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Property of Healthcare Training Leader. Authorization to reprint by Healthcare Training Leader for individual use only.
Phone: 800-767-1181 Web: www.hctrainingleader.com
TCM Documentation and Flow Sheet
Patient Name: ______________________________________________________________________________________
Patient DOB: ____/_____/_______ Discharge Date/Day:____/_____/_______ M Tu W Th F Sa Su
Patient’s Physician: __________________________________________________________________________________
Reason for Admission: _______________________________________________________________________________
Contact Information: Patient Caregiver Name:______________________________ Relationship: ___________________
Preferred method of contact: phone cell text e-mail
Phone: Home: (_______)______________________
Cell: (_______)______________________
Work: (_______)______________________
E-mail address (if applicable): _____________________________________________________________
Is Home Health Involved? No Yes — if yes, please include home health contact information:
Contact person: ___________________________________ Company name:_________________________________________
Phone: (_______)__________________________________ Fax: (_______)__________________________________________
E-mail (if applicable): _______________________________________________________________________________________
Discharge Information: Diagnosis(es) at discharge: _________________________________________________________________________________
Discharging physician (name and phone #): ______________________________________________________________________
Discharge Information Obtained: Discharge summary: Date rec’d: _____/______/________
Copies of discharge instructions: Date rec’d: _____/______/________
Most recent diagnostic test results: Test name: _________________________________ Date rec’d: _____/______/________
Test name: _________________________________ Date rec’d: _____/______/________
Test name: _________________________________ Date rec’d: _____/______/________
Patient Current Location: Home Family member home Non-family member home Assisted living facility Rest home
Other: ________________________________________________________________________________________________
Initial Communication Post-Discharge:
1st attempt: Date: ___/___/____ Time: ____:_____ □ am □ pm Method: call fax e-mail mail Initial: _________
2nd attempt: Date: ___/___/____ Time: ____:_____ □ am □ pm Method: call fax e-mail mail Initial: _________
Add'l attempts: Date: ___/___/____ Time: ____:_____ □ am □ pm Method: call fax e-mail mail Initial: _________Date: ___/___/____ Time: ____:_____ □ am □ pm Method: call fax e-mail mail Initial: _________ Date: ___/___/____ Time: ____:_____ □ am □ pm Method: call fax e-mail mail Initial: _________ Date: ___/___/____ Time: ____:_____ □ am □ pm Method: call fax e-mail mail Initial: _________
** Once you reach patient or caregiver go to page 2.
TCM Deadlines for Post-Discharge Contact:
2 days post discharge date ____/____/______ 7 days post discharge date ____/____/______ 14 days post discharge date ____/____/______
First 2 attempts must be within 2 business days of discharge (see date at top of page). Continue attempting to reach the patient, even if unsuccessful during the first 2 days. The non-face-to-face service can be provided incident to under general supervision.
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Page 1 of 4
TCM Documentation and Flow Sheet Page 2 of 4
Patient Name: ___________________________________________ DOB: ____/____/______ Discharge Date: ____/____/______
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Initial Communication Post-Discharge section continued ...
Disposition: _________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
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__________________________________________________________________________ initial: _________ date: ____________
Summary of clinical staff member's discussion with patient/caregiver during initial post-discharge communication: ____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
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___________________________________________________________________________ initial: _________ date: _____________
Supervising Licensed Physician, PA, NP, or CCNS name:________________________________________________________________
First Face-to-Face Follow-up Visit:
Review progress notes in patient's record for information:
First face-to-face visit occurred on: Date: ____/____/______ Time: ______:_______ □ am □ pm
Location of visit: Office Home Rest Home Other____________________________
Number of calendar* days since discharge: 7 or fewer 8-14 15 or more
Medication reconciliation performed? No Yes (If yes, date: ____/____/______)
Level of medical decision-making: High Moderate Low/Straightforward
Face-to-face visit performed by (provider name and credentials): ________________________________________________________
Progress notes signed by the treating provider for the above date of service? Yes No
* Calendar days include weekends and holidays.
Summary of recommendations: _____________________________________________________________________________
_______________________________________________________________________________________________________
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__________________________________________________________________________ initial: _________ date: _________
First face-to-face follow-up visit must be no longer than 14 calendar days post-discharge to qualify
for TCM.
TCM Documentation and Flow Sheet Page 3 of 4
Patient Name: ___________________________________________ DOB: ____/____/______ Discharge Date: ____/____/______
Additional Non-Face-to-Face Services:
Patient Non-Face-to-Face Supervising Physician Initial and Date Services Documentation Record at Receiving Clinic Each Entry
_________________________________ __________________________ _______________ _________________________________ __________________________ _______________ _________________________________ __________________________ _______________ _________________________________ __________________________ _______________ _________________________________ __________________________ _______________ _________________________________ __________________________ _______________ _________________________________ __________________________ _______________ _________________________________ __________________________ _______________ _________________________________ __________________________ _______________ _________________________________ __________________________ _______________ _________________________________ __________________________ _______________ _________________________________ __________________________ _______________ _________________________________ __________________________ _______________ _________________________________ __________________________ _______________ _________________________________ __________________________ _______________ _________________________________ __________________________ _______________ _________________________________ __________________________ _______________ _________________________________ __________________________ _______________ _________________________________ __________________________ _______________ _________________________________ __________________________ _______________ _________________________________ __________________________ _______________ _________________________________ __________________________ _______________ _________________________________ __________________________ _______________ _________________________________ __________________________ _______________ _________________________________ __________________________ _______________ _________________________________ __________________________ _______________ _________________________________ __________________________ _______________ _________________________________ __________________________ _______________ _________________________________ __________________________ _______________ _________________________________ __________________________ _______________ _________________________________ __________________________ _______________ _________________________________ __________________________ _______________ _________________________________ __________________________ _______________ _________________________________ __________________________ _______________ _________________________________ __________________________ _______________ _________________________________ __________________________ _______________ _________________________________ __________________________ _______________ _________________________________ __________________________ _______________ _________________________________ __________________________ _______________ _________________________________ __________________________ _______________ _________________________________ __________________________ _______________ _________________________________ __________________________ _______________ _________________________________ __________________________ _______________ _________________________________ __________________________ _______________ _________________________________ __________________________ _______________
Additional Non-Face-to-Face Services section continued ...
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Additional non-face-to-face services provided within 30 days post-discharge must be performed by licensed clinical staff members, or personally performed by physician or
qualified NPP. Initial and date each entry below, including licensure initials. Examples of Additional
Non-Face-to-Face Services
Review discharge information:
- Document provider name,date and findings.
- Pending diagnostic tests and treatments: Documentif nothing pending or list ofpending tests and treatments, action recommended for each,dates and results received for each.
Communication with other providers involved in patient’s care:
- List each providercommunicated with, date of each communication,and findings and results from each communication.Document if nocommunication required.
Education: (patient, family,
guardian, and/or caregiver): - Date of education, who was
educated (and if applicable their relationship with the patient), who provided education, topic ofeducation, results and follow-up. Document if noeducation required.
Community resource arrangement(s):
- Document resources required, who arranged each resource, date each resource arranged, result ofeach resource. Document ifnone needed.
Assess and support treatment regimen adherence and medication management:
- Document date, topic,result and name of staffproviding support.Document if none needed.
TCM Documentation and Flow Sheet Page 4 of 4
Patient Name: ___________________________________________ DOB: ____/____/______ Discharge Date: ____/____/______
________________________________________________________________________________________________
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Patient Non-Face-to-Face Supervising Physician Initial and Date Services Documentation Record: at Receiving Clinic Each Entry:
_____________________________________________________________ __________________________ _______________ _____________________________________________________________ __________________________ _______________ _____________________________________________________________ __________________________ _______________ _____________________________________________________________ __________________________ _______________ _____________________________________________________________ __________________________ _______________ _____________________________________________________________ __________________________ _______________ _____________________________________________________________ __________________________ _______________ _____________________________________________________________ __________________________ _______________ _____________________________________________________________ __________________________ _______________ _____________________________________________________________ __________________________ _______________ _____________________________________________________________ __________________________ _______________ _____________________________________________________________ __________________________ _______________ _____________________________________________________________ __________________________ _______________ _____________________________________________________________ __________________________ _______________ _____________________________________________________________ __________________________ _______________ _____________________________________________________________ __________________________ _______________ _____________________________________________________________ __________________________ _______________ _____________________________________________________________ __________________________ _______________ _____________________________________________________________ __________________________ _______________ _____________________________________________________________ __________________________ _______________ _____________________________________________________________ __________________________ _______________ _____________________________________________________________ __________________________ _______________ _____________________________________________________________ __________________________ _______________ _____________________________________________________________ __________________________ _______________ _____________________________________________________________ __________________________ _______________ _____________________________________________________________ __________________________ _______________ _____________________________________________________________ __________________________ _______________ _____________________________________________________________ __________________________ _______________ _____________________________________________________________ __________________________ _______________ _____________________________________________________________ __________________________ _______________ _____________________________________________________________ __________________________ _______________ _____________________________________________________________ __________________________ _______________ _____________________________________________________________ __________________________ _______________ _____________________________________________________________ __________________________ _______________ _____________________________________________________________ __________________________ _______________ _____________________________________________________________ __________________________ _______________ _____________________________________________________________ __________________________ _______________ Note: The person who signs below and closes this document has NO bearing on whose name the TCM services should be billed under. CMS states that TCM services should be billed under the physician or NPP who provides the mandatory face-to-face encounter. Ideally, to ensure continuity of care, it would also be the same person, but this is not required.
TCM 30-Day-Period Closure:
Date range included in this document: Start date: ____/____/______ End date: ____/____/______
Document reviewed and closed by: ________________________________________________ ____/____/_____ Physician or NPP Signature and Licensure Date
Need Targeted TCM Services Coding Training?This immediately available online training session can help....
Simply put, TCM codes 99495 and 99496 allow your practice to be paid for services you’re already providing to help your patients successfully transition post-discharge — services you currently o�er for FREE. Utilizing TCM codes correctly can be tricky. It requires attention to detail and a thorough understanding of their compliance requirements. But, when you consider the possible increased reimbursement, it is well worth it.
This is where physician and certi�ed professional coder, Michael Stearns, MD, CPC, CFPC can help. During a 60-minute online training, Dr. Stearns will provide you with step-by-step instructions on how to accurately utilize and comply with these complex codes. After this training, you’ll be able to start submitting claims for TCM immediately — and getting paid more for them, too.
Here are just a few of the questions you’ll get answered during this must-attend, 60-minute practical session:
• How does service location �t into the equation? • Do patients have to be a certain age to qualify? • Can you only use codes 99495 and 99496 for established patients? • What diagnoses should be used? • What type of providers can take advantage of these codes (MDs, PA, etc.)? • What if you can’t reach the patient or caregivers during the two days post-discharge? • How are calendar days and business days used when providing TCM services? • What if the patient isn’t present for the face-to-face meeting, but the caregiver shows up? • And much more!
Transitional Care Management: Get Paid What You Deserve
To register online, go to:
HTTPS://HEALTHCARE.TRAININGLEADER.COM/PRODUCT/TCM3/
Or call us at 800-767-1181
