Anti Fraud Tips Regarding the TCM CPT Codes _June 2017

2017 OIG Work Plan Red Flag:    Transition of Care Management (TCM) CPT Codes
TCM was designed to assist the patient with the transition from an inpatient setting back to the home or another outpatient setting. The goal of reconciliation of medications, outpatient therapy, community services or other healthcare services- will assist the patient from being readmitted.
Benefit to Patient: Assist with reduced inpatient admissions.
Benefit to provider: This is a great - high revenue CPT code. Medicare reimbursement ranges from $190 – 280.00 (better paying than most established patient CPT codes.)
Risks: Follow the rules set forth in the Federal Register and CMS Fact Sheet. Educate your staff on what needs to be performed and documented prior to seeing the patient as well what needs to occur during the patient visit and during the following 29 days. The patient and provider both win when there is compliance with TCM rules and lose when required steps of the TCM codes are eliminated.
OIG 2017 Work Plan, Page 32
We will determine whether payments for TCM services were in accordance with Medicare requirements.”
CMS December 2016 TCM Fact Sheet:
AAFP TCM Services (J. Bloink and K. Adler) 2013:
Please contact me if you have other questions.
Jacqueline Bloink, MBA, RHIA, CFE, CHC, CPC-I, CPC, CMRS

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