Coding 99495 and 99496 takes more effort than deciding whether the patient is seen 7 vs. 14 days after discharge.
The CPT® guidelines for transitional care management (TCM) codes 99495 and 99496 seem straightforward, initially, but the details are trickier than is commonly recognized. Here’s what you need to know to report these services appropriately.
How TCM Services Differ
CPT® added TCM service codes in 2013 to reward medical providers for care that facilitates the transition of a patient with moderate or high complexity medical decision-making (MDM) from an inpatient hospital setting to the patient’s community setting. These codes acknowledge a provider’s comprehensive responsibility and coordination of care for a patient, from discharge through 29-days after the date of discharge:
99495 Transitional Care Management Services with the following required elements:
- Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge
- Medical decision making of at least moderate complexity during the service period
- Face-to-face visit, within 14 calendar days of discharge
99496 Transitional Care Management Services with the following required elements:
- Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge
- Medical decision making of high complexity during the service period
- Face-to-face visit, within 7 calendar days of discharge
On first glance, a provider may mistakenly classify these two codes based on whether the patient is evaluated face-to-face within seven days (99495) or 14 days (99496) of discharge. Deeper evaluation shows this assumption to be incorrect.
TCM service codes may be used for new and established patients to the provider (Originally, these codes were applicable to established patients, only). For reimbursement, TCM codes require:
- Non-face-to-face communication within two business days of discharge;
- A face-to-face encounter within seven to 14 days of discharge; and
- Medication reconciliation and management no later than the first face-to-face encounter.
Note: Inpatient status includes acute hospital, rehabilitation hospital, and long-term acute care hospital. The patient’s community setting includes home, domiciliary, rest home, or assisted living.
Communication Is Key
Communication within the first two business days post discharge can be performed by the physician or other qualified health professional and/or licensed clinical staff under the physician’s direction. Communication may be with direct contact (face-to-face), via telephone, or by electronic send/receive messaging.
Documentation of this communication should extend beyond “patient OK.” Post discharge communication may assess and support treatment regimen adherence and medication management. Communication can also facilitate access to care and service needed by the patient and family. If the physician or other qualified professional is not directly involved in this communication, documentation of the conversation must be shared with the provider to address the status of the patient and the need for follow-up on any pending diagnostic tests or treatments.
Communication regarding care within the two-day window may be engaged with the patient, and/or family member, guardian, caretaker, surrogate decision maker, or other professional. This communication gives opportunity to educate the patient and family members and clarify post-discharge instructions.
MDM Matters
TCM code selection is based on whether the patient requires moderate or high complexity MDM for medical and/or psychosocial problems, and whether the patient is evaluated with a face-to-face encounter within seven or 14 days of discharge.
Vignettes from the CPT® Changes 2013 exemplifies the use of 99495:
- (Child) A 6-year old who is neurologically impaired and developmentally delayed and has a chronic seizure disorder is discharged from the hospital after an admission for breakthrough seizures.
- (Adult) An 84-year-old woman with hypertension and osteoarthritis is discharged from the hospital after a one-week stay for congestive heart failure.
Vignettes from the CPT® Changes 2013 exemplifies the use of 99496:
- (Child) A 6-month-old child born at 25 weeks gestation with a diagnosis of chronic lung disease on home oxygen, diuretics, bronchodilators and high caloric formula is discharged from the hospital after admission for respiratory failure.
- (Adult) A 93-year-old man is discharged after hospitalization for a myocardial infarction, complicated by hyperglycemia and delirium.
Use TCM code 99495 when the patient requires moderate to high complexity MDM and is evaluated face-to-face between seven and 14 days after discharge. Use TCM code 99496 when the patient requires high complexity care MDM and is evaluated face-to-face within seven days of discharge. Establishing the level of MDM is based on the number of diagnoses and/or management options, amount of data and/or complexity, and risk.
Although TCM codes require continuous provider access from the moment of discharge through 29 days post discharge, the provider may bill separately for additional evaluation and management (E/M) services provided within the month if performed on a date after the initial face-to-face visit.
Keep Track of Global Services
Only one provider may report a TCM code within a patient’s 30 days post discharge. If the patient is re-admitted within the 30 days, another TCM may not be reported within the original 30-day window.
A lengthy list of codes may not be reported within the 30-day timeframe of a TCM, including:
- Care plan oversight services (99339, 99340, 99374-99380)
- Prolonged services without direct patient contact (99358, 99359)
- Home and outpatient international normalized ratio monitoring (93792, 93793)
- Medical team conferences (99366-99368)
- Education and training (98960-98962, 99071, 99078)
- Telephone services (98966-98968, 99441-99443)
- End stage renal disease services (90951-90970)
- Online medical evaluation services (98969, 99444)
- Preparation of special reports (99080)
- Analysis of data (99090, 99091)
- Complex chronic care coordination services (99487-99489)
- Medication therapy management services (99487-99489)
- Medication management therapy services (99605-99607)
Lastly, if a provider performs a procedure with a global period, then the same provider may not bill TCM services during the global period.
TCM Relative Value Units Add Up
TCM codes reward patient care with work relative value units (RVUs) — a major component of the formula that generates provider payment. Per AAPC’s Work RVU Calculator, 99495 (moderate complexity TCM) has an RVU of 2.11 and 99496 (high complexity TCM) has an RVU of 3.05. In comparison, 99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity has an RVU of 1.50, and 99215 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity has an RVU of 2.11.
Providers should use TCM codes to be reimbursed for work involved in transitioning patients with moderate or high complexity MDM from inpatient to community settings. Just remember the rules.