CPT Code 99495 For Billing Transitional Care Management (TCM)

As defined by the American Medical Association (AMA), Current Procedural Terminology (CPT®) codes provide doctors and other health care providers with “a uniform language for coding medical services and procedures to streamline reporting, increase accuracy and efficiency.”

According to the US Centers for Medicare & Medicaid Services (CMS) reference on transitional care management, TCM reimbursement is limited to the treatment of patients with a disease that necessitates medium or high-level decision-making. This includes time spent coordinating patient services for specific medical or psychosocial needs, as well as assisting them with daily tasks.

The CMS handbook further specifies that approved methods of patient/provider communication include not only direct patient contact, but also interactive engagement via phone and “electronic” media.

What is Medicare Transitional Care Management?

Transitional Care Management (TCM) programs are designed to help patients transition from inpatient to community care. Following a hospitalization or other inpatient facility stay, a patient may need the right care and medical support to deal with the new diagnosis or therapy modification. This transitional care is handled by the physicians and patient’s family.

There are two CPT codes used to report TCM services:

• CPT code 99495 – moderate medical complexity, requiring a face-to-face contact within 14 days of discharge.
• CPT code 99496 – high medical complexity, requires a face-to-face contact within seven days of discharge.

What is CPT Code 99495?

CPT code 99495 is a transitional care management that allows the reimbursement of TCM services for patients requiring “medical decision making of moderate complexity.”

Communication between the patient and the practitioner must take place within two business days after discharge and may involve “direct contact, telephone [and] electronic” media. One face-to-face visit is also required within 14 days of the patient’s release along with non-face-to-face consultations done digitally.

Non-face-to-face services provided by the physician or other qualified health care provider include:

• Obtain and review discharge information
• Review and follow-up on pending diagnostic tests and treatments
• Interact with other qualified health care professionals to address system-specific problems
• Educate patients, families, guardians, and caregivers
• Establish or re-establish referrals and arrange for community care resources
• Assist in scheduling any necessary follow-up appointments

Who Can Bill CPT Code 99495?

Eligible billing practitioners for CPT Code 99495 include physicians and other “qualified health professionals” (QHPs), such as physician assistants (PAs), nurse practitioners (NPs), non-physician practitioners (NPPs), certified nurse-midwives (CNMs), and clinical nurse specialists (CNSs).

TCM needs a face-to-face visit, initial patient contact, and medication reconciliation within specific time periods. The initial face-to-face visit is included in the TCM service and does not require separate reporting. Additional E/M services beyond the initial face-to-face encounter can be reported separately.

As of January 1, 2024, the average one-time reimbursement rate for CPT Code 99495 is approximately $203.34 and varies by location.

How To Document & Bill TCM CPT Code 99495?

Documentation covers the time of the initial post-discharge communication with the patient or caregivers, the date of the in-person visit, and the complexity of medical decision-making. Only one practitioner may report these services, and only once per patient, within 30 days following discharge.

Another TCM cannot be recorded by the same practitioner or group for any subsequent discharge(s) within 30 days. The same practitioner may report hospitalization, observation, discharge, and TCM. The same practitioner should not report TCM services delivered in the post-operative period.

Other billing points to consider include:

• Only one physician or NPP can report TCM services.
• Report once per patient during the 30-day period.
• Same provider can discharge the patient, record discharge services, and bill TCM.
• Face-to-face visits on the same day as the discharge day do not count.
• Provide necessary E/M services separately to address clinical difficulties.
• TCM services cannot be billed throughout the post-operative global surgical period.

Modifier 54 is not necessary if TCM services are provided by another individual throughout a surgical package’s postoperative period.

A physician or other qualified health care professional who reports code 99495 may not report care plan oversight services, prolonged services without direct patient contact, anticoagulant management, medical team conferences, education and training, telephone services, end stage renal disease services, online medical evaluation services, preparation of special reports, analysis of data, complex chronic care coordination services, and medication therapy management services during the time period covered by the transitional care management services codes.

When is TCM Code 99495 Applicable?

TCM service begins from the very first day of discharge from a community settings or healthcare facilities, including:

• Inpatient acute care hospital
• Long-term acute care hospital
• Skilled nursing facility/nursing facility
• Inpatient rehabilitation facility
• Inpatient psychiatric hospitals
• Hospital observation status or partial hospitalization
• Community mental health centers

Transitional care management programs aim to reduce patient readmissions following release from an acute-care facility or hospital that makes it different from remote patient monitoring (RPM) and chronic care management (CCM). It is generally used in conjunction with principal care management (PCM) to treat patients with a single chronic ailment after the TCM period expires.

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With HealthArc’s comprehensive healthcare platform and clinical TCM software, streamline your transitional care management (TCM) services with a focus on smooth patient transition, lower readmission rates, seamless communication, and increased overall patient involvement.

Request a free demo or call our team at +201 885 5571 to understand how we can help your organization reach its long-term transitional care management goals.