CPT 99495E&M

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CPT 99495 covers the care coordination services provided when a patient transitions from a hospital, skilled nursing facility, or other inpatient setting back to their home or community. This includes all the communication, medication reconciliation, and follow-up care during the first 14 days after discharge.

Showing rates for

National Average

Base Medicare rate

$201.20

This calculator gives a typical-case estimate using standard Medicare modifier rules. Actual payment depends on payer policies, documentation, code-specific CMS status indicators, and locality. Verify before billing.

RVU breakdown

Work RVU

2.78

PE RVU (NF)

3.27

MP RVU

0.17

Total RVU

6.22

Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High

NCCI bundling edits

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Billing tips

Ensure the face-to-face visit occurs within 14 days (not 7 days) of discharge to qualify for 99495 versus 99496
Impact: Using 99496 when visit occurs within 7 days pays $268.71, a $67.51 increase (33.5% higher reimbursement)
Document interactive contact within 2 business days of discharge (phone call, email, or other direct communication with patient/caregiver)
Impact: Missing this element is the #1 denial reason, resulting in $201.20 lost revenue per claim
Perform and document medication reconciliation including review of all discharge medications, comparison to pre-admission list, and resolution of discrepancies
Impact: Auditors specifically look for medication reconciliation; absence can trigger recoupment of full payment
Only one practitioner can bill TCM per discharge episode; ensure your practice has a system to prevent duplicate billing across multiple providers
Impact: Duplicate TCM billing triggers immediate denial and potential fraud investigation
Use time-tracking tools to document all non-face-to-face services during the 30-day period including phone calls, care coordination, and documentation review
Impact: Comprehensive time logs support medical necessity and protect against downcoding during audits
Bill TCM services at the end of the 30-day period or when all required elements are completed, not on the date of the face-to-face visit
Impact: Premature billing before completing all required elements can result in denial and complicate rebilling

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Frequently asked questions

What is the difference between CPT 99495 and 99496?

The primary difference is the timing of the required face-to-face visit and the level of medical decision making. CPT 99496 requires the face-to-face visit within 7 days of discharge and involves high complexity medical decision making, paying $268.71. CPT 99495 allows the visit within 14 days and requires moderate complexity, paying $201.20. Both require interactive contact within 2 business days.

Can 99495 be billed with an E/M visit code on the same day?

No, the face-to-face visit required for TCM is included in the 99495 code and cannot be separately billed. The TCM code encompasses both the face-to-face visit and all the care coordination activities during the 30-day post-discharge period. Billing both would constitute unbundling and result in denial.

How many times can you bill 99495 for the same patient?

You can bill 99495 only once per discharge episode within a 30-day period. However, if the patient has a new discharge from a different admission, you can bill TCM again for that separate discharge, even if the 30-day periods overlap, as long as you clearly document they are for different discharge episodes.

What counts as interactive contact for CPT 99495?

Interactive contact is real-time direct communication between the practitioner or clinical staff and the patient or caregiver. Acceptable methods include telephone calls, video visits, secure patient portal messages with real-time responses, or in-person contact. Leaving a voicemail without actual conversation does not satisfy the requirement.

Can a nurse practitioner bill 99495 independently?

Yes, nurse practitioners and physician assistants can bill 99495 under their own NPI if they perform or directly supervise all required elements including the face-to-face visit. Medicare pays NPPs at 85% of the physician rate ($171.02 for 99495). The NPP must be working within their scope of practice and state regulations.

What documentation proves medication reconciliation for 99495?

Documentation must show: (1) a list of medications the patient was taking before admission, (2) medications prescribed at discharge, (3) a comparison identifying discrepancies, (4) clinical decisions about continuing, discontinuing, or modifying medications, and (5) communication of the final medication list to the patient and other treating providers. A dated, signed medication reconciliation form or detailed clinical note serves as proof.

Is 99495 covered by Medicare and commercial insurance?

Yes, Medicare covers 99495 and reimburses at $201.20 nationally for 2025 (non-facility rate). Most commercial payers also cover TCM codes, though reimbursement rates vary by contract. Some Medicaid programs cover it, but policies vary by state. Always verify coverage with specific payers before billing, as some require prior authorization or have unique documentation requirements.