Transitional Care Management

by Steve Adams, CPC

CMS has approved the reimbursement for transitional care management (TCM) services – codes 99495 and 99496.

In simple language – CMS is trying to reduce hospital readmissions and ensure better outcomes for patients being discharged from an inpatient setting to an outpatient setting. They think they can do this if patients are contacted by telephone by a qualified employee of their primary care physician within two business days of discharge and then sees the patient in their office within seven calendar days for 99496 (high complexity) or fourteen calendar days for 99495 (moderate complexity). To encourage providers to help reduce the readmission rates, they have agreed to pay approximately $163 for 99495 and $230  for 99496.

To qualify for either the 99495 and/or 99496, the service must be documented and include the following:

  • Communication (face-to-face, telephonic, or electronic) within two business days after discharge to the patient
  • A face-to-face encounter within seven to fourteen days after discharge
  • Moderate (99495) to high medical decision-making (99496)

In the final rule, CMS was very clear that the first provider to bill would be the first provider to be reimbursed. If you are denied for this service, there is no appeal process available.

Some important information about these codes:

  • Billing this code assumes you will be responsible for the patient for a period of 30 days.
  • Have a qualified staff member contact the patient within two business days –not calendar days.
  • You must see the patient within the seven or fourteen calendar day thresholds. If you don’t see the patient within the fourteen days for the 99495, or within seven days for the 99496, OR don’t contact the patient within two business days – don’t bill the 99495 or 99496.
  • You must reconcile the patient’s medication prior to the first face-to-face service.
  • You should document the review of the discharge summary and document any additional communication that should be communicated to the patient and or responsible party by the qualified staff member.
  • The 99495 and/or 99496 include the reimbursement for the initial telephone call and the face-to-face visit with the seven or fourteen day period. You will not bill for these separately.
  • Additional medically necessary evaluation and management services after the seven or fourteen day face-to-face visit may be billed.
  • CMS advises providers to bill for the service at the end of the 30 day coverage period. In other words, 30 days following discharge.

Please make sure that you also document the following:

  • Patient’s discharge date
  • Date and name of individual making the first telephone call
  • That medications have been reconciled
  • The date of the provider’s first face-to-face encounter
  • That the discharge summary has been reviewed and relevant information was communicated to the patient or other responsible party
  • The medical decision making for the patient as either high (99496) or moderate (99495) I have developed a form that captures relevant information for the transitional care management codes and can forward a copy to you if you send me an email at:

One last note – you are not “required” to provide transitional care management services to your patients that are discharged from inpatient to outpatient status. Many of you will continue to bill a follow-up hospital visit in your office as an evaluation and management code (99201-99215) depending on the patient’s status with your office.

For additional information, Novitas (A Medicare Carrier) published a list of FAQs from its providers as it pertains to transitional care management.  Click here to view. 

Steve Adams, CPC, PCS is a Senior Consultant for InGauge Healthcare Solutions, Inc., an InHealth company.   Contact him for consulting and educational services at  Efficiency in Practice is the free eNewsletter for medical practice managers who want to save time, money and reduce risk.  For more information and to access your FREE report, Patient Collections: It’s Make or Break for Many Practices, visit 

This article can be reprinted freely online, as long as the entire article and this resource box are included.


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