Transitional Care Management (TCM)
A discharge response clock your team can run every day
Transitional Care Management covers the 30 days after a patient leaves the hospital or a facility. We design the workflow that finds the discharge, makes the two-business-day contact, reconciles medications and gets the patient in front of a clinician within 7 or 14 days, with documentation that supports the claim.
- CPT 99495 · 99496
- Contact within 2 business days
- Face-to-face within 7 or 14 days
- 30-day service period
Who it's for
Built for the teams that run this program
Primary care practices
Practices that learn about discharges late, or not at all, and want a reliable way to see patients within the TCM windows.
Groups with care managers or RNs
Teams that already call patients after discharge but are not capturing the work, or whose notes would not support 99495 or 99496.
ACOs and value-based contract holders
Organizations measured on readmissions, unplanned admissions and timely follow-up, where transitional care is the main lever.
Practices running APCM or CCM
Teams that need a clean month-end rule for patients who are discharged mid-month while enrolled in another care management program.
Design & launch
How we design and launch it
We build the program inside your EHR and your existing staffing, then pilot it before it scales.
- 1
Map discharge sources
Hospital ADT feeds, HIE notifications, health plan reports and portal messages: we document where each discharge alert comes from and who receives it.
- 2
Assign roles and coverage
Who makes the contact call, who reconciles medications, who books the visit, and who covers weekends and holidays so the two-business-day window is not missed.
- 3
Build templates
A contact-attempt note, a TCM visit template with medication reconciliation and medical decision making prompts, and a discharge tracking list or registry.
- 4
Hold visit slots
Protected 7-day and 14-day appointment slots on provider schedules, so a high-complexity patient is not pushed past the window.
- 5
Pilot with one team
One provider panel or site runs the workflow first. We shadow the calls and visits and fix the failure points before rollout.
Gate: Go / no-go on the pilot's own numbers.
- 6
Train and scale
Staff training on the timing rules and documentation, then rollout across sites with a weekly discharge huddle.
Operations
How the program runs day to day
The response clock from our playbook, built into your daily routine.
The response clock
Each checkpoint has an owner, a work queue and a documented outcome.
48 hours
High utilizers
Outreach after an ED visit or inpatient stay for the patients who drive the most utilization, even when the encounter does not qualify for TCM.
2 business days
TCM interactive contact
Direct, telephone or electronic contact with the patient or caregiver, or documented attempts, within two business days of discharge.
7 days
First follow-up milestone
Face-to-face visit for high-complexity patients (99496). We aim for this window whenever clinically appropriate.
14 days
Second checkpoint
Face-to-face visit for moderate-complexity patients (99495), and a check that anyone not yet seen is rescheduled or escalated.
What happens each day
- Morning discharge review: new alerts are logged with discharge date, setting and the business-day deadline.
- Contact calls cover symptoms, medications in hand, follow-up appointments, home services and red flags.
- Discharge summaries and pending test results are requested and tracked until received.
- Medication reconciliation is completed no later than the face-to-face visit.
- Referrals, home health, DME and community resources are coordinated and documented.
- Patients who decline or cannot be reached are flagged for provider review.
Documentation & compliance
Documentation and compliance essentials
Medicare fee-for-service rules for CY 2026.
TCM codes at a glance
99495
- Medical decision making
- At least moderate complexity
- Interactive contact
- Within 2 business days of discharge
- Face-to-face visit
- Within 14 calendar days of discharge
99496
- Medical decision making
- High complexity
- Interactive contact
- Within 2 business days of discharge
- Face-to-face visit
- Within 7 calendar days of discharge
The 30-day TCM period begins on the day of discharge. Only one practitioner may report TCM for a patient's 30-day period, and it is reported once per period.
Documentation essentials
- Date of discharge and the qualifying setting (for example inpatient hospital, observation, skilled nursing facility or inpatient rehabilitation).
- Discharge to a community setting such as home, a domiciliary or assisted living.
- Date and method of the interactive contact, or each unsuccessful attempt, within two business days.
- Date of the face-to-face visit and the complexity of medical decision making.
- Medication reconciliation and management, completed no later than the face-to-face visit.
- Non-face-to-face services: discharge information reviewed, pending tests followed up, education, referrals and community resources.
KPIs we track
What we measure with you
Discharge capture rate
Share of known discharges that reach the TCM work queue.
Two-business-day contact rate
Share of eligible discharges with a successful or documented contact attempt on time.
7- and 14-day visit completion
Face-to-face visits completed within the window that matches the patient's complexity.
Medication reconciliation rate
Visits with reconciliation documented by the face-to-face date.
30-day readmission rate
Readmissions among patients in a TCM period, trended over time.
Documentation pass rate
TCM claims whose notes pass an internal audit against the required elements.
Baselines and targets are set from your own data at the start of an engagement. We do not promise specific results.
FAQs
Common questions
What counts as a business day for the two-day contact?
CMS FAQs describe business days as Monday through Friday, excluding holidays, regardless of the practice's normal hours or when you learned of the discharge. We write your coverage plan around that definition, including what happens when the office is closed.
Can we still bill TCM if we could not reach the patient within two business days?
CMS has allowed TCM when two or more separate, timely contact attempts are documented and the other requirements, including the face-to-face visit, are met. Confirm the current guidance before relying on it, and document every attempt.
Does a discharge to a skilled nursing facility qualify?
TCM requires the patient to return to a community setting. A hospital discharge to a skilled nursing facility does not start a TCM period; a later discharge from the facility to home can.
Do you submit TCM claims?
No. Your practice remains the billing party. We design the workflow, templates and audits so your coders have what they need.
Related services
Programs that work alongside this one
Complex Care & High-Utilizer Management
Post-discharge outreach, TCM, readmission and avoidable ED reduction.
Learn moreChronic & Principal Care Management (CCM / PCM)
Care plans, monthly time-based care management and documentation.
Learn moreAdvanced Primary Care Management (APCM)
G0556–G0558 monthly care management, levels by complexity.
Learn moreACO Programs (MSSP, ACO REACH, LEAD)
Quality reporting, benchmarks and participant readiness.
Learn more
Ready to simplify the complex?
Book a consultation.
A working conversation about your patients, payers, EHR and staffing, and whether this program fits. Please do not send patient information.