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Transitional Care Management Services

The CPT Codes 99495 and 99496 are used to report transitional care management services (TCM).

These services are covered for a new patient or established patient and the code selection will be considered based on the MDM and the problems require either "Moderate Complexity or High Complexity".

The TCM service is eligible who discharged from as mentioned below locations,

  • Inpatient hospital setting (including acute hospital, a rehabilitation hospital, long-term acute care hospital).
  • Partial hospital, 
  • Observation status in a hospital, 
  • Skilled nursing facility
  • Nursing facility to the patient's community setting 
    • Home, 
    • Domiciliary, 
    • Rest home, 
    • Assisted living. 

Guidelines

  • TCM is included in one face-to-face visit within the specified timeframes, in combination with non-face-to-face services that may be performed by the physician or other qualified health care professional.
  • Only one individual may report these services and only once per patient within 30 days of discharge.
  • Another TCM may not be reported by the same individual or group for any subsequent discharge(s) within 30 days.
  • The same individual should not report TCM services provided in the postoperative period of a service that the individual reported.

Non-Face To Face Service

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

  • Obtaining and reviewing the discharge information (eg, discharge summary, as available, or continuity of care documents).
  • Reviewing the need for or follow-up on pending diagnostic tests and treatments.
  • Interaction with other qualified health care professionals who will assume or reassume care of the patient's system-specific problems.
  • Education of patient, family, guardian, and/or caregiver.
  • Establishment or reestablishment of referrals and arranging for needed community resources.
  • Assistance in scheduling any required follow-up with community providers and services.
The first face-to-face visit is part of the TCM service and not reported separately. 

Additional E/M services provided on subsequent dates after the first face-to-face visit may be reported separately. 

TCM requires interactive contact with the patient or caregiver, as appropriate, within two business days of discharge. 

The contact may be direct (face-to-face), telephonic, or by electronic means. Medication reconciliation and management must occur no later than the date of the face-to-face visit.

CPT Codes

  • CPT 99496 -The face-to-face visit must occur within 7 calendar days of the date discharge and MDM must be of "High complexity". 
  • CPT 99495 -  The face-to-face visit must occur within 14 calendar days of the date of discharge and MDM must be "Moderate complexity".



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