GeneralBase2026 Compliant

CPT 99495

2026 Billing Guide

TCM, Moderate MDM, 14 Days

Reimbursement

$186.20

Threshold

N/A

2026 Status

Active

What is CPT Code 99495?

CPT 99495 is defined as: Transitional care management services for a patient whose medical and/or psychosocial problems require moderate complexity medical decision making during the transitions in care from an inpatient hospital setting, observation setting, or skilled nursing facility to the patient's community setting (home, domiciliary, rest home, or assisted living). Requires communication within 2 business days and a face-to-face visit within 14 calendar days.

This code is primarily used for General services. It falls under the category of Transitional Care Management (TCM) and is valid for the 2026 calendar year according to the CMS Physician Fee Schedule.

2026 RVU Components

Relative Value Units (Non-Facility)

Standard Formula Applied

Work RVU

2.36

Physician Effort

PE (Non-Fac)

2.92

Practice Expense

Malpractice

0.3

Risk Factor

Total RVU

5.58

Note: [(Work RVU * Work GPCI) + (PE RVU * PE GPCI) + (MP RVU * MP GPCI)] * Conversion Factor

2026 CMS Policy Intelligence

efficiency shield

Exempt from -2.5% efficiency cut as it is a core value-based care management service.

longitudinal care bridge

2026 policy encourages using TCM as a gateway to enrolling patients in permanent CCM (99490) or BHI (99484) programs after the 30-day period.

telehealth permanency

The 14-day face-to-face visit can be performed via two-way audio-video telehealth in 2026 for most eligible sites (verify rural/originating site rules).

Administrative Framework

Global Period

030 (30-day period beginning on the date of discharge)

Place of Service

11 (Office)12 (Home)13 (Assisted Living)

NCCI Exclusions

Do not bill with:99490 (CCM - generally cannot bill concurrently with TCM)99457 (RPM - allowed if medically necessary but check local MAC)99231-99233 (Hospital care on discharge day)

Operational Requirements

minimum time

30-day management period

staff type

Physician or QHP (Face-to-face), Clinical Staff (Non-face-to-face)

frequency

Once per discharge (by one individual/practice within 30 days)

add on codes

care plan requirement

Interactive contact within 2 business days; Face-to-face visit within 14 calendar days; Medication reconciliation on or before the face-to-face visit.

Compliance Checklist

Date of discharge and the facility name

Documentation of the interactive contact within 2 business days (call logs/patient portal)

Face-to-face visit date (within 14 days) and complexity documentation

Medication reconciliation completed on or before the visit date

Non-face-to-face care coordination activities (e.g., referral management, community resource linking)

Audit Defense

No specific audit defense elements defined.

2026 Update

Audit focus on the 2-day contact: 'Two business days' excludes weekends and holidays – track specific dates in the record.

Common Clinical Scenarios

Patient discharged after CHF exacerbation requiring medication titration and home health coordination

Post-operative patient with stable recovery but requiring moderate MDM for multiple chronic comorbidities

CMS Eligibility: Moderate medical or psychosocial complexity post-discharge. 30 days post-discharge

Target Specialties & Utilization

Primary CareCardiologyPulmonologyGeriatrics

Typical Clinical Indications (ICD-10)

I50.9 (Heart failure)J44.1 (COPD exacerbation)E11.65 (Type 2 diabetes with hyperglycemia)

Billing Differentiation

VS 99496

99496 requires high complexity MDM and 7-day face-to-face visit.

VS 99490

TCM (99495) is a 30-day post-discharge bundle; CCM (99490) is an ongoing monthly service for chronic needs.

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Official Data Provider: CMS Physician Fee Schedule (2026)