By Cyber Sense Billing Team · Published · Updated
What transitional care management covers
Transitional care management, or TCM, pays for the work a family practice does to help a patient move safely from an inpatient hospital, observation stay, skilled nursing facility, or similar setting back to the community. It covers the period beginning on the day of discharge and continuing for the next 29 days. Two CPT codes describe the service: 99495 for moderate complexity medical decision making with a face-to-face visit within 14 calendar days of discharge, and 99496 for high complexity medical decision making with a face-to-face visit within 7 calendar days. Because TCM pays more than a standard follow-up visit, it rewards practices that have a dependable discharge follow-up process.
The interactive contact within two business days
TCM requires an interactive contact with the patient or caregiver within two business days after discharge. The contact can be by phone, electronic communication, or in person, and can be made by the physician or clinical staff under direction. It should address the patient's status and needs, not just schedule an appointment. If two or more separate attempts are made within the timeframe and documented, but contact is not achieved, CMS guidance allows the service to be reported if all other requirements are met. Documentation of the date, time, who called, and what was discussed is essential.
Non-face-to-face services during the period
Beyond the contact and the visit, TCM includes non-face-to-face work as appropriate: reviewing discharge information, following up on pending tests, interacting with other clinicians who will care for the patient, educating the patient and family, establishing referrals and community resources, and assisting with scheduling. Medication reconciliation must be completed no later than the date of the face-to-face visit. The chart should show this work so the TCM claim reflects more than a single office visit.
The face-to-face visit and choosing the code
The face-to-face visit is part of TCM and is not billed separately. The code is chosen based on medical decision making over the service period and the timing of the visit. A patient seen within 7 days with high complexity decision making supports 99496. A patient seen within 7 days with moderate complexity, or within 8 to 14 days with moderate or high complexity, supports 99495. Telehealth may be used for the visit where payer rules allow; confirm current rules for the date of service.
When to submit the claim
Medicare allows the TCM claim to be submitted once the face-to-face visit is furnished, and does not require holding it until the end of the 30-day period. The date of service reported should follow current CMS guidance. Only one practitioner may report TCM for a patient within the 30 days after discharge, and it can be reported only once in that period. If a patient is readmitted, a second TCM may not be reported in the same 30-day window. Commercial payers that recognize TCM may have different rules, so check them separately.
Services that cannot be billed with TCM
Certain care management services overlap with TCM. Medicare has historically restricted billing some services, such as certain home health and hospice supervision codes and some care plan oversight codes, during the TCM period, and has relaxed other restrictions over time, including allowing chronic care management during the same period in some cases. Rules change with annual fee schedule updates, so review the current CMS TCM FAQ before billing overlapping services.
A workflow that captures TCM reliably
The biggest barrier to TCM is knowing that a patient was discharged. Practices that succeed set up discharge notifications from local hospitals or health information exchanges, assign a staff member to review them daily, call patients within the required window using a standard script, and reserve appointment slots for post-discharge visits within 7 days. The visit template should include prompts for medication reconciliation and review of discharge records. A monthly report comparing discharge notifications to TCM claims shows how many eligible patients were missed and why.
Frequently asked questions
Does TCM require a new patient relationship?
No. TCM may be furnished to new or established patients. The practice taking responsibility for the transition reports it, and only one practitioner may bill TCM for the period.
Which discharges should we prioritize?
Patients with high medical complexity, multiple medication changes, or limited support at home benefit most from early follow-up and are more likely to support 99496 when seen within seven days. Use discharge summaries to triage calls each morning so the highest-risk patients are reached first.
Can TCM be billed if the patient dies before the visit?
No. TCM requires the face-to-face visit. If the patient dies before it occurs, the practice may report an appropriate E/M for services actually provided instead, according to CMS guidance.
Can we bill a regular E/M instead of TCM?
Yes, if TCM requirements are not met, such as no timely contact attempts, the practice may bill an appropriate E/M for the visit instead.
Does an emergency department visit qualify as a discharge?
No. TCM applies to discharges from inpatient, observation, skilled nursing, and similar facility settings, not emergency department visits alone.
Can the contact be made by a medical assistant?
Clinical staff under the physician's direction may make the contact, consistent with state scope rules and payer policy.
Sources and further reading
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This article is general information, not legal or coding advice. Always check current CPT®, ICD-10-CM, CMS and payer guidance. Questions? Contact us.