99495-99496: Two New Codes to Report Transitional Care Management (TCM) Services

Nancy B. Alston

Primary care specialties will receive the largest increase in payment by virtue of a new payment for managing a Medicare beneficiary’s care when the beneficiary is discharged from an outpatient hospital observation, inpatient hospital, community mental health center, partial hospitalization services or from an SNF. While announcing its new policy, CMS acknowledged that the extensive non-face-to-face care coordination provided by physicians and nurses was not considered in the existing payment schedule for E/M (Evaluation & Management) services. The new directive will provide payments for physicians as well as other healthcare providers for coordinating care transitions of Medicare beneficiaries after they are discharged from hospitals/skilled nursing facilities to assisted living facilities or their own homes. The new rule is effective from January 1, 2013.

The New Codes: 99495 & 99496

CMS has a clear objective in introducing these new codes for Transitional Care Management (TCM) services. They are intended to prevent emergency department visits and re-hospitalizations during the first 30 days after discharge. Apart from primary care physicians who would be billing for most of these services, specialists who provide necessary services can also bill these new CPT codes.

TCM Code Requirements

  • 99495, TCM: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within two 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, TCM: Communication (direct contact, telephone, electronic) with patient and/or caregiver within two business days of discharge; Medical decision-making of high complexity during the service period, face-to-face visit within seven calendar days of discharge.

It is to be noted that both these codes necessitate communication with the patient and/or care provider within two business days of discharge, plus a face-to-face visit with the patient within a fixed time period. Decision regarding medication and management must be made at least by the day of the face-to-face visit.

Non face-to-face care coordination services can be carried out by the provider and/or licensed clinical staff under his/her direction. However, the face-to-face visit is to be performed by the providers themselves with staff assistance.

Fee Schedule for the New TCM Codes

The values assigned to the new TCM codes are 4.82 relative value units for Code 99495 and 6.79 relative value units for Code 99496. Provided the Congress prevents the impending 26.5% cut to payments for physicians and maintains the current conversion factor of $34.0066, the payments for these codes will be:

In non-facility (Physician office) settings:

  • Code 99495: $163.91
  • Code 99496: $230.90

In facility (Outpatient hospital) settings:

  • Code 99495: $134.67
  • Code 99496: $197.58

These codes can be billed only after at least 30 days post discharge, when the service period is completed. The primary care incentive payments will not be added to these amounts.

Points to Keep in Mind

  • Make sure that you bill only for post-discharge patients who require moderate or high-complexity medical decision making.
  • The initial face-to-face visit need not necessarily be in the office.
  • The first face-to-face visit with the patient after discharge is part of the TCM service and cannot be reported separately. E/M services provided additionally can be reported separately.
  • Documentation guidelines for E/M are not applicable to these codes. Providers must therefore take into account how they would like to document the non face-to-face services that are required by codes. Complexity of the medical decision making, timing of the first communication after discharge, and date of the face-to-face visit will have to be documented.
  • Providers can use these codes to bill for new as well as established patients.
  • Discharge services and the face-to-face visit required under the TCM code cannot be provided on the same day. However, the same practitioner who bills for discharge services can also bill for TCM services. Importantly, the same practitioner cannot report TCM services provided during a post-surgery period for a service with a global period since it is understood that these services are already included in the payment for the underlying procedure.
  • A very important point to remember is that only one practitioner can bill for TCM services during the 30 days post discharge of a patient. The first practitioner to bill for the service alone will receive reimbursement. Therefore, practitioners should necessarily communicate with the patient and/or caregiver, and the discharging physician to be clear about who will be managing the TCM services.
  • Practitioners can bill for TCM only once in the 30 days after discharge even if the patient happens to be discharged 2 or more times within the 30-day period.
  • Providers cannot bill for other care coordination services (such as care plan oversight codes 99339, 99340, 99374 – 99380) provided during the TCM period.
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