From the Guidelines
For a new patient with commercial insurance presenting for a transition visit from hospital, code 99496 would be the appropriate choice rather than 99205. This is because 99496 is specifically designed for transitional care management services for patients with high medical decision complexity within 7 days of discharge, as opposed to 99205 which is a new patient office visit code that doesn't account for the transitional nature of the encounter 1. The key aspects of 99496 include:
- Communication with the patient within 2 business days of discharge
- A face-to-face visit within 7 calendar days of discharge
- Moderate to high complexity medical decision making involved in managing the patient's transition In contrast, 99205 is used for evaluations that are comprehensive and highly complex or take 60 min (with more than half spent counseling) 1. Given the context of a transition visit from hospital, 99496 is the more suitable code as it captures the work involved in managing the transition from hospital to home or community setting, including medication reconciliation, coordination of follow-up care, and addressing any post-discharge issues. Some key points to note when using 99496 include:
- It typically provides better reimbursement than 99205 because it recognizes the additional work involved in post-discharge care coordination
- It requires documentation of the moderate to high complexity medical decision making involved in managing the patient's transition
- It is specifically designed for patients with high medical decision complexity within 7 days of discharge, making it the most appropriate choice for this scenario.
From the Research
Billing Codes for Transition Visits
There are no research papers to assist in answering this question about the billing code to use for a new patient with commercial insurance that presents for a transition visit from hospital: 99496 or 99205, as the provided studies 2, 3, 4, 5 do not discuss medical billing codes.
Relevant Information
- The studies provided discuss various medical topics, including thyroid cancer diagnosis 2, sepsis and immunosuppression 3, plasma membrane channels formed by connexins 4, and the genetics of multiple sclerosis 5.
- None of the studies mention medical billing codes or provide guidance on coding for transition visits.
- To determine the correct billing code, it may be necessary to consult a medical billing resource or guidelines specific to the patient's insurance provider.