E/M Codes for TCM Services

Two new CPT codes were approved in 2013, giving healthcare providers the opportunity to capture the full scope of their efforts while treating chronically ill patients. Specifically, patients with co-morbidities who frequently moved back and forth between their community and an acute care setting.

Download our free whitepaper, Making The Jump InTo Transitional Care Management Billing, for more on E/M codes for TCM services.

Transitional Care Management (TCM) aims to decrease readmission to acute care facilities by providing patients and their caregiver the ability to address needs as they arise. TCM services are different than other Evaluation and Management (E/M) codes because they span a period of time. It’s vital to understand E/M codes for TCM because they will allow your organization to be accurately reimbursed for the full spectrum of your efforts. Having a thorough understanding of TCM billing and documentation will safeguard your organization from critical auditing issues down the road.

The Two Approved E/M Codes For TCM Services

CPT® code 99495:

• Communication between the patient or caregiver and healthcare professional within two business days of discharge
• Moderate complexity Medical Decision Making during the 29 days post-discharge
• Face-to-face visit within 14 calendar days of discharge

CPT® code 99496:

• Communication between the patient or caregiver and healthcare professional within two business days of discharge
• High complexity Medical Decision Making during the 29 days post-discharge
• Face-to-face visit within 7 calendar days of discharge

More Terminology and Definitions

Current Procedural Terminology goes on to specify that:

• “Within 2 days of discharge is Monday through Friday except holidays without respect to normal practice hours or date of notification of discharge.”
• If your practice has normal practice hours on a Saturday, Saturday will also count as a normal business day during which you have a chance to make contact with your patient.
• If you attempt communication by any means, be it telephone, email, or face-to-face, and after two tries you are unsuccessful, document this in the patient’s chart and the service may be reported.

In relation to providing the first face-to-face visit:

• For CPT® code 99495, you have up to 14 days after discharge to see the patient face-to-face.
• For CPT® code 99496, you have up to 7 days to see your patient face-to-face to evaluate their status post-discharge.
• The first face-to-face visit is an integral part of the TCM service, and may NOT be reported with an E/M code. If, during the course of the next 29 days, additional E/M services are medically necessary, these may be reported separately. You cannot report an E/M and a TCM service on the same day.

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