Wiki Billing 99495

[mwells2020]

Has anyone ever billed the 99495, Transitional Care Management Services to BCBS before? If so, did it pay ok? The patient was in the hospital and seen 4 days after being discharged. I have never billed this before so I am curious as to how this will pay. Thank You in advance!

 

[OpenClaims]

Hi! I code for the CPT often, and we sometimes get kickback on it. In order for the Transition of Care codes to be accepted, the following must be met.

1. Patient must be admitted, not an Emergency Department visit.
2. Patient must be contact for a TOC IP Outreach within 2 business days of their discharge.
3. Patient must be seen within 14 business days of their discharge date.
4. These are not applicable for someone who is being transferred from IP to a nursing facility. They must be discharged home.

Here is a link to CMS information regarding this. Transition of Care - CMS

Some kickback that I typically see:

• Payors will often come back and say that you need to check for the IP outreach, as this is often missed.
• Providers try to bill 99496 when the documentation only supports a 99495, so paying attention to MDM is important.
• Some providers will try to bill a TOC when the patient was in the ED and not actually admitted to Obs. or IP.