed for TCM. Claims:

  • Procedure HCPCS codes to identify non-TCM billing
  • Rendering Provider TIN and Facility ID to determine if activity was billed by attributed TIN
  • Date of activity to determine if <=14 days from discharge date
Follow-up visit within 14 days with other TIN Any activity within 14 days of the discharge date furnished by a different TIN than the patient’s TIN that was not billed for TCM. Claims:

  • Procedure HCPCS codes to identify non-TCM billing
  • Rendering Provider TIN and Facility ID to determine if activity was billed by non-attributed TIN
  • Date of activity to determine if <= 14 days from discharge date
No follow-up No activity was furnished within 14 days of the discharge date. Claims:

  • Procedure HCPCS codes to identify non-TCM billing
  • Date of activity to determine if >14 days from discharge date