Medical coding for transitional care management

Current procedural terminology codes (CPT) are developed by the Relative Value Scale Update Committee (RUC), which is a special subsection of the American Medical Association (AMA). The AMA RUC consists of a panel of health policy experts, physicians, and other diverse stake holders who define the CPT codes, which new ones need to be developed, and those which require revision. At times, major payors such as the Centers for Medicare and Medicaid Services (CMS) collaborate with the AMA to develop and revise codes as needed. Large influential payors, especially those affiliated with Federal and State governments, can have a stake in the development and revision of codes. Payors are equally concerned about delivering the proper care as well as the accurate documentation of services in order to aggregate encounter data. This is used to improve care, reduce cost and build efficiencies within the healthcare delivery system.

Transitional care management

Amongst some of the newer code sets to be released within the last few years are transitional care management (TCM) codes. Transitional care management follows the handoff of a patient from the inpatient setting to the outpatient setting and is more than just an office visit after discharge. It involves the oversight, management and coordination of medical services, psychosocial services, and community needs. This may involve mental health, nutritional care, and activities of daily living. This helps ensure that the patient makes a better transition back into the community while they recover.

Over the years there has been increasing awareness that patients who leave the inpatient setting need additional services to transition them to a lower level of care, or to the private home or domiciliary environment. Better recovery and reduced readmission is as much about clinical care as it is about other facets of psychosocial and community needs. Transitioning patients in a smoother fashion also can improve their overall wellbeing and limit mental and emotional externalities associated with medical intervention and chronic disease. Community physicians often faced the brunt of these transitional care services but had few options to document them and receive reimbursement.

New Codes – CMS & AMA

CMS and AMA have worked cooperatively to develop codes for transitional care management and chronic care management. An initial proposed rule was made by CMS in 2012 which paved the way for the AMA’s RUC to create CPT codes for this purpose, and assign descriptions and relative value units. In 2015 the entire care management services section of the CPT book underwent changes in which complex chronic care coordination codes were revised and transitional care management codes were added. The transitional care codes are as follows:

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 high complexity during the service period
  • Face-to-face visit within 7 calendar days of discharge

The TCM codes require moderate or high medical decision making depending on the nature of the patient. Additionally, there is a time requirement. To bill a 99495 the patient must be seen within 14 days and to bill a 99496 code the patient must been seen within 7 days. The three elements are the time frame to see the patient, the complexity of medical decision making, and the face to face requirement.

Eligible providers and discharge locations

Providers who are eligible to bill for transitional care services include MDs and DOs of any specialty as well as other qualified health care professionals including physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse midwives. The requirement for a comprehensive medical evaluation limits allied health professionals from providing this service. Rural health clinic or federally qualified health center services cannot bill for these services either, but qualified providers who practice in these settings may be able to bill for TCM outside the clinic on a fee for service basis.

Eligible locations of discharge include acute care hospitals, rehabilitation hospitals, long term acute care facilities, and skilled nursing facilities. Full hospitalization is not required, as partial hospitalization and release from observation status also qualifies. The discharge must be made into the community setting such as a private home, domiciliary or rest home, and assisted living facility. Step down care from a hospital to a skilled nursing facility does not qualify as an eligible discharge; the discharge must be into an outpatient community setting.

Coordination of care

True coordination of care is the key to a successful hand-off. The discharging physician should communicate with the receiving community physician who is providing the TCM services, as necessary. As part of the discharge process and inpatient reimbursement, the discharging physician should be providing some level of care coordination to the community physician. If the same physician or provider within the same practice is discharging and receiving the outpatient, then CMS views physicians of the same specialty who are within the same tax ID to be the same person/provider.

Once the receiving physician sees the patient they need to look at the discharge summary and outgoing care in order to decide what else needs to occur (ie medical evaluation, referrals, psycho-social needs, etc). These all amount to services within the three needed areas of transitional care management.

Initial Contact Requirement

Initial contact with the patient needs to be made within two business days of discharge, and this does not include weekends. However, if all other TCM requirements of the patient were met and it took longer than two days to establish contact, payment would still be considered by CMS. This is due to the fact that some patients may be unreachable following discharge and proper documentation is critical in such instances in order to receive payment. Initial contact with the patient can be in-person, by phone, or by electronic means.

The initial patient contact needs to be provided by a clinical staff member such as a physician or medical mid-level (PA, NP). This is critical in order to cover the medical encounter requirement. As mentioned, providers who cannot fulfill the medical evaluation requirement cannot bill for such services. If the discharging physician is the same as the receiving physician, they cannot use the discharge visit to qualify for the TCM services. This is still part of the discharge and the TCM encounter needs to be a separate visit entirely. Additionally, the patient’s medication reconciliation needs to happen within two days of the initial face to face visit. If the patient is readmitted to the hospital or dies within the 30 day TCM period, then the E&M component can still be billed separately so long as sufficient documentation is provided. If other unrelated medically-necessary E&Ms are required then those can be billed separately unless physicians are providing services that have a global period associated with them.


Transitional care management services are vital to discharged patients and can help improve the recovery process as well as prevent readmission. This is especially relevant for patients with multiple chronic conditions and comorbidities. However, like most new and complex services and codes, these must be carefully documented in order to receive reimbursement. If a practice is providing such services then it is important that the entire office and care team is on board in order to meet the billing requirements. Additionally, improved coordination with the discharging physician or entity is needed to make sure the time and service requirements are met.


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