Part of Transitional Care Management
CPT 99496: Transitional Care Management, high complexity
TCM for a discharge requiring high complexity medical decision making, with a face-to-face visit within 7 days.
Time threshold & code combinations
One service per discharge, covering the 30 days following discharge; face-to-face visit must occur within 7 calendar days.
- Mutually exclusive with 99495 for the same discharge
- Do not separately bill the required face-to-face visit as its own E/M code
Who can bill
- Physicians
- Non-physician practitioners eligible to bill E/M services
Eligibility & billing requirements
- Patient discharged to a community setting from an inpatient or qualifying institutional stay
- Medical decision making of high complexity related to the transition
- Interactive contact within 2 business days of discharge
- Medication reconciliation no later than the face-to-face visit
- Face-to-face visit within 7 calendar days of discharge
When to use it
High-acuity discharge
A patient discharged after a heart failure exacerbation with multiple medication changes is contacted the next business day and seen face-to-face on day 5 with high complexity decision making.
Billing: 99496
Complex multi-comorbidity patient
A patient with several active, unstable conditions is discharged from an inpatient psychiatric stay, reached by phone within 2 business days, and seen in clinic on day 6.
Billing: 99496
Documentation checklist
- Discharge date and setting
- Contact date/method (including unsuccessful attempts, if any)
- Medication reconciliation notes
- Face-to-face visit note dated within 7 days, supporting high complexity
Common billing mistakes
- Billing 99496 without medical decision making that actually supports high complexity
- Missing the tighter 7-day face-to-face window