As of January 1st, 2024, Transitional Care Management (TCM) still falls under CPT 99496. TCM is a critical component of patient care that addresses the complexities of the transition period following a patient’s discharge from an inpatient setting. Family physicians and other healthcare providers play a pivotal role in managing this transition to ensure patients receive the necessary follow-up care. Learn the specifics of TCM, focusing on CPT code 99496, its requirements, components, and the healthcare professionals authorized to bill for these services.
What is Medicare Transitional Care Management (TCM)?
Medicare TCM services are designed to support patients during the hand-off period between inpatient and community settings. This period can be fraught with challenges, including medical crises, new diagnoses, and changes in medication therapy. Effective TCM ensures that patients receive timely communication and follow-up care, reducing the risk of readmissions and improving overall health outcomes.
What is CPT Code 99496?
CPT code 99496 pertains to transitional care management that involves high-complexity medical decision-making and requires a face-to-face visit within seven days of discharge. This code is used when the patient’s condition necessitates comprehensive management and coordination of care to ensure a smooth transition from the hospital to the home or another care setting.
TCM Coding: An Overview
There are two primary CPT codes to report TCM services:
- CPT code 99495: This code is for moderate medical complexity requiring a face-to-face visit within 14 days of discharge.
- CPT code 99496: This code is for high medical complexity requiring a face-to-face visit within seven days of discharge.
Both codes involve crucial components and requirements to be met for effective transitional care management. 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.
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 high complexity during the service period
- Face-to-face visit within 7 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.
