In simple words: This code covers the doctor's work to manage a patient's care as they transition back home after leaving a healthcare facility (like a hospital or nursing facility).It includes a follow-up appointment within two weeks of leaving the facility, as well as phone calls, emails, or other communication to check in on the patient and help coordinate their ongoing care at home.

This code represents transitional care management (TCM) services for new or established patients transitioning from an inpatient hospital setting (including acute hospital, rehabilitation hospital, long-term acute care hospital), partial hospital, observation status in a hospital, or skilled nursing facility/nursing facility to a community setting (e.g., home, rest home, assisted living). TCM begins on the date of discharge and continues for 29 days. It includes one face-to-face visit within 14 days of discharge (for moderate medical decision-making complexity) along with non-face-to-face services performed by the physician or other qualified healthcare professional/clinical staff.Non-face-to-face services may include communication with the patient, family, or other professionals, care coordination, education, medication management, and resource identification.The physician's non-face-to-face services may involve reviewing discharge information, following up on tests, interacting with other healthcare professionals assuming patient care, patient education, referrals, and arranging community resources.

Example 1: A patient is discharged home after a hospital stay for pneumonia. The physician provides TCM services, including a follow-up visit, phone calls to check on the patient's progress, and coordination with home health services., An elderly patient is discharged from a skilled nursing facility after a hip replacement. The physician uses 99495 to bill for TCM services, which include a home visit, medication management, and coordination with physical therapy services. , A patient with complex medical conditions is discharged from the hospital after an exacerbation of heart failure.The physician provides TCM services, including frequent phone calls to monitor the patient’s condition, adjust medications, and coordinate care with a visiting nurse.

Documentation should include details of the patient's discharge, the initial contact within two business days, the date and content of the face-to-face visit, medication reconciliation, care coordination activities, level of medical decision making, and any communication with the patient, family, or other healthcare providers. The documentation must support the level of medical decision making and the need for TCM services.