Although transitional care management codes have been around since 2013, many coders still struggle with finding the right one to use in a situation. These CPT codes aim to reward providers for successfully transitioning a patient from the inpatient setting to their regular lives, and they use similar definitions, but there is more to them than just how long before the patient presents again.

The two transitional care management codes are defined as follows:

99495: Transitional Care Management Services 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 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

At first glance, these codes seem nearly identical save for the distinction between a visit after 7 days and a visit after 14 days. Notice, however, that 99495 specifies that the medical decision making must be “at least moderate,” while 99496 can only apply when the medical decision making is high. In other words, 99495 can also apply to situations that used high complexity medical decision making, but 99496 can not apply to anything lower.

Despite this distinction, both transitional care management codes have much more in common. Both require the physician or another qualified member of his/her staff to check in with the patient within 2 days of discharge, and neither one can apply during a global period. Additionally, these codes cannot be reported again if the patient must return to the facility within 30 days of discharge.