CPT 99495 & 99496: Description, Rules & Reimbursement Guide

By Sudeep Bath | January 30, 2024

Transitional care is one of the most vulnerable points in a patient’s journey, and getting it wrong can quickly lead to complications, readmissions, and higher costs. CPT codes 99495 and 99496 were created specifically to recognize the time, coordination, and clinical judgment required to safely guide patients from hospital or facility discharge back to their home or community setting. This comprehensive guide breaks down the 99495 and 99496 CPT code descriptions, eligibility criteria, documentation requirements, and reimbursement rules so providers, billers, and practice leaders can confidently capture every compliant dollar while improving continuity of care.

Table of Contents

What Are CPT 99495 and 99496?

Transitional Care Management (TCM) is a set of services that supports patients as they move from an inpatient setting (such as a hospital, SNF, or partial hospitalization) back to their home or community setting. To bill for this work under Medicare and many commercial payers, providers primarily use CPT 99495 and CPT 99496.

CPT 99495:
TCM services with moderate medical decision-making complexity and a required face-to-face visit within 14 calendar days of discharge.
CPT 99496:
TCM services with high medical decision-making complexity and a required face-to-face visit within 7 calendar days of discharge.

Both codes cover a 30-day TCM period, beginning on the date of discharge from the qualifying facility and extending for the next 29 days.

99495 CPT Code Description in Detail

The official 99495 CPT code description (paraphrased) refers to TCM services with moderate complexity medical decision-making, with communication initiated within 2 business days of discharge and a face-to-face visit within 14 days.

Key elements of CPT 99495 description:

Service type: Transitional Care Management (TCM) with moderate complexity MDM.

Communication requirement:

Direct contact (phone, electronic, or in-person) with the patient or caregiver must occur within 2 business days of discharge.

Face-to-face visit requirement:

At least one in-person visit within 14 calendar days of discharge.

Medical decision-making level:

At least moderate complexity MDM during the 30-day TCM period.

Covered work includes:

Reviewing discharge information and summaries.
Medication reconciliation and management.
Coordination with community services and other clinicians.
Managing new or existing conditions that arose during hospitalization.

The 99495 CPT code description is built to reflect situations where the patient is at meaningful risk after discharge but does not require the highest level of complexity and intensity captured by 99496.

99496 CPT Code Description in Detail

The 99496 CPT code description (paraphrased) covers TCM services with medical decision-making of high complexity, communication within 2 business days, and a face-to-face visit within 7 days of discharge.

Key elements of CPT 99496 description:

Service type: Transitional Care Management with high complexity MDM.

Communication requirement:

Direct contact, telephone, or electronic communication with the patient or caregiver within 2 business days of discharge.

Face-to-face visit requirement:

At least one in-person visit within 7 calendar days of discharge, not via telehealth if the payer requires an in-person encounter.

Medical decision-making level:

High complexity MDM during the 30-day TCM period.
Clinical scenarios typically include patients with:
Multiple comorbidities and unstable conditions.
Recent serious acute events (e.g., stroke, MI, advanced decompensation) requiring complex post-discharge management.

The 99496 CPT code description emphasizes the need for more intensive follow-up and higher clinical risk, which justifies higher reimbursement.

Side-by-side Overview: 99495 vs 99496

Aspect	CPT 99495 (Moderate TCM)	CPT 99496 (High TCM)
Primary use	Transitional care with moderate complexity MDM	Transitional care with high complexity MDM
99495 / 99496 cpt code description	TCM, communication ≤ 2 business days, visit ≤ 14 days, moderate MDM	TCM, communication ≤ 2 business days, visit ≤ 7 days, high MDM
Required communication	Within 2 business days of discharge (phone, electronic, or in-person)	Same: within 2 business days of discharge
Required face-to-face visit	In-person visit within 14 days of discharge	In-person visit within 7 days of discharge
MDM level	At least moderate complexity	High complexity
TCM period	30 days post-discharge (same for both codes)	30 days post-discharge (same for both codes)
99495 cpt code reimbursement	National average around low–200 USD range (varies by payer & year)	Higher than 99495; often around upper-200s or more, varies by payer
Telehealth usage	Certain elements may be delivered via telehealth if payer allows	Same; requirements differ by payer and policy

Eligibility Criteria for Billing TCM (Both Codes)

For both CPT 99495 and CPT 99496, several core eligibility rules apply.

Eligible settings (discharge from):

Inpatient acute care hospital.
Inpatient psychiatric facility.
Long-term care hospital.
Skilled nursing facility (SNF).
Inpatient rehabilitation facility.
Hospital outpatient observation or partial hospitalization.

Destination setting:

Patient must be transitioning to home, domiciliary, rest home, or assisted living equivalent.

TCM period:

30 days, starting on the date of discharge (Day 1) and continuing through Day 30.

Provider types:

Physicians and certain qualified non-physician practitioners (e.g., NPs, PAs, CNSs) may bill TCM, depending on payer policy.
Only one TCM code (99495 or 99496) can be billed per patient per 30-day period, and only one provider or group may bill during that period.

Required Components: Communication, Visit, and MDM

Both codes share the same structural requirements; the key differences are timing and level of medical decision-making.

Initial Communication (within 2 business days)

Must be a documented contact with the patient or caregiver: phone, secure messaging, patient portal, or in-person.
Can be performed by clinical staff under the direction of the billing provider, depending on payer rules.

Face-to-face Visit

For 99495: one in-person visit within 14 days of discharge.
For 99496: one in-person visit within 7 days of discharge.
The date of service reported for TCM is the date of this face-to-face visit, not the discharge date.

Ongoing Medical Management over 30 Days

Medication reconciliation and management.
Review of diagnostic tests and follow-up labs.
Coordination with specialists, home health, and community resources.
Education and support for patient and caregiver regarding the care plan.

Medical Decision-Making: Moderate vs High

Choosing between CPT 99495 vs 99496 depends on the complexity of medical decision-making (MDM) documented during the TCM period.

Moderate complexity (99495) typically includes:

Multiple chronic conditions with some risk of exacerbation.
Prescription drug management with some adjustments.
Need for reviewing test results and coordinating care but without high immediate risk.

High complexity (99496) often involves:

Serious acute or chronic conditions with significant risk of morbidity/mortality.
Complex medication regimens, polypharmacy, high-risk drugs, or major adjustments.
Intensive coordination with multiple specialists, frequent changes to the care plan, or high risk of readmission.

Payers expect documentation clearly supporting the selected MDM level, aligned with current E/M guidelines.

99495 CPT Code Reimbursement

99495 cpt code reimbursement varies by payer, region, contract, and year, but is generally lower than 99496 because it represents moderate, not high, complexity.

Key reimbursement points for CPT 99495:

Medicare national average

Often around the low-200 USD range as a typical benchmark, though exact figures change annually.

Commercial payer reimbursement

May be higher or lower than Medicare, depending on negotiated contracts and local fee schedules.

Payment limitations

Only one TCM claim (99495 or 99496) per 30-day period per patient.
If TCM criteria are not fully met (communication, visit timing, MDM level), reimbursement may be denied or downgraded.

Because rates update regularly, practices should verify current 99495 reimbursement in payer-specific fee schedules or tools.

99496 CPT Code Reimbursement

99496 cpt code reimbursement is higher than 99495, reflecting the high complexity and stricter 7-day follow-up requirement.

Key reimbursement points for CPT 99496:

National average trends

Frequently higher than 99495, often in the upper-200 USD range or above, depending on payer and year.

Variation by payer

Payer-specific data show a wide range of allowed amounts from roughly low-200s to over 400 USD in some contracts.

Documentation sensitivity

Payers scrutinize 99496 claims to ensure high-complexity MDM and timely face-to-face encounters are clearly documented.

Practices should routinely check their internal reports and payer fee schedules to monitor 99496 reimbursement and denial patterns.

Billing Rules and Common Denials

Accurate billing for CPT 99495 and 99496 requires aligning with CMS and payer guidelines.

Common billing rules:

Only one TCM code per 30-day period per patient.
The date of service is the date of the face-to-face visit, not the discharge date.
TCM cannot overlap with certain other codes (e.g., some global surgical packages or care management codes) during the same period, depending on payer policy.

Common reasons for denial:

No documented contact within 2 business days of discharge.
Face-to-face visit occurred outside the required 7-day (99496) or 14-day (99495) window.
Insufficient documentation to support moderate or high complexity MDM.
Another provider already billed TCM for that 30-day period.

Documentation Checklist for 99495 and 99496

To protect 99495 / 99496 cpt code reimbursement, documentation must transparently show that all components were met.

Recommended elements to capture:

Discharge details

Date of discharge.
Discharging facility and reason for admission.

Initial communication

Date/time of phone or electronic contact.
Who was contacted (patient, caregiver), and by whom (staff or provider).

Face-to-face visit

Date of visit (this becomes the billed DOS).
Location of visit (office, home, assisted living).
Summary of exam, risk assessment, and plan of care.

Medical decision-making details

Number and complexity of problems addressed.
Data reviewed (labs, imaging, external notes).
Risk of complications, morbidity, or mortality.

Care coordination

Communication with specialists, home health agencies, or community services.
Medication reconciliation entries and any changes.

A clear, structured note makes it easier to support either 99495 or 99496 during audits.

Best Practices to Maximize TCM Revenue and Outcomes

For providers using 99495 and 99496, a structured workflow improves both patient outcomes and revenue integrity.

Suggested best practices:

Create a standardized TCM workflow

Discharge notification → eligibility check → same-day assignment to care team → scheduled follow-up.

Use a TCM tracking dashboard

Track days since discharge, pending calls, and upcoming face-to-face visits to avoid missing the 2-day and 7/14-day windows.

Leverage clinical staff

RNs or care coordinators can handle initial outreach and much of the care coordination, under provider supervision.

Align TCM with other value-based programs

TCM helps reduce readmissions, which benefits ACOs and value-based contracts.

With well-designed processes and compliant documentation, both 99495 cpt code reimbursement and 99496 cpt code reimbursement can significantly support practices managing complex transitions of care while improving patient safety.

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Frequently Asked Questions (FAQs)

Q1. What is Transitional Care Management (TCM)?

TCM refers to services provided to patients transitioning from an inpatient setting (hospital, rehab, skilled nursing facility) back to their community setting. It ensures smooth care coordination, reduces readmission risks, and improves patient outcomes during the 30‑day post‑discharge period.

Q2. What are CPT codes 99495 and 99496?

99495: TCM with moderate medical decision‑making and a face‑to‑face visit within 14 days of discharge.
99496: TCM with high‑complexity medical decision‑making and a face‑to‑face visit within 7 days of discharge.

Q3. Who can bill for TCM codes?

Physicians, nurse practitioners (NPs), physician assistants (PAs), clinical nurse specialists (CNSs), and certified nurse midwives can bill for these services, often with support from clinical staff under direct or general supervision.

Q4. What services are included in TCM?

Initial contact with the patient or caregiver within 2 business days of discharge (via phone, email, or in person)
Medication reconciliation to ensure safe post‑discharge care
Care coordination with specialists, therapists, and community services
A timely face‑to‑face visit based on complexity (7 or 14 days)

Q5. What is the difference between 99495 and 99496?

The difference lies in medical decision‑making complexity and timing of the follow‑up visit:

99495: Moderate complexity; visit within 14 days.
99496: High complexity; visit within 7 days.

Q6. How much time is required for these codes?

There’s no specific time requirement, but providers must document all non‑face‑to‑face activities (care coordination, chart review, patient/caregiver education) performed during the 30‑day post‑discharge period.

Q7. Can TCM services be delivered via telehealth?

Yes. The interactive contact and even the face‑to‑face visit can be performed through approved telehealth platforms if all Medicare guidelines are met.

Q8. How often can TCM be billed?

TCM codes can be billed once per patient per 30‑day transition period. Only one provider may bill for TCM during that period, even if multiple specialists are involved.

Q9. What documentation is required for TCM?