How To Use CPT Code 99495

CPT 99495 refers to transitional care management services with specific required elements, including communication, medical decision making, and a face-to-face visit. This article will cover the description, procedure, qualifying circumstances, usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 99495.

1. What is CPT 99495?

CPT 99495 is a medical billing code used to describe transitional care management services provided by healthcare professionals to patients transitioning from a healthcare facility to their home or another care setting. These services include communication with the patient or caregiver, medical decision making, and a face-to-face visit within a specified time frame. The purpose of these services is to ensure a smooth transition and continuity of care for the patient.

2. 99495 CPT code description

The official description of CPT code 99495 is: “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; At least moderate level of medical decision making during the service period; Face-to-face visit, within 14 calendar days of discharge.”

3. Procedure

The 99495 procedure involves the following steps:

1. Establishing communication with the patient or caregiver within two business days of discharge from the healthcare facility.
2. Assessing the patient’s needs and providing necessary support during the transition period.
3. Coordinating care with other healthcare providers involved in the patient’s care.
4. Performing a face-to-face visit with the patient within 14 calendar days of discharge.
5. Engaging in at least moderate level of medical decision making during the service period.

4. Qualifying circumstances

Patients eligible to receive CPT code 99495 services are those who have been discharged from a healthcare facility, such as a hospital, skilled nursing facility, or partial hospitalization program, and are transitioning to their home or another care setting. The patient’s care must require at least a moderate level of medical decision making, and the healthcare provider must be able to establish communication with the patient or caregiver within two business days of discharge. Additionally, a face-to-face visit must occur within 14 calendar days of discharge.

5. When to use CPT code 99495

It is appropriate to bill the 99495 CPT code when the healthcare provider has met all the required elements for transitional care management services, including communication, medical decision making, and a face-to-face visit within the specified time frame. The provider should ensure that the patient’s care requires at least a moderate level of medical decision making and that all necessary support and coordination of care are provided during the transition period.

6. Documentation requirements

To support a claim for CPT 99495, healthcare providers must document the following information:

• Date and method of communication with the patient or caregiver within two business days of discharge.
• Assessment of the patient’s needs and support provided during the transition period.
• Coordination of care with other healthcare providers involved in the patient’s care.
• Date and details of the face-to-face visit within 14 calendar days of discharge.
• Medical decision making of at least moderate complexity during the service period.

7. Billing guidelines

When billing for CPT code 99495, healthcare providers should ensure that they have met all the required elements for transitional care management services and have documented the necessary information to support their claim. Providers should also be aware of any payer-specific guidelines or requirements related to billing for these services. Additionally, it is important to differentiate between CPT 99495 and CPT 99496, which is used for transitional care management services with a higher level of medical decision making and a shorter face-to-face visit time frame.

8. Historical information

CPT 99495 was added to the Current Procedural Terminology system on January 1, 2013. There have been no updates to the code since its addition.

9. Similar codes to CPT 99495

Five similar codes to CPT 99495 and how they differentiate are:

1. CPT 99496: This code is used for transitional care management services with a high level of medical decision making and a face-to-face visit within seven calendar days of discharge.
2. CPT 99483: This code is used for cognitive assessment and care plan services for patients with cognitive impairment.
3. CPT 99487: This code is used for complex chronic care management services with at least 60 minutes of clinical staff time per month.
4. CPT 99489: This code is an add-on code for each additional 30 minutes of clinical staff time spent on complex chronic care management services.
5. CPT 99490: This code is used for chronic care management services with at least 20 minutes of clinical staff time per month.

10. Examples

Here are 10 detailed examples of CPT code 99495 procedures:

1. A patient discharged from the hospital after a stroke requires transitional care management services to ensure proper follow-up and coordination of care with their primary care physician and rehabilitation team.
2. A patient discharged from a skilled nursing facility after a hip replacement surgery requires transitional care management services to coordinate home health services and physical therapy appointments.
3. A patient discharged from a partial hospitalization program for mental health treatment requires transitional care management services to coordinate outpatient therapy and medication management.
4. A patient discharged from the hospital after a heart attack requires transitional care management services to ensure proper follow-up with their cardiologist and management of medications.
5. A patient discharged from a hospital after a complicated surgical procedure requires transitional care management services to coordinate wound care and monitor for potential complications.
6. A patient discharged from a skilled nursing facility after a prolonged stay for a chronic illness requires transitional care management services to coordinate home health services and manage medications.
7. A patient discharged from a hospital after a severe asthma exacerbation requires transitional care management services to ensure proper follow-up with their pulmonologist and management of medications.
8. A patient discharged from a hospital after a diabetic crisis requires transitional care management services to coordinate outpatient diabetes education and management of medications.
9. A patient discharged from a hospital after a seizure requires transitional care management services to ensure proper follow-up with their neurologist and management of medications.
10. A patient discharged from a hospital after a severe allergic reaction requires transitional care management services to coordinate follow-up with an allergist and management of medications.