top of page

CPT 99496
Description, Billing Rules, and Use Cases

CPT 99496 is used to report Transitional Care Management (TCM) services delivered to a patient discharged from a hospital, skilled nursing facility, or similar setting. This code reflects a higher complexity TCM episode that requires contact within 2 business days, a face-to-face visit within 7 calendar days, and high medical decision making. It supports continuity of care for patients at elevated risk of complications after discharge.

What is CPT Code 99496?

CPT Code 99496 is a comprehensive TCM code used to support a patient’s safe transition from facility-based care to a community setting. It reflects both the clinical complexity and the urgency of timely follow-up. This code includes all non-face-to-face care coordination plus one in-person visit that must occur within 7 calendar days of discharge.

​

To bill CPT 99496, providers must meet the following requirements:

  • Make interactive contact with the patient or caregiver within 2 business days of discharge

  • Complete a face-to-face office visit within 7 calendar days

  • Deliver and document high complexity medical decision making during the 30-day care period

 

This code is used once per discharge, by one provider or group, and cannot be split across multiple clinicians or billed alongside certain overlapping services.

CPT 99496 Billing Requirements and Eligibility

CPT 99496 is used to report high-complexity Transitional Care Management (TCM) services following a patient’s discharge from an eligible inpatient or institutional setting. The service includes both face-to-face and non-face-to-face components that must be delivered within strict timeframes, and the patient’s condition must justify high-level clinical decision making over the course of the 30-day episode.

Patient Eligibility Criteria

To bill CPT 99496, the patient must:

​

  • Be discharged from one of the following settings:

    • Inpatient hospital (including acute, rehab, psychiatric)

    • Skilled nursing facility or nursing facility

    • Partial hospitalization or observation status

  • Transition to a qualifying community setting:

    • Home, rest home, assisted living, short-term housing, or residential care setting

 

Patients may be new or established and must have a medical condition or care complexity that warrants intensive follow-up and coordination during the transition.

Service Requirements

To meet CPT 99496 requirements:

  • Interactive communication (e.g., phone call, video, or secure message) with the patient or caregiver must occur within 2 business days of discharge

  • A face-to-face office visit must occur within 7 calendar days of discharge

  • The provider must deliver care involving high medical decision making, as defined by the current E/M guidelines

  • The 30-day service period begins on the date of discharge and includes both direct and indirect care components

Who can Bill CPT 99496

  • CPT 99496 may be billed by:

    • Physicians

    • Nurse Practitioners (NPs)

    • Physician Assistants (PAs)

  • Other Qualified Healthcare Professionals (QHPs)

 

The services must be personally overseen by the billing provider. Clinical staff may assist with non-face-to-face care components under supervision, but may not bill the service independently.

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

Billing Documentation Checklist

To compliantly bill CPT 99496, ensure the following items are documented in the patient record:

​

  • Discharge summary and source of transition:

    • Facility type (e.g., inpatient hospital, SNF, partial hospitalization)

    • Date of discharge and transition destination (e.g., home, rest home, assisted living)

  • Date and method of interactive contact:

    • Occurs within 2 business days of discharge

    • May be phone, in-person, or secure electronic communication

    • Includes patient or caregiver engagement and summary of discussion

  • Date of face-to-face visit:

    • Must be completed within 7 calendar days of discharge

    • Cannot be billed separately from the TCM code

    • Includes any patient evaluation, assessment, or education provided

  • Medical decision making documentation:

    • Must reflect a high level of complexity, per E/M guidelines

    • Includes number/severity of problems addressed, volume of data reviewed, and overall risk profile

  • Care coordination activities (may be performed by provider or supervised staff):

    • Review of discharge paperwork, test results, and medication changes

    • Communication with home health, specialists, or other involved care teams

    • Patient or caregiver education to support adherence or risk mitigation

    • Scheduling of follow-up services or arranging community resources

  • Provider credentials and attestation:

    • Billing must be performed by a physician or QHP

    • Clinical staff participation must be under general supervision

    • Service is not provided during a global surgical period

  • Claim integrity checks:

    • Only one TCM code (99495 or 99496) may be billed per discharge

    • Provider has not submitted a separate E/M for the included face-to-face visit

    • No other provider or group is billing a TCM claim for the same 30-day period

CPT 99496 Time Thresholds and Code Combinations

CPT 99496 is a time-sensitive transitional care code that requires both interactive communication and a face-to-face visit within narrow windows. It also demands high-complexity medical decision making. Billing is valid only when all service conditions are satisfied during the 30-day post-discharge period.

​

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

Table showing CPT 99496 billing scenarios based on contact and visit timing, decision-making level, and mutual exclusivity with E/M services.

Important to Note:

CPT 99496 may be billed once per discharge only when all of the following occur:

​

  • Interactive contact with the patient or caregiver is made within 2 business days of discharge

  • A face-to-face visit occurs within 7 calendar days of discharge

  • Medical decision making over the service period is classified as high complexity

When to Use CPT 99496:
Common Scenarios and Use Cases

CPT 99496 is used when a provider delivers high-complexity transitional care following a patient’s discharge from a facility. It applies when communication and follow-up occur within tight timeframes and the clinical complexity of the case is significant.

​

Here are examples of how CPT 99496 is used in practice:

​

  • Hospital Discharge Following Stroke with Multiple Comorbidities
    A neurology provider:

    • Contacts the caregiver by phone the day after discharge

    • Reviews inpatient notes, imaging, and medication changes

    • Conducts a clinic visit on day 5 to review rehab plan and coordinate specialist follow-up
      Billing: 99496 (high-complexity decision making with 7-day visit window met)

​

  • Discharge After Complex Pneumonia with Home Oxygen Setup
    A pulmonologist:

    • Calls the patient the next morning to confirm home oxygen delivery and review discharge instructions

    • Reviews the hospital course, orders labs, and adjusts inhaler therapy

    • Sees the patient in person on day 6 and updates care plan
      Billing: 99496 (face-to-face visit within 7 days and high MDM justified)

​

  • Psychiatric Hospital Discharge for Suicidal Depression
    A behavioral health NP:

    • Contacts the patient’s family caregiver via secure video two days after discharge

    • Coordinates outpatient therapy, checks medication adherence, and initiates safety planning

    • Holds an in-person appointment on day 4 to reinforce post-discharge plan
      Billing: 99496 (TCM requirements and timing met; high risk and complexity)

​​

Can CPT 99496 and 99214 Be Billed Together?

CPT 99496 and CPT 99214 cannot typically be billed together on the same date if the 99214 visit is the one used to satisfy the TCM face-to-face requirement. That encounter is bundled into the transitional care service and not separately reimbursable.

​

However, a separate 99214 service may be billed during the same 30-day TCM period if:

  • It is medically necessary

  • It addresses a different problem or condition

  • The visit is distinctly documented and meets all the usual E/M criteria

 

To avoid denials, documentation must show that the services were separate and unrelated to the TCM episode covered by 99496.

Common CPT 99496 Billing Mistakes
(and How to Avoid Them)

CPT 99496 has strict timing and complexity requirements. Claims are often denied due to small lapses in documentation or confusion around bundled services.

​

  • ❌ Late Face-to-Face Visit
    The in-person visit must occur within 7 calendar days of discharge. If it takes place on day 8 or later, CPT 99496 is invalid — even if all other requirements are met.

  • ❌ Contact Not Made Within 2 Business Days
    Interactive communication (e.g., phone or secure message) must be completed within 2 business days post-discharge. Passive outreach or delayed contact does not satisfy the requirement.

  • ❌ Medical Decision Making Doesn’t Meet Moderate Complexity
    CPT 99496 requires high-complexity medical decision making. If the case reflects only moderate complexity, report CPT 99495 instead.

  • ❌ E/M Code Billed Separately for the TCM Visit
    The face-to-face visit that qualifies the provider to bill CPT 99496 is included in the code. Do not report a separate E/M service for that encounter unless it is completely unrelated and separately documented.

  • ❌ Global Period Overlap or Duplicate TCM Claims​​
    TCM services may not be billed:

    • During a global surgical period for a related procedure

    • By multiple providers for the same patient and discharge period

    • Without a clear link to a single transitional care episode

bottom of page