2025 CPT code 99496
(Active) Effective Date: N/A Revision Date: N/A Evaluation and Management - Transitional Care Management Services Evaluation and Management Feed
Transitional care management services involving high-level medical decision-making, requiring a face-to-face visit within 7 days of discharge.
Modifiers may be applicable depending on the specific circumstances of service.Refer to the official CPT manual for guidance.
Medical necessity is established by the patient's need for comprehensive care coordination and management during their transition from an inpatient setting.This ensures a safe and efficient transition, reducing the risk of readmission and improving patient outcomes.
The physician or other qualified healthcare professional is responsible for managing the patient's transition of care, coordinating services with other providers, and ensuring a smooth transition to the community setting. This includes proactive communication with the patient and care team, medication reconciliation, and addressing any immediate needs or concerns.
In simple words: This code covers the doctor's care for a patient after they leave the hospital and go home. It includes a visit with the doctor within 7 days and other support to make sure the transition is smooth.
CPT code 99496 reports transitional care management (TCM) services for patients requiring a high level of medical decision-making during their transition from an inpatient setting (hospital, skilled nursing facility, etc.) to their community setting.This includes a face-to-face visit within 7 calendar days of discharge, along with non-face-to-face services such as communication with the patient and other healthcare providers, medication reconciliation, and care coordination.The initial contact with the patient or caregiver must occur within two business days of discharge. The face-to-face visit is part of the TCM service and isn't billed separately; additional E&M services on subsequent dates may be billed separately.
Example 1: A 70-year-old patient is discharged from the hospital following a hip replacement. The physician performs a face-to-face visit within 7 days, coordinates home health services, reviews medication reconciliation, and addresses concerns about post-operative pain management and physical therapy., A 60-year-old patient is discharged from a skilled nursing facility after a stroke. The physician conducts a face-to-face visit within 7 days to assess the patient's recovery and coordinates with a rehabilitation center for ongoing physical and occupational therapy.The physician also reconciles medications and addresses family concerns about the patient's progress., A 55-year-old patient is discharged from the hospital following a heart attack. The physician performs a face-to-face visit within 7 days, adjusts medication based on the patient's current condition, facilitates cardiac rehabilitation, and addresses concerns about dietary changes and lifestyle modifications.
* Documentation of the initial contact (within 2 business days of discharge)* Date and details of the face-to-face visit (within 7 days of discharge)* Evidence of high-level medical decision-making.* Documentation of any non-face-to-face services provided (communication with patient, family, other providers; medication reconciliation).* Discharge summary review.
** Only one provider may bill for TCM services per patient within 30 days of discharge.The face-to-face visit must occur before the end of the 30-day period.The same provider may bill for both discharge services and TCM, but the discharge services may not substitute for the required face-to-face visit.
- Revenue Code: Y1 (OTHER - MEDICARE FEE SCHEDULE)
- RVU: The RVUs for this code vary based on location and payer.Consult the CMS Physician Fee Schedule for the most up-to-date information.
- Global Days: The global period for 99496 is the 30-day period following discharge.The face-to-face visit and other included services must fall within this timeframe.
- Payment Status: Active
- Modifier TC rule: Not applicable.
- Fee Schedule: Historical fee schedule data varies depending on the payer and location.Consult historical CMS Physician Fee Schedules for more information.
- Specialties:Family Medicine, Internal Medicine, Cardiology, Neurology, and other specialties depending on patient needs.
- Place of Service:Office, Home, Assisted Living Facility, other locations as appropriate.