Do You Understand the New Medicare Transitional Care Management Service Codes?


Effective January 1, 2013, Medicare and other payers will pay for two new CPT codes (99495 and 99496) that are used to report physician or qualifying non-physician practitioner transitional care management (TCM) service for patients, following a discharge from a:

  • Hospital
  • Skilled Nursing Facility (SNF)
  • Community Mental Health Center (CMHC)
  • Outpatient observation
  • Partial hospitalization

Using Transitional Health Codes in Your Practice

and including a transition to:

  • Home
  • Domiciliary
  • Rest Home
  • Assisted Living

These two codes require the medical decision-making to be of moderate to high complexity. Each code encompasses one face-to-face visit and non face-to-face services, for instance, arranging home health agencies for patient care.

Codes are selected based on medical decision-making associated with the patient’s condition, the time when the communication is initiated with the patient, and the time when the face-to-face encounter occurs following discharge. The first face-to-face encounter is included. The codes may be reported only once per 30 calendar days. See the full code description at the end of this article.

The following are FAQs on the codes with answers provided by CMS.

Q: What date of service should be used on the claim?
A: The 30-day period for the TCM service begins on the day of discharge and continues for the next 29 days. The reported date of service should be the 30th day.

Q: What place of service should be used on the claim?
A: The place of service reported on the claim should correspond to the place of service of the required face-to-face visit.

Q: If the codes became effective on Jan. 1 and, in general, cannot be billed until 29 days past discharge, will claims submitted before January 29th with the TCM codes be denied?
A: Because the TCM codes describe 30 days of services and because the TCM codes are new codes beginning on January 1, 2013, only 30-day periods beginning on or after January 1, 2013 are payable. Thus, the first payable date of service for TCM services is January 30, 2013.

Q: The CPT book describes services by the physician’s staff as “and/or licensed clinical staff under his or her direction.” Does this mean only RNs and LPNs, or may medical assistants also provide some parts of the TCM services?
A: Medicare encourages practitioners to follow CPT guidance in reporting TCM services. Medicare requires that when a practitioner bills Medicare for services and supplies commonly furnished in physician offices, the practitioner must meet the “incident to” requirements described in Chapter 15 Section 60 of the Benefit Policy Manual 100-02.

Q: Can the services be provided in a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC)?
A: While FQHCs and RHCs are not paid separately by Medicare under the Physician Fee Schedule (PFS), the face-to-face visit component of TCM services could qualify as a billable visit in an FQHC or RHC. Additionally, physicians or other qualified providers who have a separate fee-for-service practice when not working at the RHC or FQHC may bill the CPT TCM codes, subject to the other existing requirements for billing under the MPFS.

Q: If the patient is readmitted in the 30-day period, can TCM still be reported?
A: Yes, TCM services can still be reported as long as the services described by the code are furnished by the practitioner during the 30-day period, including the time following the second discharge. Alternatively, the practitioner can bill for TCM services following the second discharge for a full 30-day period as long as no other provider bills the service for the first discharge. CPT guidance for TCM services states that only one individual may report TCM services and only once per patient within 30 days of discharge. Another TCM may not be reported by the same individual or group for any subsequent discharge(s) within 30 days.

Q: Can TCM services be reported if the beneficiary dies prior the 30th day following discharge?
A: Because the TCM codes describe 30 days of care, in cases when the beneficiary dies prior to the 30th day, practitioners should not report TCM services but may report any face-to-face visits that occurred under the appropriate evaluation and management code.

Q: Medicare will only pay one physician or qualified practitioner for TCM services per beneficiary per 30 day period following a discharge. If more than one practitioner reports TCM services for a beneficiary, how will Medicare determine which practitioner to pay?
A: Medicare will only pay the first eligible claim submitted during the 30 day period that commences with the day of discharge. Other practitioners may continue to report other reasonable and necessary services, including other E/M services, to beneficiaries during those 30 days.

Open Door Forum Call Including TCM Code Information

CMS is holding a Open Door Forum on Tuesday, March 12, 2013, at 2:00 p.m. Eastern (ET) which will include some information about TCM codes, and an opportunity for listeners to ask individual questions of the presenters.

CALL AGENDA: (subject to change)

I. Opening Remarks

  • Chair – Stewart Streimer (CM)
  • Co-Chair – Dr. William Rogers (OPE)
  • Moderator – Barbara Cebuhar (in lieu of Matthew Brown, OPE)

II. Announcements & Updates

  • Physician Compare Website Redesign
  • DMEPOS Competitive Bidding
  • Ordering & Referring
  • Transitional Care Management:
  • Health Insurance Marketplace

III. Open Q&A

Open Door Participation Instructions:

To participate by phone:

Dial: 1-800-837-1935 & Reference Conference ID: 78871126. Call in 15 minutes before the start of the call.

Persons participating by phone do not need to RSVP

TTY Communications Relay Services are available for the Hearing Impaired.  For TTY services dial 7-1-1 or 1-800-855-2880. A Relay Communications Assistant will help.

Encore: 1-855-859-2056; Conference ID: 78871126.

Encore is an audio recording of this call that can be accessed by dialing 1-855-859-2056 and entering the Conference ID. This recording will be accessible beginning 2 hours after the ODF and expires after 3 business days.

99495 – 99496 Management Of Transitional Care Services

These codes include:

  • Moderate to high complexity medical decision making needs during care transition
  • First interaction (can be face-to-face, by telephone, or electronic) with patient or his/her caregiver and must be done within 2 working days of discharge. If two separate attempts are made in a timely manner, but are unsuccessful and other TCM criteria are met, the service may be reported. Medicare, however, expects attempts to communicate to continue until they are successful.
  • Initial face-to-face interaction within described time frame (99495 = 14 days and 99496 = 7 days) and include medication management
  • All services  from the discharge day up to 29 days post-discharge

Examples of non face-to-face services provided by physicians and non-physician providers included in TCM codes are:

  • Arrangement of follow-up and referrals with community resources and providers
  • Contacting qualified health care professionals for specific problems of patient
  • Review of discharge information
  • Need for follow-up care review based on tests and treatments
  • Patient, family and caregiver education

Note that the non-physicians who may bill TCM codes are Nurse Practitioners (NPs), Physician Assistants (PAs), Clinical Nurse Specialists (CNSs), and Certified Nurse Midwives (CNMs), unless they are otherwise limited by their state scope of practice.

Physicians reporting TCM codes are most likely to be primary care physicians, however other specialties may report them. Both CPT and Medicare prohibit a physician who reports a service with a global period of 10 or 90 days from also reporting the TCM service.

Examples of non face-to-face services provided by staff under the guidance of physicians and non-physician providers included in TCM codes are:

  • Caregiver education to family or patient, addressing independent living and self-management
  • Communication with patient and all caregivers and professionals regarding care
  • Determining which community and health resources would benefit the patient
  • Providing communication with home health and other patient-utilized services
  • Support for treatment and medication adherence
  • The facilitation of services and care

These TCM codes do not include (and may be billed separately):

  • E/M services after the first face-to-face visit
  • Tests and procedures

The following services cannot be billed during the time period covered by transitional care:

  • care plan oversight services (99339, 99340, 99374 – 99380)
  • prolonged services without direct patient contact (99358, 99359)
  • medical team conferences (99366 – 99368)
  • end stage renal disease services (90951 – 90970)
  • online medical evaluation services (98969, 99444)
  • education and training (98960 – 98962, 99071, 99078)
  • anticoagulant management (99363, 99364)
  • telephone services (98966 – 98968, 99441 – 99443)
  • preparation of special reports (99080)
  • analysis of data (99090, 99091)
  • complex chronic care coordination services (99481X – 99483X)
  • medication therapy management services (99605 – 99607)

99495 – Transitional Care Management Services (Medicare reimburses $163.99 for non-facility) 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 (Medicare reimburses $231.36 for non-facility) 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 (note that discharge and TCM may not be billed on the same day.)

What questions do you need to answer in your practice to insure you are correctly using the TCM codes?

  1. Have you spoken with all payers to determine which ones will reimburse you for TCM codes?
  2. If you do not see your patient in the hospital, how will you know your patient is in the hospital? Most hospitals/facilities should call you to schedule a follow-up visit for the patient, triggering a TCM event. If this is not being done, how will you know your patient has been discharged? Hospitals have a vested interest in making this work as they want to prevent readmissions, so they should be helpful in working on a communication plan.
  3. Who in your practice has primary responsibility for managing the discharged patients and triggering the first contact and face-to-face visit within the time frames? What manual or electronic tickler system will be used to alert staff?
  4. What forms for a paper chart or templates for an EMR will be needed for documentation of all services provided?
  5. Do your providers know the difference between moderate and high complexity medical decision making? If not, get them up to speed.
  6. Will your billing system flag the claim with the TCM code to be dropped at 30 days, or will you need an alert system to be sure the claim is dropped appropriately? Can your billing system be programmed to hold charges to review for TCM patients that will not be paid during the TCM period in addition to the TCM code? If not, what’s your plan?

Posted in: Collections, Billing & Coding, Day-to-Day Operations, Medical Coding Education, Medicare & Reimbursement, Medicare This Week

Leave a Comment (28) ↓


  1. Gerald Collins March 11, 2013

    In your Q & A above there is a slight error

    Q: Can the services be provided in a Federally Qualified Health Center (FQHC) or Rural Health Center (RHC)?

    The correct terminology is Rural Health Clinic (RHC) per CMS.

    • Mary Pat Whaley March 11, 2013


      Thanks so much for catching that – I’ll correct it!

      Best wishes,

      Mary Pat

  2. Cynthia Young March 21, 2013

    Good evening Mary –

    I’m trying to confirm two (2) questions regarding these new TCM codes/services:

    1. Can physicians write-off the co-pays?
    2. Can these services be provided in a SNF? I’ve read some conflicting information regarding this item, but most of the information that I’ve found say NO. Please advice and if you have the actual Medicare ruling on this that would be helpful.

    Thank you!

    • Mary Pat Whaley March 25, 2013

      Hi Cynthia,

      Nice to hear from you!

      1. The only way that I know of that physicians could/should write off co-pays/co-insurance is through a financial assistance program that facilitates write off for financial hardship. You need to develop hardship criteria and apply the same criteria to all patients. The key here is detailed documentation of the program and its application.

      2. From the FAQs I provided, Medicare does not indicate that the transition services are for transition from an inpatient hospital to a SNF, but from skilled care to a home or community based care such as assisted living. I have not seen this addressed anyplace directly from CMS.

      Best wishes,

      Mary Pat

  3. LaDawn March 26, 2013

    Q: What place of service should be used on the claim?
    A: The place of service reported on the claim should correspond to the place of service of the required face-to-face visit.

    Can you elaborate on the answer as I don’t fully understand? Can the provider bill POS 11?

    • Mary Pat Whaley March 27, 2013

      Hi LaDawn,

      Great clarifying question!

      The Transitional Care Management services include one face-to-face visit during the 30-day post-discharge period. Depending on where that face-to-face visit takes place, you would use the appropriate POS. The possibilities include POS 11 (office), POS 22 (outpatient hospital), POS 12 (home), POS 13 (assisted living facility), POS 50 (FQHC), or POS 72 (RHC).

      For a patient visit in a physician practice, you would use POS 11.

      Best wishes,

      Mary Pat

  4. Karen April 2, 2013

    Thank you for this info! May I run scenario by you? The patient presents for the face-to-face visit included in TCM. During the visit the patient reveals a new problem – unrelated to the reason for the hospitalization. The provider performs a seperately identifiable EM service along with the TCM visit. Can the EM related to the new problem be billed with -25 modifier and this still count as the face-to-face under TCM?

    • Mary Pat Whaley April 4, 2013

      Hi Karen,

      CMA states: Yes, other reasonable and necessary Medicare services may be reported during the 30 day period, with the exception of those services that cannot be reported according to CPT guidance and Medicare HCPCS codes G0181 and G0182.”

      That would leave us to believe that a sick visit ties to a separate diagnosis would be paid in conjunction wit the TCM, however, I have not seen your particular question answered by any reputable source. Until someone has tested it the old-fashioned way – by sending a claim out – we may not know the answer to that question. Different Medicare carriers may also have set up their claims systems differently, so one person using a carrier in one state may get a different answer from a different carrier in a different state. You might end up having to send in the medical record to substantiate the second service, or file an appeal.

      Have any other reader learned the answer to Karen’s question?

      Thank you,

      Mary Pat

  5. Tammy Angley April 5, 2013

    Hi Mary,

    We are very confused on these new codes.My question is what date to use to file 99495 and 99496? I know we need to see patient within 7 days or 7-14 days after discharge but we assume you cant use that date to file codes on 30th day. Also my question is do we file an E/M on the day we see them in the time frame of 7-14 days?

    • Mary Pat Whaley April 6, 2013

      Hi Tammy,

      These new codes are confusing!

      You are using the date of the 30th day of the TCM period for your date of service. Here’s an example:

      Mrs. Jones was discharged from the hospital on March 3, 2013. You contacted her on March 5th (within 2 days of discharge) to make sure things were going well with her transition and that she was following the discharge instructions given to her at the hospital. You scheduled her appointment with the physician at the practice for March 12th (within 14 days of discharge.) On April 1st, you process the claim for TCM services provided between March 3rd and April 1st, using the CPT code 99495 and date of service 4/1/2013. You do not use the E/M code for the visit during the 14 days, as that is included as part of the 99495.

      I hope this clarifies the process.

      Best wishes,

      Mary Pat

  6. JENNY July 11, 2013

    Do I need to put the hospital admission and discharge dates on the claim form when I file the TCM? When I have tried putting these dates and using the 30th day service date, I get an error on my electronic claim form that states the date of service is not within the hospitalization dates. I just wondered if I could leave the hospitalization dates off?

    • Mary Pat Whaley July 16, 2013

      Hi Jenny,

      You are correct – The admission and discharge dates should not be listed on the claim form!

      Best wishes,

      Mary Pat

  7. chris July 15, 2013

    This is the best, most helpful info on this topic I’ve found anywhere!!
    Keep up the good work Mary Pat !!

    Simple, concise and to the point of exactly what needs to go on the claims!

    • Mary Pat Whaley July 16, 2013

      Thanks, Chris. We always appreciate the feedback!

      Best wishes,

      Mary Pat

  8. carol July 19, 2013

    does the TCM code replaces the OV codes?? These codes are quite confusing. please clarify for me.
    thank you

    • Mary Pat Whaley July 29, 2013

      Hi Carol,

      Yes, the TCM code replaces the OV code for the face-to-face visit AND the non-face-to-face visit during the 30-day period.

      Best wishes,

      Mary Pat

  9. carol July 19, 2013

    If I’m billing the TCM code 99495 do i still use the E/M codes with this and is a Modifier used?
    Does the TCM code replaces the OV codes?? These codes are quite confusing. please clarify for me.
    thank you

    • Mary Pat Whaley July 29, 2013

      Hi Carol,

      The TCM codes cover the non-face-to-face visit with two days and the face-to-face visit within 7 or 14 days. You do not need an additional E/M or a modifier. If you see the patient again for a face-to-face visit during the 29 days after discharge, you may bill an additional E/M code, but I suggest billing it on a separate claim.

      Best wishes,

      Mary Pat

  10. June mcwilliams August 1, 2013


    I would like to get clarification on the terminology for this code… The CPT manual says Medical Team conferences include face-to-face participation by a minimum of three qualified healthcare professionals from different specialties….

    Our practice bills this code mostly for workers comp work status reports where the physician and the nurse case manager are present… I am confused because on some patient’s accounts code 99366 will pay with no problem… yet on the same patient’s account the code will deny because there is no mention in the notes of three professionals being present… We use a standard template where some of the verbiage never changes… so the standard line.. ” A nurse case manager was present for this visit…. ” never changes…

    Yesterday I spoke to an insurance rep. who said the code denied because “The treatment received and length of time less than 30 minutes not reported separately.” (???) Of course they are reading from scripts and the rep could not explain this denial to me… *smile…

    So the bottom line is do we need to have a third person present in the exam room and modify our notes to say as much? (I am not clear because the section that provides a definition of a medical team conference says “minimum of three qualified healthcare professionals…” but the other section that defines the specific code only says “team of healthcare professionals… ” What does “Team conference services of less than 30 minutes duration are not reported separately” mean.

    My apologies, I am not a coder… I am a biller so I am trying to gain an understanding of how to get this code paid or how to appeal the code when it denies… Thank you for your time…

    • Mary Pat Whaley August 6, 2013

      Hi June,

      This area is confusing.

      You do need to have three qualified health professionals from 3 different specialties or disciplines, so it can’t be just any three people, it must be at least three people collaborating on a patient’s care. I am not sure the case manager actually meets the definition of “qualified health professional.”

      The AMA (owners of CPT) state that “physician or other qualified healthcare professional” is an individual who is qualified by education, training, licensure/regulation (when applicable), and facility privileging (when applicable) who performs a professional service within his/her scope of practice and independently reports that professional service. These professionals are distinct from “clinical staff”. A clinical staff member is a person who works under the supervision of a physician or other qualified healthcare professional and who is allowed by law, regulation and facility policy to perform or assist in the performance of a specified professional service, but who does not individually report that professional service.

      Case managers are usually RNs and typically do not provide care and bill it to payers. They are employees or contractors for insurance companies and/or employers. Note that any qualified health professional that participates and bills for the medical team conference must have performed face-to-face evaluations or treatments of the patient, independent of any team conference, within the previous 60 days.

      An example of medical team conference would be when an oncologist, a maternal-fetal specialist and a nephrologist would meet to discuss a pregnant patient with kidney cancer (I just made that combination up!)

      When using the medical team conference code, you do have to report the amount of time spent because a team conference less than 30 minutes does not qualify – for example “I spent 43 minutes in a medical team conference with Dr. Jones and Dr. Smith on 8/6/13 for Mrs. XYZ.” This is what “The treatment received and length of time less than 30 minutes not reported separately” and “Team conference services of less than 30 minutes duration are not reported separately” means. If it is less than 30 minutes, it is not eligible for reimbursement.

      I hope this answers your question.

      Best wishes,

      Mary Pat

  11. Rex August 6, 2013

    Mary Pat, we are in discussions with our physicians and auditors about what time period the medical decision making (MDM) covers. Some believe that it is the first face-to-face visit and everything that happened prior to that visit. Some believe that the service period is defined by the entire 30 day period and that is what should be used to decide the MDM. Would love to know your thoughts and what the buzz at CMS might be. Can you help?

    • Mary Pat Whaley August 6, 2013

      Hi Rex,

      The MDM is directly related to the face-to-face visit.

      The 99495 code descriptions states “Medical decision making of at least moderate complexity during the service period face-to-face,” which is rather clunky way of saying “during the F2F visit performed during the 30-day post-discharge period.

      The same is true for 99496, but substituting “high complexity” for “at least moderate complexity.”

      Keep in mind that any F2F visits after the original visit are separately billable using standard outpatient established patient E/M codes.

      Best wishes,

      Mary Pat

  12. Harikrishnan August 17, 2013

    Excellent answer and information on TCM thanking you for this info, it was really useful for us.

  13. Christie Carman August 26, 2013

    Can this be a TCM following up an Emergency Room visit as well?

    • Mary Pat Whaley August 26, 2013

      Hi Christie,

      The TCM codes are not appropriate for after an emergency room visit. It is for transition back into the community after a hospitalization or stint in other inpatient-type facility.

      Best wishes,

      Mary Pat

  14. Kathy August 28, 2013

    Very useful information!! But I want to gain clarity here. Example, if a pt was discharged on 02/11/13, and provider reported 99496 for DOS 02/17/13, Medicare had denied the claim as guidelines not met as in the DOS should be reported on the 29th day from DOD. Are you saying that provider should have reported DOS 03/12/13?

    • Mary Pat Whaley August 29, 2013

      Hi Kathy,

      Per Medicare: “The 30-day period for the TCM service begins on the day of discharge and continues for the next 29 days. The reported date of service should be the 30th day.”

      In your example, 2/11/13 (date of discharge) is Day One. Day Thirty (and the date of service for the TCM code) is indeed 3/12/13, however, it has come to my attention that some MACs are using the first day after discharge as Day One, in which case Day Thirty would be 3/13/13. It’s unfortunate that it has to be so darn complicated. Also, be sure that the discharging hospital has filed their claim, as the TCM is not supposed to pay if there is no claim from the hospital with the discharge date.

      Remember that if you see the patient again during the 30-day period, you CAN charge another E/M code for the service.

      Best wishes,

      Mary Pat