For almost 10 years now, health care providers have been using transitional care management (TCM) codes to receive reimbursement for treating patients with complex medical conditions during the immediate post-discharge period. Here’s a closer look at both TCM codes CPT 99495 and CPT 99496, and a look at current rates of reimbursement available to doctors and clinical staff.

> New to transitional care management? Read more about the basics of TCM here.

A closer look at transitional care management/TCM codes

As outlined by the American Medical Association (AMA), Current Procedural Terminology (CPT®) codes offer doctors and other health care professionals “a uniform language for coding medical services and procedures to streamline reporting, increase accuracy and efficiency.” Once established by the AMA, CPT codes are then assigned an average reimbursement rate in the Physician Fee Schedule published each year by the U.S. Centers for Medicare & Medicaid Services (CMS).

According to the official CMS guide to transitional care management, that reimbursement is restricted to the treatment of patients with a condition requiring either medium or high-level decision-making. This includes time spent coordinating patient services for specific medical care or psychosocial needs, and guiding them through activities of daily living.

The CMS guide also makes it clear that eligible methods of patient/provider communications include not only direct patient contact, but also interactive contact via telephone and “electronic” media. And that gives healthcare providers using these TCM codes the chance to further embrace virtual care technologies.

Guide to TCM codes: CPT 99495

What is CPT Code 99495?

99495 is a CPT code that allows for the reimbursement of transitional care management services for patients requiring “medical decision making of at least moderate complexity.” Communication between the patient and practitioner must begin within 2 business days of discharge, and can include “direct contact, telephone [and] electronic” methods. One face-to-face visit is also required within 14 days of the patient’s discharge; this visit cannot be conducted virtually, and should not be reported separately.

Who’s the billing practitioner?

Eligible billing practitioners for CPT Code 99495 include physicians or other “qualified health professionals” (QHPs) — often advanced practitioners like physician assistants (PAs) or nurse practitioners (NPs). QHPs can also include non-physician practitioners (NPPs), where authorized by state law; certified nurse-midwives (CNMs); or clinical nurse specialists (CNSs).

What’s the reimbursement rate for CPT 99495?

As of January 1, 2022, CPT 99495 offers a one-time reimbursement of $209.02.

Guide to TCM codes: CPT 99496

What is CPT Code 99496?

CPT 99496 allows for the reimbursement of TCM services for patients in need of “medical decision making of high complexity.” Communication between the patient and practitioner must begin within 2 business days of discharge; eligible methods are listed as “direct contact, telephone [and] electronic” methods. In addition, one face-to-face visit — which cannot be virtual and should not be reported separately — must be made within 7 days of the patient’s discharge.

Who’s the billing practitioner?

Eligible billing practitioners for CPT Code 99496 include physicians or other eligible QHPs, such as PAs, NPs, CNMs, CNSs or NPPs.

What’s the reimbursement rate for CPT 99496?

As of January 1, 2022, CPT code 99496 offers a one-time reimbursement of $281.69.

What else should clinical care teams know about TCM codes?

The goal of transitional care management services is to prevent patient readmissions after acute-care facility or hospital discharge. As such, TCM is separate from other care management codes for remote patient monitoring (RPM) and chronic care management (CCM) and can be billed during the same months as care provided under those models. It’s also frequently used in conjunction with principal care management (PCM) to treat patients with a single complex condition after the TCM period ends.

“TCM services begin the day of discharge,” the CMS guide adds. “Medicare may cover these services to help a patient transition back to a community setting after a stay at certain facility types.”

Those community settings are listed as nursing homes, assisted living facilities, or the patient’s home or domiciliary. Facility types eligible for discharge include:

  • Inpatient acute care hospitals or facilities
  • Inpatient psychiatric hospitals or facilities
  • Long-term care hospitals
  • Skilled nursing facilities (SNFs)
  • Inpatient rehabilitation facilities
  • Hospital outpatient observations or partial hospitalizations
  • Partial hospitalizations at a Community Mental Health Center

And because these are care management codes, “auxiliary personnel may provide the non-face-to-face services of TCM under the general supervision of the physician or NPP subject to applicable state law, scope of practice, and the Medicare Physician Fee Schedule (PFS) ‘incident to’ rules and regulations,” the CMS guide points out, indicating support for the necessity of coordinated care.

“CNMs, CNSs, NPs, and PAs may also provide the non-face-to-face services of TCM incident to the services of a physician,” the CMS guide adds, further facilitating coordination of services.  

“Only one healthcare provider may bill for TCM during the 30-day period following discharge,” explains Elizabeth Hylton in a recent review of TCM at the American Academy of Professional Coders (AAPC) Knowledge Center. “Usually, these codes are in the realm of primary care, but there are circumstances where the patient’s condition that required admission is managed by a specialist.”

In addition to face-to-face patient care, TCM codes work to eliminate preventable readmissions associated with care transitions by reimbursing non-face-to-face services such as:

  • Creating a personalized care plan for each patient
  • Revising the comprehensive care plan based on changes arising from ongoing condition management
  • Reviewing discharge info, such as discharge summaries or continuity-of-care documents
  • Reviewing the need for — or following up on — diagnostic tests or other related treatments
  • Interacting with other health care professionals involved in that patient’s care
  • Offering educational guidance to the patient, as well as their family, guardian or caregiver
  • Establishing or re-establishing referrals
  • Arranging necessary community resources
  • Helping to schedule and align necessary follow-up services or community providers

For another perspective on how to use TCM codes to reduce readmission rates — as well as some common mistakes to avoid — check out this helpful overview from the AAPC, a professional association serving the medical coding community.

Looking for more info or guidance on the use of TCM codes?

See these TCM codes mapped out with other RPM-adjacent care management models like PCM, CCM and RTM with our handy Reimbursement Tree.

And if your organization is seeking ways to leverage TCM codes or other telehealth technology for patient care, we’re standing by to help: Contact us today to connect to a CareSimple specialist.