What Is Transitional Care Management?
Transitional Care Management (TCM) refers to structured clinical services provided to patients during the 30-day period following discharge from a hospital or similar facility. The purpose of TCM is to reduce readmissions, improve outcomes, and facilitate a seamless shift from inpatient care to community or home-based care.
TCM is reimbursed under Medicare Part B and recognized by most commercial payers that follow CPT code standards. Eligible providers include physicians and several types of non-physician practitioners (NPs, PAs, CNSs, CNMs), depending on state scope of practice.
TCM CPT Codes & Requirements
Reference table with all TCM codes, face-to-face visit windows, and minimum requirements. Both codes include coordination tasks and medication reconciliation.
| Code | Description | Threshold |
|---|---|---|
99495 | Moderate clinical complexity TCM | Within 14 days face-to-face visit after discharge |
99496 | High clinical complexity TCM | Within 7 days face-to-face visit after discharge |
- • Both codes require contact with patient within 2 business days of discharge
- • Both codes include coordination tasks and medication reconciliation
- • Only one TCM code is billed per patient in the 30-day period following a qualifying discharge
Core Components of TCM Services
To bill for either 99495 or 99496, documentation and workflows must consistently address these elements:
Appropriate Discharge Sources
TCM applies when a patient is discharged from:
Early Contact Post-Discharge
2 Business Days Contact Requirement
There must be direct contact (via phone, electronic message, or in-person) with the patient or caregiver within 2 business days of discharge.
This contact may be made by the provider or supervised clinical staff, but the supervising provider must document involvement.
Medical Decision Making & Complexity
99495 - Moderate Complexity
Requires moderate complexity medical decision-making. The clinician must address clinical issues that exceed straightforward medical decisions.
99496 - High Complexity
Requires high complexity medical decision-making. Conditions or patient needs are more intricate, involving multiple data points, diagnoses, or significant risk components.
Medical decision-making levels are defined in the AMA CPT and E/M guidelines.
Face-to-Face Follow-Up
A face-to-face visit with the patient must occur within the appropriate timeframe:
This visit can be in-person or via telehealth, where permitted. It must be separate from the discharge visit itself and clearly documented.
Care Plan & Coordination Tasks
During the 30-day TCM period, services often include:
Clinical staff can handle many coordination tasks under general supervision, but the billing provider is responsible for oversight and must document supervision and care decisions.
Billing & Compliance
Billing Frequency
Provider Eligibility
TCM services may be billed by:
Non-physician practitioners must be authorized by state law to perform the services billed.
Documentation Essentials
Good clinical documentation should include:
Workflow Example
Discharge event
Triggers TCM eligibility
Initial contact
Within 2 business days, the care team contacts the patient or caregiver
Complexity evaluation
Provider evaluates clinical complexity and chooses the appropriate CPT code (99495 or 99496)
Face-to-face visit
Scheduled and documented within the required window (7 days for 99496, 14 days for 99495)
Documentation & billing
All coordination tasks are documented and gathered for billing compliance
Transitional Care Management is an evidence-based approach to optimize patient outcomes after discharge. The two principal CPT codes - 99495 and 99496 - reflect different levels of medical complexity and required timing of follow-up visits while ensuring care continuity. Correct use of these codes supports compliance, enhances revenue capture, and encourages better clinical outcomes during care transitions.