CPT 99495

Definition

CPT 99495 is a Medicare billing code for Transitional Care Management services with moderate medical decision-making complexity, requiring a direct patient contact within two business days of discharge and a face-to-face visit within 14 calendar days. It reimburses the 30-day post-discharge care episode as a single bundled payment, encompassing the initial contact, care coordination activities conducted during the month, and the in-person visit.

The 2026 Medicare national average reimbursement for CPT 99495 is approximately $178 per patient per discharge event. Rates are updated annually through the Medicare Physician Fee Schedule; providers should verify current figures on CMS.gov before projecting program revenue.

Regulatory basis

CPT 99495 was established by CMS under the Medicare Physician Fee Schedule as part of the Transitional Care Management framework. The authoritative billing reference is the CMS Medicare Learning Network TCM fact sheet, which defines eligible discharge settings, required service components, and documentation standards.

The \u201cmoderate\u201d medical decision-making complexity designation is assessed per standard Evaluation & Management (E/M) guidelines. In practice, moderate complexity is the most common post-discharge scenario and covers the majority of patients transitioning from an acute hospital stay to a community setting.

Who uses it and when it applies

• Physicians and qualifying non-physician practitioners (NPs, PAs, CNSs, CNMs) billing for TCM services
• Patients discharged from inpatient hospital stays (acute, psychiatric, rehab), observation, or partial hospitalization
• Patients discharged to a community setting (home, assisted living, domiciliary) \u2014 NOT to SNF, LTAC, or inpatient rehab
• Cases where medical decision-making complexity is moderate (most common post-discharge scenario)

Related terms

• CPT 99496 \u2014 the high-complexity TCM code (7-day face-to-face window)
• Transitional Care Management (TCM) \u2014 the CMS care model CPT 99495 bills
• 30-day readmission \u2014 the clinical outcome TCM aims to reduce
• Care coordination \u2014 the broader function TCM operationalizes

How Positive Check relates

Positive Check automates the 2-business-day patient contact required for CPT 99495 billing, generates structured documentation, and escalates concerns to clinical staff in real time. See the Post-Discharge Follow-Up solution for the full workflow, or the CPT 99495 billing guide for eligibility and documentation details.