The Hidden Potential in SNF Transitional Care Billing

Transitional Care Management (TCM) is a very important service, particularly for patients being discharged from a hospital setting to a Skilled Nursing Facility (SNF). Patients with comorbidities usually experience challenges in controlling their health after a hospital stay, resulting in increased readmissions and ineffective recovery.

TCM ensures that these patients are provided with uninterrupted care and services during their transition, either from the hospital to the SNF or from the hospital to home after an extended stay. Such a comprehensive approach improves the management of patients' health and minimizes the development of complications. In addition, such a method provides hidden opportunities for the SNFs to enhance the reimbursements.

This blog will explore detailed information on how TCM can be effectively implemented in Skilled Nursing Facilities to unlock hidden potential.

Billing Guidelines for TCM

It is essential to implement the following CMS rules for correct billing to avoid denials and ensure reimbursement:

1. Who can get TCM Services?

TCM services are for patients who are discharged from certain healthcare settings and need help transitioning back to the community. This includes patients leaving hospitals, skilled nursing facilities (SNFs), psychiatric hospitals, rehabilitation centers, and other inpatient care facilities.

2. Billing Codes

There are two billing codes to TCM services:

• CPT 99495 is used if the medical decision making is of moderate complexity. It is advisable for a face to face visit to occur within 14 days of discharge.
• CPT 99496 is used if the medical decision making is of high complexity.  It is advisable for a face to face visit to occur within 7 days of discharge.

It is possible to bill only one of these codes for each discharge.

3. Who can provide TCM Services?

TCM can be provided and billed by:

• Doctors (MDs and DOs)
• Nurse Practitioners (NPs)
• Physician Assistants (PAs)
• Certified Nurse Midwives (CNMs)
• Clinical Nurse Specialists (CNSs)

5. Time Frame

The time allotted for billing TCM services is 30 days after the patient is discharged. The provider has to provide ongoing support at this stage. If TCM is not paid within 30 days from the patient’s readmission into a hospital, it cannot be billed.

6. Place of Service

A TCM visit usually occurs in the provider’s office (POS 11), but one can be arranged in the patient’s home or other community-based setting. There must be a correct record of place of service during billing.

7. Documentation Requirements

You must clearly document the following in the patient’s records:

• Date of discharge
• Date and method of the interactive contact
• Date of the face-to-face visit
• The complexity of the medical decision-making
• Care coordination activities summary during the time frame

Points to be Kept in Mind:

• Only one healthcare provider is allowed to bill for services for the patient per discharge.
• You are not able to bill TCM if the patient is readmitted within that period.
• Only one TCM code (99495 or 99496) may be billed for any given 30–day period.
• After the end of the 30-day TCM, you can start CCM services (if needed).
• TCM services cannot be billed in combination with hospice care, Chronic Care Management (CCM),  or home health supervision during the same timeframe.

How to Bill TCM?

The processes applied in billing TCM services involve four steps, such as: 

1. Verify CMS Requirements Were Met for Each Patient

Before billing for TCM, providers must ensure all Medicare (CMS) requirements have been fully completed. This includes confirming the patient was discharged from a qualifying facility (like a hospital or SNF), that an interactive contact (call, email, or in-person) was made within 2 business days, a face-to-face visit occurred within 7 or 14 days depending on the CPT code, and that ongoing care coordination was provided during the 30 days. If any of these steps are missed, the provider cannot bill for TCM services.

2. Submit Claims to CMS

TCM services are billed after the completion of 30 days from the discharge of the patient. Providers must wait until all services related to care coordination are completed. After 30 days, the provider submits the claim to Medicare using the correct CPT code as per the conditions applied under CMS rules.

3. Send an Invoice to Patients Receiving TCM Services

After submitting the claim to CMS, the provider should also bill the patient for any applicable co-pays or out-of-pocket charges. TCM is covered under Medicare Part B, which means the patient may owe 20% of the Medicare-approved amount, unless they have a supplemental plan or Medicaid coverage. Sending a clear invoice ensures transparency and helps with revenue collection.

4. Determine No Conflicting Codes Billed

Before submitting a claim, the provider must check for any conflicting services that may have been billed during the 30-day TCM period. This includes services like Chronic Care Management (CCM), home health care supervision, or certain behavioral health codes. TCM cannot be billed with these overlapping services, and doing so can lead to claim denials or audit risks. A proper check ensures accurate billing and compliance with CMS rules.

Benefits of SNF TCM

SNF TCM offers clinical and financial value by ensuring patients receive continuous support after hospital discharge. The following are the hidden potentials in SNF transitional care billing:

1. Increased Reimbursement Opportunities

TCM services provided to patients discharged from SNFs are reimbursed under specific CPT codes (99495 and 99496). This allows providers to bill for essential post-discharge care coordination that would otherwise go unpaid. SNFs and associated providers can increase revenue streams by capturing these services while improving continuity of care for patients transitioning back into the community or home setting.

2. Reduction in Readmissions

Skilled Nursing Facilities benefit from TCM services by reducing preventable hospital readmissions after discharge. CMS penalizes frequent readmissions, so offering TCM allows SNFs and associated outpatient providers to coordinate timely follow-up and support. This improves patient outcomes and protects the facility’s financial standing, aligning with value-based care incentives that reward quality over quantity of services rendered.

3. Increased Patient Volume

SNFs that refer discharged patients for TCM enable outpatient providers to increase service capacity without additional clinical burden. As more SNF discharges qualify for transitional care, providers can consistently bill Medicare for these services. This creates a dependable revenue source tied to post-acute care, allowing practices to grow while supporting patients through their recovery journey after leaving the SNF.

How 24/7 Medical Billing Services Simplifies TCM

24/7 Medical Billing Services simplifies TCM by handling the entire billing cycle with precision and care. Their expert team makes the process smooth and stress-free from verifying patient eligibility and ensuring CMS compliance to assigning correct CPT codes and submitting clean claims. In fact, they help providers, including SNFs, avoid coding conflicts, reduce denials, and receive timely reimbursements.

FAQs

Q1. Are telehealth visits allowed for TCM?

Yes, TCM visits can be conducted via telehealth if they meet Medicare’s requirements.

Q2. Does TCM include medication reconciliation?

Yes, medication reconciliation and management must be provided within two business days post-discharge.

Q3. Can TCM services be provided remotely?

Yes, TCM services can be delivered remotely, such as through telehealth or phone calls, as long as the required elements are met.

Q4. What is the difference between TCM and CCM?

TCM focuses on post-hospital discharge care, whereas CCM addresses long-term management of chronic conditions in outpatient settings.