top of page

CPT 99495
Description, Billing Rules, and Use Cases

CPT 99495 is used to report Transitional Care Management (TCM) services provided after a patient is discharged from a hospital, skilled nursing facility, or other qualifying setting. The code reflects a coordinated care period that includes contact within 2 business days and a face-to-face visit within 14 calendar days. CPT 99495 requires moderate medical decision making and supports improved outcomes during the high-risk post-discharge window.

What is CPT Code 99495?

CPT 99495 is a time-sensitive care management code used to support a patient’s transition from inpatient or institutional care back to a community setting. It applies to the first 29 days following discharge and covers both non-face-to-face care coordination and one in-person visit that occurs within 14 calendar days of the discharge date.

​

To report CPT 99495, the following must occur:

  • Initial communication with the patient or caregiver within 2 business days of discharge

  • A face-to-face office visit within 14 calendar days

  • The provider must deliver care involving moderate medical decision making (as defined by E/M guidelines)

 

This service may only be billed once per discharge, by one provider, and cannot overlap with postoperative services or duplicate discharge-day visits.

CPT 99495 Billing Requirements and Eligibility

CPT 99495 is used to report Transitional Care Management (TCM) services delivered after a patient is discharged from a qualified facility to a home or community setting. The goal is to reduce hospital readmissions and support continuity of care during the 30-day post-discharge period.

​

This code requires timely communication, in-person follow-up, and a moderate level of medical decision making, all of which must be documented in the medical record.

Patient Eligibility Criteria

To bill CPT 99495, the patient must be:

​

  • Discharged from a qualifying facility:

    • Inpatient hospital (acute, rehab, psychiatric)

    • Skilled nursing facility or nursing facility

    • Partial hospitalization or observation status

  • Transitioning to a community setting:

    • Private residence

    • Group home or rest home

    • Assisted living facility

    • Temporary housing (e.g., hotel, shelter, short-term accommodations)

 

The service may be provided to new or established patients with medical and/or psychosocial needs requiring transitional care support.

Service and Setup Requirements

CPT 99495 includes both face-to-face and non-face-to-face components delivered during the TCM episode. These must be coordinated and documented carefully:

  • Interactive contact with the patient or caregiver must occur within 2 business days of discharge

    • Can be face-to-face, phone, or electronic (e.g., secure messaging)

  • Face-to-face office visit must occur within 14 calendar days of discharge

  • Care must involve moderate medical decision making over the 30-day period

  • The same provider may not bill 99495 more than once per discharge

  • Service must not conflict with global postoperative periods

Who can Bill CPT 99495

CPT 99495 may be billed by:

  • Physicians

  • Nurse Practitioners (NPs)

  • Physician Assistants (PAs)

  • Other qualified healthcare professionals (QHPs)

 

It may not be billed by clinical staff alone. The billing provider must personally oversee the care plan and meet decision-making criteria under E/M guidelines.

Billing Frequency and Time Requirements

  • CPT 99496 can only be billed once per patient per discharge

  • It must not overlap with another TCM claim for the same patient in the same 30-day period

  • The face-to-face visit is included in the code and may not be billed separately as an E/M

  • Additional services provided during the TCM period may be billed if they are distinct and properly documented

CPT 99495 Billing Documentation Checklist

To compliantly bill CPT 99495, the following elements must be clearly documented in the patient record:

​

  • Patient discharge details:

    • Date and type of facility (e.g., inpatient hospital, SNF, partial hospitalization)

    • Destination setting (e.g., home, assisted living, rest home)

  • Date and method of initial contact within 2 business days:

    • Must be interactive (phone, in-person, or secure electronic message)

    • Include who initiated contact and the content addressed

  • Date of the face-to-face visit:

    • Must occur within 14 calendar days of discharge

    • Document any evaluation, physical findings, care planning, or education provided

  • Confirmation that the service period involved moderate medical decision making:

    • Number and complexity of problems addressed

    • Amount and/or complexity of data reviewed

    • Risk of complications, morbidity, or mortality

  • Evidence of non-face-to-face transitional care services:

    • Review of discharge paperwork and test results

    • Communication with other care team members or community providers

    • Patient/caregiver education or medication reconciliation

    • Scheduling follow-ups or arranging home/community services

  • Provider qualifications:

    • Service must be delivered and billed by a physician or qualified healthcare professional (QHP)

    • Time and effort by clinical staff must be under supervision and tied to the care episode

  • Attestation that:

    • This is the only TCM claim submitted for this patient within the 30-day window

    • The provider is not billing TCM as part of a global surgical period

    • The visit associated with TCM is not separately billed as an E/M

CPT 99495 Time Thresholds and Code Combinations

CPT 99495 can only be billed when the required transitional care services are completed within specific timeframes and meet the appropriate medical decision-making level. This code is time-sensitive and cannot be reported if follow-up occurs too late or requirements are incomplete.

​

Use the table below to determine the correct code(s) to report based on the total time spent delivering TCM services:

Table outlining CPT 99495 billing rules based on timing of contact and face-to-face visit, provider qualifications, and decision-making complexity.

Important to Note:

CPT 99495 may be billed once per discharge only if all of the following are met:

​

  • The provider or care team makes interactive contact with the patient or caregiver within 2 business days of discharge

  • A face-to-face visit is completed within 14 calendar days

  • Medical decision making over the 30-day episode is of moderate complexity

  • The service is not duplicated or reported by another provider within the same time period

  • The provider is not billing this during a global surgical period for a related service

When to Use CPT 99495:
Common Scenarios and Use Cases

CPT 99495 is used when a provider coordinates care for a patient after discharge from a facility, completing contact within 2 business days and a face-to-face visit within 14 days. It applies to transitions that require moderate medical decision making during the post-acute period.

​

Here are examples of how CPT 99495 is used in practice:

​

  • Discharge from Skilled Nursing Facility to Assisted Living
    A primary care provider:

    • Receives notification of discharge and contacts the patient’s family within 48 hours

    • Reviews medication changes and confirms that home health is in place

    • Sees the patient in clinic 10 days after discharge
      Billing: 99495 (moderate MDM, 14-day visit window met)

​

  • Hospital Discharge After COPD Exacerbation
    A pulmonologist:

    • Contacts the patient by phone the day after discharge to confirm medication pickup and oxygen use

    • Reviews the hospital discharge summary and pending labs

    • Schedules and completes a clinic visit on day 7
      Billing: 99495 (transitional care with moderate complexity)

​

  • Partial Hospitalization Discharge for Behavioral Health Patient
    A behavioral medicine provider:

    • Calls the patient within 24 hours to confirm therapy continuity and address safety planning

    • Coordinates care with outpatient counseling and medication management

    • Conducts an in-person assessment on day 12 post-discharge
      Billing: 99495 (TCM requirements and timing fully met)

​​

Common CPT 99495 Billing Mistakes
(and How to Avoid Them)

Transitional Care Management (TCM) codes like CPT 99495 come with strict timing and documentation requirements. Missing even one component can lead to denied claims or audit exposure.

​

  • ❌ No Patient Contact Within 2 Business Days
    Interactive communication with the patient or caregiver must occur within 2 business days of discharge. Automated messages or late outreach do not meet this requirement.

  • ❌ Face-to-Face Visit Occurs After Day 14
    CPT 99495 may only be billed if the post-discharge visit occurs within 14 calendar days. If the visit happens on day 15 or later, the code is no longer valid.

  • ❌ Medical Decision Making Doesn’t Meet Moderate Complexity
    CPT 99495 requires at least moderate medical decision making. If documentation reflects only straightforward or low-complexity MDM, use of the code is not compliant.

  • ❌ Using TCM in the Global Surgical Period
    TCM services may not be billed if the patient is still in the global period of a surgery or procedure performed by the same provider. This is considered bundled care.

  • ❌ Reporting the TCM Visit Separately as an E/M Code​​
    The face-to-face visit within 14 days is included in CPT 99495 and should not be billed as a separate E/M encounter. Additional visits during the 30-day period may be reported separately, if distinct

bottom of page