Necessary Requirements to Bill for Transitional Care Services Using 99495 and 99496
| Step 1 |
| Interactive Contact with the Patient or Caregiver |
| ■ Within 2 business days following discharge from an inpatient setting to an outpatient setting. |
| ■ Contact may be way of a telephone call, email or face-to-face visit. |
| ■ Can be accomplished by the provider or competent clinical staff. |
| ■ Attempts to make contact should continue after the first 2 business days if initial contact is unsuccessful. |
| ■ If two or more separate contact attempts are made unsuccessfully and documented in the medical record one may bill for the TCM service if all other elements are met. |
| Step 2 |
| Non-Face-to-Face Services Provided by Physicians or APPs |
| ■ Acquire and review discharge information (e.g., discharge summary or continuity of care documents). |
| ■ Review need for or follow-up on pending diagnostic tests and treatments. |
| ■ Communicate with other health care professionals who will assume or reassume care of the patient's system-specific problems. |
| ■ Provide education to the patient, family, guardian, and/or caregiver. |
| ■ Establish or re-establish referrals and arrange for needed community resources. |
| ■ Assist in scheduling required follow-up with community providers and services. |
| Non-Face-to-Face Services Provided by Clinical Staff Under the Direction of a Physician or APP |
| ■ Communication with agencies and community services the patient uses. |
| ■ Provide education to the patient, family, guardian, and/or caretaker to support self-management, independent living, and activities of daily living. |
| ■ Evaluate and support treatment regimen adherence and medication management. |
| ■ Identify available community and health resources. |
| ■ Assist the patient and/or family in accessing needed care and services. |
| Step 3 |
| Face-to-Face Visit |
| ■ A face-to face visit is a required element of TCM billing. |
| ■ Services with moderate medical decision complexity with a face-to-face visit within 14 days of discharge use CPT code 99495. |
| ■ Services with high medical decision complexity with a face-to-face visit within 7 days of discharge use CPT code 99496. |
| ■ For eligible telehealth services, the use of a telecommunications system substitutes for an in-person encounter. |
APP, Advanced Practice Provider; CPT, Current Procedural Terminology; TCM, transitional care management.