Transitional Care Management (TCM) and Chronic Care Management (CCM) Billing Codes for Community-Based Organizations (CBOs)

updated 5 mths ago

Transitional Care Management (TCM) and Chronic Care Management (CCM) Medicare billing codes allow for the billing of services that support Medicare patients with complex conditions post hospital discharge and through on-going monthly support.

TCM billing codes can be submitted by providers who assist patients during an initial period post-discharge from a hospital, skilled nursing facility (SNF), or community mental health hospital stay to a community setting. CCM billing codes compensate providers who provide services to chronically ill Medicare beneficiaries outside of the office setting.

Because these are Medicare Part B services, they cannot be provided in a hospital setting and must be administered by a provider post-discharge. There is flexibility within Medicare guidelines for delegation of TCM and CCM activities which could give CBOs in aging and disability networks the opportunity to partner with Medicare providers and administer these services. According to 2019 data, only 4 percent of eligible Medicare Fee For Service (FFS) beneficiaries received a CCM billed service and only 17.9 percent received a TCM billing service.

CBO Key Takeaways

Many Medicare Part B beneficiaries potentially eligible for TCM and CCM services could already be served by CBOs:

Step 1: Find a Medicare provider willing to partner. In 2019, the majority of providers billing for CCM were primary care physicians.[1] Others included nurse practitioners, certified clinical nurse specialists, physician assistants or specialist physicians. Additionally, CBOs in aging and disability networks may want to explore partnerships with Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) who can also bill for both services. This works similarly for TCM and the CBO would be considered “auxiliary” personnel to the supervising physician per state law.[2]

Step 2: Establish a contract with the Medicare provider for service delivery and reimbursement. For CCM the Medicare provider bills for the service and is paid by Medicare.[3] For information on establishing contracts with health care providers see the Contracting Toolkit from the Aging and Disability Business Institute.

Step 3: Provide the service. Below are some requirements for TCM and CCM.

TCM codes[4] require providers to:
- communicate with the patient or caregiver within two business days of discharge
- make a medical decision of at least moderate complexity or high complexity; and
- have a face-to-face visit within seven- or 14-days post discharge depending on the level of medical decision making required.
CCM codes[5] are applicable for patients if:
- the patient has two or more chronic conditions expected to last at least 12 months or until the end of life;
- the chronic conditions place the patient at significant risk of death, decompensation, or functional decline; and
- the provider establishes, implements, revises, or monitors a comprehensive care plan accessible to the patient.
CCM services are subject to the deductible and 20 percent coinsurance requirements under Medicare Part B. This can be an impediment to Medicare beneficiaries receiving CCM services. This would position dual-eligible or low-income subsidy patients as more likely recipients of CCM services than non-dually enrolled because Medicaid would cover the monthly charge.