How To Use CPT Code 99496

CPT 99496 refers to transitional care management services with specific required elements, including communication, high-level medical decision making, and a face-to-face visit within seven days of discharge. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 99496.

1. What is CPT 99496?

CPT 99496 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 involve communication with the patient or caregiver, high-level medical decision making, and a face-to-face visit within seven calendar days of discharge from the facility.

2. 99496 CPT code description

The official description of CPT code 99496 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; High level of medical decision making during the service period; Face-to-face visit, within 7 calendar days of discharge.”

3. Procedure

1. Healthcare provider receives notification of patient’s discharge from a healthcare facility.
2. Provider or designated staff member contacts the patient or caregiver within two business days of discharge to discuss the patient’s needs and schedule a face-to-face visit.
3. Provider conducts a face-to-face visit with the patient within seven calendar days of discharge, addressing patient assessment, support, education, care coordination, and medication management, among other areas.
4. Provider engages in high-level medical decision making throughout the service period, overseeing management or coordinating services for the patient’s transitional care.
5. Provider documents all required elements of the transitional care management services provided, including communication, medical decision making, and face-to-face visit details.

4. Qualifying circumstances

Patients eligible to receive CPT 99496 services are those who have been discharged from a healthcare facility, such as an inpatient hospitalization, partial hospitalization, observation, or skilled nursing facility, and are transitioning to their home or another care setting. The patient’s care must require high-level medical decision making, and the provider must be able to conduct a face-to-face visit within seven calendar days of discharge. Additionally, the provider must be the first point of contact for the patient’s transitional care management or coordination of services.

5. When to use CPT code 99496

It is appropriate to bill CPT 99496 when the following criteria are met:

• The patient is transitioning from a healthcare facility to their home or another care setting.
• The patient’s care requires high-level medical decision making.
• The provider or designated staff member communicates with the patient or caregiver within two business days of discharge.
• A face-to-face visit is conducted within seven calendar days of discharge.
• All required elements of transitional care management services are documented.

6. Documentation requirements

To support a claim for CPT 99496, the following information must be documented:

• Date and method of communication with the patient or caregiver within two business days of discharge.
• Details of the high-level medical decision making conducted during the service period.
• Date and details of the face-to-face visit within seven calendar days of discharge, including patient assessment, support, education, care coordination, and medication management, among other areas.
• Provider’s role in overseeing management or coordinating services for the patient’s transitional care.

7. Billing guidelines

When billing for CPT 99496, ensure that all required elements of transitional care management services are documented and that the patient’s care meets the criteria for high-level medical decision making. Additionally, be aware of similar codes, such as CPT 99495, which involves a face-to-face visit within 14 calendar days of discharge and at least moderate-level medical decision making. It is essential to select the appropriate code based on the specific services provided and the patient’s needs.

8. Historical information

CPT 99496 was added to the Current Procedural Terminology system on January 1, 2013. The code was updated on January 1, 2023, with a revised descriptor that clarified the required elements of transitional care management services.

9. Similar codes to CPT 99496

Five similar codes to CPT 99496 and how they differ are:

1. CPT 99495: Involves a face-to-face visit within 14 calendar days of discharge and at least moderate-level medical decision making.
2. CPT 99490: Refers to chronic care management services, which focus on managing patients with multiple chronic conditions over an extended period.
3. CPT 99487: Describes complex chronic care management services, requiring a higher level of care coordination and management for patients with multiple chronic conditions.
4. CPT 99489: Represents an add-on code for each additional 30 minutes of complex chronic care management services beyond the initial 60 minutes.
5. CPT 99483: Pertains to cognitive assessment and care plan services for patients with cognitive impairment, such as Alzheimer’s disease or dementia.

10. Examples

1. A patient is discharged from the hospital following a stroke and requires close monitoring and coordination of care with multiple specialists. The provider conducts a face-to-face visit within seven days of discharge and engages in high-level medical decision making throughout the service period.
2. A patient is discharged from a skilled nursing facility after a hip replacement surgery. The provider communicates with the patient within two business days of discharge, schedules a face-to-face visit within seven days, and oversees the patient’s care coordination and medication management.
3. A patient with congestive heart failure is discharged from the hospital and requires close monitoring of their condition and medication adjustments. The provider conducts a face-to-face visit within seven days of discharge and engages in high-level medical decision making to manage the patient’s care.
4. A patient is discharged from a partial hospitalization program for mental health treatment and requires ongoing care coordination and support. The provider communicates with the patient within two business days of discharge and conducts a face-to-face visit within seven days, addressing the patient’s needs and coordinating care with other providers.
5. A patient with diabetes is discharged from the hospital following a foot ulcer treatment. The provider communicates with the patient within two business days of discharge, schedules a face-to-face visit within seven days, and engages in high-level medical decision making to manage the patient’s care and prevent complications.
6. A patient is discharged from an observation stay at the hospital after a fall and requires follow-up care and coordination with physical therapy services. The provider conducts a face-to-face visit within seven days of discharge and oversees the patient’s care coordination and support.
7. A patient with chronic obstructive pulmonary disease (COPD) is discharged from the hospital after an exacerbation. The provider communicates with the patient within two business days of discharge, schedules a face-to-face visit within seven days, and engages in high-level medical decision making to manage the patient’s care and prevent future exacerbations.
8. A patient is discharged from a skilled nursing facility after a pneumonia treatment and requires ongoing monitoring and medication management. The provider conducts a face-to-face visit within seven days of discharge and oversees the patient’s care coordination and support.
9. A patient with a history of substance abuse is discharged from a partial hospitalization program and requires ongoing care coordination and support. The provider communicates with the patient within two business days of discharge and conducts a face-to-face visit within seven days, addressing the patient’s needs and coordinating care with other providers.
10. A patient is discharged from the hospital following a complicated surgical procedure and requires close monitoring and coordination of care with multiple specialists. The provider conducts a face-to-face visit within seven days of discharge and engages in high-level medical decision making throughout the service period.