Transitional Care Management, moderate complexity (14 days)
Audit Defense & Denial Intelligence
Research-based denial patterns from OrbDoc Bill Analyzer
1. TCM visit not completed within required 14-day post-discharge timeframe
Very Common99495 (Transitional Care Management, moderate complexity) requires face-to-face visit within 14 days of hospital/SNF discharge. Visit on day 15 or later = automatic denial. Interactive contact (phone call) must occur within 2 business days of discharge, but face-to-face visit timing determines code eligibility. Missing 14-day window is most common TCM denial.
Common Causes
- • Patient discharged Friday, first available appointment day 16 (Monday 2 weeks later) - missed 14-day window
- • Patient no-show for day 10 appointment, rescheduled to day 17 - denied
- • Interactive contact within 2 days but visit scheduled day 20 - contact timing met but visit timing failed
Resolution Strategy
Verify discharge date and visit date. If visit truly within 14 days, appeal with discharge summary showing discharge date and office visit note showing visit date. If visit day 15+, cannot appeal - TCM code not eligible. May bill as standard office visit (99213-99215) instead based on visit complexity. To prevent future denials: flag hospital discharge patients for priority scheduling within 7-10 days, leaving buffer for patient availability.
2. Interactive contact not documented within 2 business days of discharge
Common99495 requires documented interactive contact (phone, email, text) with patient/caregiver within 2 business days of discharge. Face-to-face visit within 14 days also required but separate criterion. Both must be met. Interactive contact must be documented with date, time, method, and person contacted.
Common Causes
- • Patient discharged Friday, first contact Tuesday (3 business days) - missed 2-day window
- • Contact made but not documented in chart (no proof for audit)
- • Voicemail left but no return call - not considered 'interactive' contact
Resolution Strategy
Document interactive contact in chart: 'Spoke with patient by phone on [date, 1 business day post-discharge], discussed discharge instructions, medication changes, confirmed follow-up appointment scheduled.' If contact made but not documented, cannot prove - denial stands. If contact not made within 2 business days, cannot appeal - TCM criteria not met. May bill standard office visit instead. Future: establish post-discharge call protocol ensuring contact within 1 business day with documentation template.
Relative Value Units (RVUs)
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Clinical Information
When to Use
Patient discharged from hospital/SNF requiring moderate complexity face-to-face visit within 14 days
Common Scenarios
Documentation Requirements
- Contact with patient/caregiver within 2 business days of discharge
- Face-to-face visit within 7-14 days of discharge
- Medication reconciliation documented
- Discharge summary reviewed and incorporated into care plan
- 30+ minutes of non-face-to-face transitional care services
Coding Guidelines
Bundling Rules
- Cannot bill with CCM same month
- Cannot bill with E/M visit on day of TCM face-to-face encounter
- Requires 2-day contact and 14-day face-to-face visit
Exclusions
- Do not use if face-to-face visit >14 days post-discharge
- Do not use if high complexity (use 99496)
- Cannot bill in same month as other care management codes
Coding Notes
Clinical scenarios
- Contact with patient/caregiver within 2 business days of discharge
- Face-to-face visit within 7-14 days of discharge
- Medication reconciliation documented
- Contact with patient/caregiver within 2 business days of discharge
- Face-to-face visit within 7-14 days of discharge
- Medication reconciliation documented
- Contact with patient/caregiver within 2 business days of discharge
- Face-to-face visit within 7-14 days of discharge
- Medication reconciliation documented
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Frequently Asked Questions
CPT 99495 is the billing code for "Transitional Care Management, moderate complexity (14 days)". Patient discharged from hospital/SNF requiring moderate complexity face-to-face visit within 14 days
Medicare pays approximately $201.20 for CPT 99495 (national average). Actual payment varies by geographic location due to GPCI adjustments. Hospital and commercial insurance rates are typically 2-4x higher than Medicare rates.
CPT 99495 has a total RVU of 3.55, broken down as: Work RVU 2.11, Practice Expense RVU 1.29, and Malpractice RVU 0.15. RVUs (Relative Value Units) determine Medicare reimbursement rates.
The most common denial reason for CPT 99495 is "TCM visit not completed within required 14-day post-discharge timeframe". 99495 (Transitional Care Management, moderate complexity) requires face-to-face visit within 14 days of hospital/SNF discharge. Visit on day 15 or later = automatic denial. Interactive contact (phone call) must occur within 2 business days of discharge, but face-to-face visit timing determines code eligibility. Missing 14-day window is most common TCM denial. Common causes include: Patient discharged Friday, first available appointment day 16 (Monday 2 weeks later) - missed 14-day window; Patient no-show for day 10 appointment, rescheduled to day 17 - denied. Appeal success rate is approximately 10-30%.
Key documentation requirements for CPT 99495 include: Contact with patient/caregiver within 2 business days of discharge; Face-to-face visit within 7-14 days of discharge; Medication reconciliation documented; Discharge summary reviewed and incorporated into care plan. Missing or incomplete documentation is a leading cause of claim denials for this code.
Bundling considerations for CPT 99495: Cannot bill with CCM same month. Cannot bill with E/M visit on day of TCM face-to-face encounter Use an NCCI bundling checker to verify specific code combinations before billing.
The typical time requirement for CPT 99495 is Face-to-face visit within 14 days of discharge, 30+ minutes non-face-to-face. Time-based codes require documentation of the actual time spent providing the service.