Transition of Care Visits

The Centers for Medicare & Medicaid Services (CMS) and Medicare Advantage plans encourage Transition of Care (TOC) visits with patients within two weeks of discharge from an inpatient stay. An inpatient stay can occur in a hospital (when the patient has been designated as inpatient rather than observation), an inpatient rehabilitation facility (IRF), or a skilled nursing facility (SNF). The purpose of this visit is to ensure any new medications or diagnoses are integrated into the office chart, needed monitoring labs or tests are done, and to assess if the patient has a new baseline.

Research shows TOC visits significantly reduce the chances of hospital readmittance within 30 days.

One of the most important aspects of the TOC visit is the reconciliation of medications. To meet the billing standard for TOC, providers should call the patient within 48 hours of discharge from the facility. The nurse or medical assistant should verify how the patient is doing at home, ensure they have everything needed, and review the complete medication list to confirm the provider’s office chart has the correct medications listed and the patient is taking them as prescribed. Documentation of this call is needed in the office chart in the event of a billing audit.

The visit with the provider should occur within 14 days of discharge from the facility, and within seven days if medically necessary. The billing code for a low or moderate complexity visit is 99495, while the billing code for a highly complex visit is 99496. Both of these codes reimburse at rates higher than standard office visits to compensate for the additional work that must be done by the provider and staff.

Dr. Beth Hodges is a family practice and palliative care/hospice physician in Asheboro, N.C., as well as a part-time medical director for HealthTeam Advantage.