Two new CPT Transitional Care Management (TCM) codes have been created to ensure better coordination of care and to provide better incentives so that patients are treated in a primary care physician (PCP). Codes 99495 and 99496 became available to PCPs in January this year and are part of CMS’ strategy to support primary care while helping patients avoid risk of readmission.

The services covered by these CPT codes are provided for a patient whose condition require moderate (99495) or high complexity (99496) medical decision-making when the responsibility of care is transferred from an inpatient hospital setting to the patient’s community setting (home, domiciliary, rest home, or assisted living).

Here are some points that PCPs need to know about billing for TCM services:

  • The community based PCP who submits claims for TCM services should have an ongoing relationship with the patient.
  • For services of moderate complexity (99495), the physician must have communicated (direct contact, telephone, electronic) with the patient within 2 business days after discharge and taken a medical decision of moderate complexity during the period. A face-to-face visit within 14 days post-discharge is also necessary.
  • For high complexity (99496) TCM services, there should be communication with the patient and/or caregiver within 2 business days after discharge, medical decision making of high complexity during the service period, and a face-to-face visit, within 7 days post-discharge.
  • The PCP has to review the discharge summary and decide if there is need for further communication with the physician responsible for discharge.
  • The discharging physician should maintain communication with the accepting community physician as necessary to perform billing for discharge day management services.

An important thing to note is that TCM services can be billed only once per patient within 30 days after the discharge. The TCM code can be billed if the patient’s face-to-face encounter takes place before the 7 to 14 days, but not if it occurs after the 14th calendar day.

Accurate medical billing for TCM depends on selecting the right codes for services rendered, making sure the discharge, communication and face-to-face encounter dates are correctly documented, and so on. A professional medical billing company can help primary care physicians get TCM medical billing and coding right for maximum reimbursement.