CPT Code 99495: Transitional Care Management (Moderate Complexity)

What is CPT code 99495?

CPT code 99495 represents transitional care management (TCM) services with moderate medical complexity provided to patients transitioning from inpatient to community settings. This code is part of the care management CPT codes introduced by the Centers for Medicare & Medicaid Services (CMS) for a unified way of coding medical services to address patients' challenges during the immediate post-discharge period.

Transitional care management services begin on the date of the patient's discharge from an inpatient setting and continue for the next 29 days. These services include:

• Communication with the patient or caregiver within two business days of discharge
• Medical decision making of at least moderate complexity
• A face-to-face visit within 14 days of discharge

Who can provide TCM services?

Eligible billing practitioners for TCM services include:

• Physicians
• Nurse practitioners
• Physician assistants
• Clinical nurse specialists
• Certified nurse midwives
• Qualified health professionals working under the supervision of these providers

This is also essential for establishments like community mental health centers or skilled nursing facilities, where transition often occurs. It's important to note that only one healthcare provider may report TCM services for a patient during the 30 days following discharge.

CPT code 99495 documentation requirements

To support billing for transitional care management, CPT code 99495, documentation must include:

• Date of the patient's hospital discharge or discharge from another inpatient facility stay
• Direct contact with the patient or caregiver within two business days of discharge. This contact may be face-to-face, by telephone, or by electronic means. Documentation should include the date, time, and method of contact.
• Face-to-face visit within 14 days of discharge
• Moderate medical decision complexity requiring multiple diagnoses or management options, moderate complexity of data to be reviewed.

Additional documentation components

Comprehensive documentation should also include:

• Medication management and reconciliation
• Review and ordering of diagnostic tests as appropriate
• Patient education and follow-up instructions
• Coordination with other healthcare providers or community settings
• Arrangements for additional services needed to support patients with complex medical conditions

CPT code 99495 billing guidelines

Successfully reporting TCM services requires understanding specific billing guidelines to avoid claim denials and ensure proper TCM reimbursement.

TCM services begin on the day of discharge and continue for the next 29 days. The key timing requirements include:

• Initial direct patient contact must occur within two business days of discharge
• The required face-to-face visit must occur within 14 days of discharge for moderate medical complexity cases (CPT code 99495)
• For high medical complexity cases (CPT code 99496), the face visit must occur within 7 days

Medicare transitional care management coverage includes both CPT codes 99495 and 99496. The reimbursement for TCM services varies based on:

• Geographic location
• Type of facility (e.g., community mental health center vs. private practice)
• Patient's specific insurance coverage

Other relevant codes

When working with transitional care management, it's important to be familiar with related codes:

• CPT code 99496: Transitional care management services with high medical decision complexity requiring a face-to-face visit within 7 days of discharge
• CPT code 99483: Cognitive assessment and care planning
• CPT codes 99484-99484: General behavioral health integration
• CPT codes 99091, 99453-99454, 99457-99458: Remote patient monitoring services