New: Transitional Care Management CPT Codes

Transitional care management (TCM) services codes 99495 and 99496 are new Current Procedural Terminology (CPT) codes that went into effect Jan. 1, 2013. Use these codes for patients discharged from an inpatient setting to the patient’s community setting (e.g., home, assisted living).

  • 99495, TCM: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within two 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, TCM: Communication (direct contact, telephone, electronic) with patient and/or caregiver within two business days of discharge; medical decision making of high complexity during the service period; face-to-face visit within seven calendar days of discharge.

The first face-to-face visit is part of the TCM and not reported separately; additional evaluation and management services after the first face-to-face visit may be reported separately. Only one individual may report TCM services and only once per patient within 30 days of discharge. 

Medicare accepts these codes, but physicians should review the Medicare rules carefully because they vary from the CPT guidelines (see the final 2013 Medicare Physician Fee Schedule [PDF], starting on page 68979). For example: Medicare requires that the physician wait to bill until the 30th day. Refer to the Centers for Medicare & Medicaid Services’ fact sheet (PDF) for guidance. Also, the American College of Physicians has compiled a chart (PDF) (see page 4) comparing the CPT guidelines and Medicare rules.  

Medicare has created a list of FAQs (PDF) regarding Medicare coverage rules for these codes, including these:

 Q: What date of service should be used on the claim?

 A: The 30-day period for the TCM service begins on the day of discharge and continues for the next 29 days. The reported date of service should be the 30th day.

 Q:  Can TCM services be reported if the beneficiary dies prior to the 30th day following discharge?

 A:  Because the TCM codes describe 30 days of care, in cases when the beneficiary dies prior to the 30th day, practitioners should not report TCM services but may report any face-to-face visits that occurred under the appropriate evaluation and management code.

 Q:  During the 30-day period of TCM, can other medically necessary billable services be reported?

 A:  Yes, other reasonable and necessary Medicare services may be reported during the 30-day period, with the exception of those services that cannot be reported according to CPT guidance and Medicare HCPCS codes G0181 and G0182.

Have a billing, coding, or payment question? Contact the TMA’s Billing and Coding Hotline at (800) 880-1300, ext. 1414, or paymentadvocacy@texmed.org

Updated Aug. 19, 2013


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