Wondering about the new Transitional Care Management Services? Wonder no more!

What are Transitional Care Management Services?

March 8 2013 update: FAQ posted


In 2013 CPT defined two new CPT codes that describe a service to patient recently discharged from a hospital.  These two new codes, 99495 and 99496 can be found in your 2013 CPT book and have an effective date of January 1, 2013, so don’t use them until then.

99495:  Transitional Care Management Services with the following required elements:

  • Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 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:  Transitional Care Management Services with the following required elements:

  • Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge
  • Medical decision making of at least high complexity during the service period
  • Face-to-face visit, within 7 calendar days of discharge.

Even more exciting, CMS is going to recognize and pay for these services!  These services are intended to improve the care of a patient who is discharged from an inpatient or observation admission, skilled nursing facility or partial hospitalization program.  Despite the CPT definition of these as services provided to established patients, Medicare allows billing TCM to new or established patients.

Who may perform and bill for these services?

A physician, Nurse Practitioner, Physician Assistant or Clinical Nurse Specialist may bill for the service.  There is no restriction on specialty designation for the physician.  However, a surgeon may not bill the service on their patient who is in a global period.  Only one physician may bill for the TCM for any one patient’s discharge from the hospital, and the physician must wait until 30 days after the discharge to bill for the service.  The first physician who submits a claim will be paid.  The physician who discharges the patient may also provide TCM services for that patient, according to Medicare.

What does the service include?

First, in order to be eligible for the service, the patient’s medical and/or social problems must be of moderate or high complexity, as defined by the E/M Documentation Guidelines.  The service is defined as including the 29 days post discharge.  During that time, the clinician or clinical staff must:

  • Contact the patient within two business days of discharge, by phone, in person or by email
  • The clinician must have a face-to-face service with the patient within the time frames listed for each code above, and this first E/M service (typically, it will be an office visit but could be a home visit) is not separately reportable.  That is, the practice may not bill for this E/M service if it intends to bill TCM codes.  Medication reconciliation is required at that visit.
  • Non-face-to-face services by the clinical staff during the 29 day post-discharge period that includes: communication with the patient, caregiver, family, home health agency and/or other community services involved in the patient’s care; education to support activities of daily living; assessment and support of the treatment regimen and medication management; identification of community and health resources and facilitating access to these resources.
  • The clinician should obtain and review the discharge summary; review the need for pending or follow up diagnostic tests; interact with other healthcare professionals involved in the patient’s care; provide education of patient, or family, or caregiver; establish or reestablish referrals and assist in scheduling medical care or community care.

Can we bill any services during the 30-day post discharge period?

Yes.  Second and subsequent E/M services after the initial bundled E/M service may be reported.  Other diagnostic or therapeutic services may be billed.

How do we interpret moderate and high medical decision making?

The same way as it is interpreted using the Documentation Guidelines.  As a rule of thumb, 99214 requires moderate MDM and 99215 requires high complexity MDM.

Anything else we can’t report with these codes?

Well, yes.  The CPT book lists a series of codes that may not be reported with TCM codes 99495 or 99496.   The list includes some active, payable codes and many codes that would not be paid under the Medicare Physician Fee Schedule or most insurances.  (CPT develops the codes, and then Medicare and other third party payers develop reimbursement policies.  Just because there is a code doesn’t mean a practice can be paid for it.)  The codes that may not be billed with the TCM codes are Care Plan Oversight (99339, 99340, 99474-99380), prolonged services without patient contact (99358, 99359), anticoagulant management (99363, 99364), medical team conferences (99366–99368), education and training (98960-98962, 99441-99443), end stage renal disease services (90951-90970), online medical evaluation (98969, 99444). Preparation of special reports (99080), analysis of data (99090, 99091), complex care coordination services (99487—99489), or medication therapy services (99605—99607) during the time period covered by the TCM codes, which is 29 days after discharge.  Of course, many of the codes in the list above are not reimbursed by most Medicare.

Anything else we should know?

Document it. Document the non-face-to-face activities of the Transitional Care Management Services to show that the criterion are met.  Document medicine reconciliation, the first non-reported E/M service, contact within two days of discharge.   Review the list of what is included and document when performed.


127 thoughts on “Wondering about the new Transitional Care Management Services? Wonder no more!

  1. Betsy are you still monitoring this thread? If so I have a question I am still unclear about. Can I bill G0810 with transitional care? I understand I cannot bill care plan oversight but what about the initial certifications ordering home health? Thanks

    • You may bill for those. This is addressed in the comments. Also, read the CMS FAQ. It states that you may not report any service listed in CPT as bundled, and G0181 and G0182 but others can be reported.

      • In lieu of the State of California acknowledging pharmacists as practitioners, can pharmacists bill under a cms approved practitioner?

        Tracy W Becker PharmD,MBA,CDE

        Divisional Vice President

        Outpatient Services

        Comprehensive Pharmacy Services

        p: 724.438.7875


        eFax: 412.291.3253

        email: Tracy.Becker@cpspharm.com

        web: http://www.cpspharm.com

        Comprehensive Pharmacy Services (CPS) – Advancing Pharmacy Practice…one patient at a time

        Core Values: Integrity • Excellence • Patient Focused • Accountability • Servant Leadership

        Confidentiality Notice: This e-mail message, including any attachments, is for the sole use of the intended recipients and may contain confidential and/or privileged information. Any unauthorized review, use, disclosure or distribution is prohibited. If you are not the intended recipient, please contact the sender by reply e-mail, delete this message and destroy all copies thereof.

    • If you read the editorial comments from CPT, licensed professional is noted. Download the CMS FAQ that is at the start of the article and you’ll see that CMS side steps that question and sends us to incident to rules.

  2. Can a primary care provider bill the TCM codes for services unrelated to a surgery during the global period of a surgery provided by anothe specialty?

    • Yes, if medically necessary. Not all surgeries will require TCM. Be sure that the non-face-to-face services are needed and that the patient meets the complexity requirements for medical and psychosocial. The CPT book editorial comments describes these.

  3. The patient was discharged from the hospital on 1-22-15 & transferred to a SNF. The patient did not see the provider for a follow-up visit until 3-6-15. Can this be considered as a TCM? Contact was made several times in between with the patient.

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