CPT 99495 – Transitional Care Management

As of January 1st, 2013, Medicare began to reimburse for CPT 99495 to improve transitions of care for patients. Specifically the CPT definition of 99495 is:

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

There are many specific scope of service requirements (e.g., coordination with home health agencies, community services, family/caretaker education, medication management) for Transitional Care Management relating to care coordination. These scope of service elements can be provided by clinical staff in a non-face-to-face manner. After provision of the non-face-to-face coordination services by clinical staff, a face-to-face visit with the billing provider is still required.

There are two codes used to reimburse for Transitional Care Management, CPT 99495 for moderate complexity patients and CPT 99596 for high complexity patients. A key difference between these codes is days after discharge in which a face-to-face visit is required, 14 days for CPT 99495 and 7 days for CPT 99496.

Note that there are restrictions around billing both Chronic Care Management and Transitional Care Management in the same time period.

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