Can 99214 and 99495 Be Billed Together?

Medical billing uses Current Procedural Terminology (CPT) codes to describe healthcare services for reimbursement. A common inquiry concerns the concurrent billing of CPT code 99214 and CPT code 99495. Understanding each code’s distinct definitions and requirements is important, as specific guidelines govern such practices.

Understanding CPT Code 99214 and CPT Code 99495

CPT code 99214 is for an office or outpatient evaluation and management (E/M) visit for an established patient. It involves a detailed history, examination, and moderate complexity medical decision-making, typically accounting for 30-39 minutes of total time. This E/M code is often used for managing acute injuries or progressive ailments requiring moderate medical oversight, reflecting a significant level of physician work and patient interaction.

In contrast, CPT code 99495 is for Transitional Care Management (TCM) services for patients with moderate medical complexity. TCM services begin after a patient’s discharge from an inpatient facility (e.g., hospital, skilled nursing facility) to a community setting. Its primary goal is to coordinate care and support the patient’s transition home, aiming to reduce hospital readmissions during a 30-day post-discharge period.

Specific Requirements for Transitional Care Management

Transitional Care Management (TCM) services under CPT code 99495 include specific components for a smooth patient transition. The 30-day service period begins on the day of discharge. Interactive communication with the patient or caregiver is required within two business days of discharge (direct contact, phone, or electronic). Unsuccessful attempts must be documented.

A mandatory face-to-face visit must occur within 14 calendar days of discharge; it cannot be virtual and is part of the TCM service, not separately billable. Medication reconciliation and management, including reviewing discharge information, assessing diagnostic test needs, and educating the patient and family on self-management, must be completed by the face-to-face visit date.

Qualified healthcare professionals (e.g., physicians, PAs, NPs, CNMs, CNSs authorized by state law) can provide these services. TCM’s objective is comprehensive care coordination, emphasizing a multidisciplinary approach to prevent readmissions and support independent living.

Billing Both CPT Codes Concurrently

Generally, the face-to-face E/M visit, a required component of CPT code 99495 (Transitional Care Management), cannot be billed separately. This work is bundled into the 99495 code, preventing duplicate payments for a service already included within the broader TCM service.

However, a separate E/M service, like 99214, may be billable during the 30-day TCM period if it addresses a distinct, significant, and separately identifiable problem unrelated to the recent discharge. For example, if a patient presents with a new, acute condition requiring a separate, medically necessary evaluation, a 99214 might be billed.

When billing a separate E/M service with TCM, strict adherence to payer guidelines (e.g., Medicare) is imperative. Modifier 25 is required to indicate the E/M service was significant and separately identifiable from the TCM service, signifying it was beyond usual care. Without clear documentation and proper modifier usage, claims are highly susceptible to denial, as payers often bundle services.

Essential Documentation for Compliance

Accurate and thorough documentation is paramount for compliance when billing CPT codes, especially for concurrent services like 99214 and 99495. For CPT code 99495, the medical record must clearly indicate the discharge date, the date of interactive contact with the patient or caregiver, and the date of the required face-to-face visit. Documentation should also detail medical decision-making complexity, medication reconciliation, and any patient education provided during the TCM period.

For CPT code 99214, standard E/M documentation requirements apply, including a detailed history, a comprehensive examination, and the complexity of medical decision-making. The total time spent on the encounter (typically 30-39 minutes) should also be recorded if time is used for code selection. When both codes are billed, documentation must unequivocally support the separate and significant nature of the 99214 service. This includes a clear explanation of why the 99214 was distinct from the bundled E/M component of the TCM, justifying the application of modifier 25.

Submitting Claims for Concurrent Services

Submitting claims for concurrent services like 99214 and 99495 requires careful attention to detail on the claim form. Claims are typically submitted using the CMS-1500 form or its electronic equivalent. When billing a separately identifiable E/M service (like 99214) during a TCM period, modifier 25 must be appended to the 99214 code. This modifier informs the payer that the E/M service was distinct and significant, warranting separate reimbursement.

On the CMS-1500 form, CPT codes are listed in Box 24D, with modifiers placed adjacent. Box 24E links the billed procedure to diagnosis codes in Box 21. While the TCM code (99495) is generally submitted after the 30-day service period concludes, any additional, separately billable E/M services performed during this period, with the appropriate modifier, can be submitted on their respective dates of service.