Wiki Documenting TCM

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City of San Jose Del Monte, BU
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Good afternoon, quick question about TCM documentation. Some of our NPs include time-based statements, such as "60 minutes total time spent..."

Example:
Total time spent for this encounter is 60 minutes. This includes time spent reviewing medical records and diagnostic tests, direct patient interaction (history taking, examination, counseling), and documenting and managing correspondence with family and other qualified health care professionals involved in the patient’s care.
Transitional care management visit requiring medical decision making of high complexity conducted today. Initial communication was made with ALF on upon patient's return to ensure their stability. Face-to-face visit conducted today which is within 7 days of discharge. Medications reconciled.

Is this okay for coding TCM, or should we ask them to focus on noting the 7- or 14-day TCM type?

Thank you so much!
 
Time can be used since the code description indicates that TCM MDM is defined by the E&M rules. CPT has a 2 page explanation of the TCM code criteria. (CPT 2025, p62-64). We allow them to document how many days since discharge, similar to above, which is really all that's required for that piece.
 
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