Which Current Procedural Terminology (CPT) codes are used for billing a Transition of Care (Transitional Care Management, TCM) service after hospital discharge, and what are the criteria for each code?

Transitional Care Management (TCM) CPT Codes

For billing Transitional Care Management services after hospital discharge, use CPT codes 99495 (moderate complexity) or 99496 (high complexity), with the key distinction being that 99495 requires a face-to-face visit within 14 days of discharge while 99496 requires a face-to-face visit within 7 days of discharge. 1

Core Billing Requirements

Two-Tiered Code Structure

• CPT 99495: Transitional care management with moderate medical decision complexity, requiring a face-to-face visit within 14 days of discharge 1
• CPT 99496: Transitional care management with high medical decision complexity, requiring a face-to-face visit within 7 days of discharge 1

Essential Service Components

Both TCM codes require the following mandatory elements to be billable:

• Interactive contact within 2 business days of discharge (typically a phone call to the patient or caregiver) 2, 3
• Face-to-face visit with the provider within the specified timeframe (7 or 14 days depending on code) 2, 3
• Non-face-to-face services including medication reconciliation, coordination of care, and patient education 2, 3

Medical Decision-Making Complexity Criteria

Moderate Complexity (99495)

To qualify for moderate complexity medical decision-making, you must meet 2 out of 3 of the following elements 4:

• Multiple problems addressed during the encounter with uncertain prognosis
• Review and coordination of medical records, test results, or external communications
• Moderate risk of complications or morbidity from treatment decisions

High Complexity (99496)

High complexity requires more extensive problem-solving, data review, or higher risk management, typically involving patients with multiple comorbidities or unstable conditions requiring intensive post-discharge management 4

Documentation Requirements

Your documentation must clearly support:

• Date and time of the 2-day contact (phone call or other interactive communication) 3
• Date of the face-to-face visit and confirmation it occurred within the required timeframe 3
• Medication reconciliation with documentation of all medications reviewed and any changes made 5
• Review of discharge summary and hospital records 5
• Care coordination activities including communication with specialists, ordering tests, or arranging follow-up services 5
• Medical decision-making complexity justifying the code level selected 4

Telemedicine Considerations

TCM services can be provided via telemedicine with appropriate modifiers:

• Use Modifier 95 for audiovisual telehealth visits or Modifier 93 for audio-only visits when the face-to-face requirement is met via telemedicine 4
• The interactive 2-day contact can be telephonic, but the face-to-face visit must meet telemedicine standards if not conducted in person 1

Common Billing Pitfalls to Avoid

Only One Provider Can Bill

Only one provider or practice can bill TCM codes per discharge episode - if another practice bills first, you cannot submit a TCM claim for that same discharge 6. This is critical because nearly 25% of TCM claims are billed by practices that are not the patient's usual primary care provider 6.

Complete Service Bundle Required

You cannot bill TCM codes if you only complete part of the service (e.g., just the phone call without the visit). Research shows that 95% of patients do not receive both the TCM call and visit, making them ineligible for TCM billing 3.

Timing Is Strict

The 2-day contact and face-to-face visit deadlines are absolute requirements - missing either deadline means you cannot bill TCM codes for that discharge 2, 3.

Cannot Double-Bill

Do not bill separate E/M codes (99211-99215) for the face-to-face visit when billing TCM codes, as the visit is already included in the TCM reimbursement 4, 7.

Advance Care Planning Add-On

When appropriate, you can bill CPT 99497 and 99498 for advance care planning discussions during TCM visits, as these are separately reimbursable services that complement transitional care 1.

Clinical Impact

Patients who receive complete TCM services (both the 2-day contact and face-to-face visit) have significantly lower 30-day readmission rates (5.0% versus 11.9% for those who do not receive complete TCM services) 3.