Transitional Care Management

Transitional Care Management

Get the TCM Toolkit

Want to be reimbursed for TCM services? The AAFP's TCM Toolkit includes resources to help you get started, including:

  • TCM components and requirements
  • Steps to implement TCM in your practice
  • Patient materials
  • A 30-day worksheet
  • A TCM medical records request template

Questions About TCM?

Find answers to frequently asked questions about Transitional Care Management.

Read the FAQ »

TCM Webcast

Stop leaving money on the table. The "Transitional Care Management: Getting Paid for What We Do Best!" webcast, presented by Marc Price, D.O., provides an overview of the benefits of offering TCM services to Medicare beneficiaries. 

What is Medicare Transitional Care Management (TCM)?

Transitional Care Management (TCM) addresses the hand-off period between the inpatient and community setting. After a hospitalization or other inpatient facility stay (e.g., in a skilled nursing facility), the patient may be dealing with a medical crisis, new diagnosis, or change in medication therapy. Family physicians often manage their patients’ transitional care.

TCM Coding

The two CPT codes used to report TCM are:

  • 99495 – moderate medical complexity requiring a face-to-face visit within 14 days of discharge
  • 99496 – high medical complexity requiring a face-to-face visit within seven days of discharge

Requirements and Components for TCM

  • Contact the beneficiary or caregiver within two business days following a discharge. The contact may be via telephone, email, or a face-to-face visit. Attempts to communicate should continue after the first two attempts in the required business days until successful.
  • Conduct a follow-up visit within 7 or 14 days of discharge, depending on the complexity of medical decision making involved. The face-to-face visit is part of the TCM service and should not be reported separately.
  • Medicine reconciliation and management must be furnished no later than the date of the face-to-face visit.
  • Obtain and review discharge information.
  • Review the need for and/or follow up on pending test/treatments.
  • Educate the beneficiary, family member, or caregiver.
  • Establish or re-establish with community providers and services, if necessary.
  • Assist in scheduling follow-up visits with providers and services, if necessary.

Discharge from any of the following:

  • Inpatient acute care hospital
  • Inpatient psychiatric hospital
  • Long-term care hospital
  • Skilled nursing facility
  • Inpatient rehabilitation
  • Hospital outpatient observation
  • Partial hospitalization

Health Care Professionals Who May Furnish and Bill TCM:

  • Physician (any specialty)
  • Clinical nurse specialist (CNS)
  • Nurse practitioner (NP)
  • Physician assistant (PA)
  • Certified nurse midwife

Non-physicians must legally be authorized and qualified to provide TCM in the state in which the service is furnished.


Transitional Care Management

Learn How Coordinated Care Benefits Patients, Quality Payment Program (QPP) Performance and Your Bottom Line

Transitional care management ensures patients who have a high-risk medical condition will receive the care they need immediately after discharge from a hospital or other facility. Learn more about how to get paid for this service.

Read more about transitional care management in the Making Sense of MACRA: Aligning Transitional Care Management (TCM) with the Quality Payment Program (QPP) supplement (PDF)


AAFP’s Position on TCM

The AAFP’s advocacy efforts have helped pave the way for Medicare payment for TCM, giving family physicians an opportunity to be paid to coordinate care for Medicare beneficiaries as they transition between settings. We believe that family physicians should be compensated for the value they bring to their patients by delivering continuous, comprehensive, and connected health care.

What You Need to Know

As health care moves from volume to value, TCM will be increasingly important. This service ensures that patients receive the care they need immediately after a discharge from a hospital or other health care facility. Continuity of care provides a smooth transition for patients that improves care and quality of life, and helps prevent unnecessary readmission, thereby reducing costs.

Approaches to Help Your Practice Get Started

  • Identify hospitals and emergency departments (EDs) responsible for most patients’ hospitalizations. With the shared goal of decreasing readmissions, develop a relationship with those hospitals to improve timeliness of notification, so the practice can reach out to patients within two business days of discharge.
  • Add this service to decrease cost of care by reducing unnecessary readmissions.
  • Add this service after AWV and chronic care management (CCM) as the volume and associated revenue of this service is hard to anticipate.

Get the TCM Toolkit

Want to be reimbursed for TCM services? The AAFP's TCM Toolkit includes resources to help you get started, including:

  • TCM components and requirements
  • Steps to implement TCM in your practice
  • Patient materials
  • A 30-day worksheet
  • A TCM medical records request template

Questions About TCM?

Find answers to frequently asked questions about Transitional Care Management.

Read the FAQ »

TCM Webcast

Stop leaving money on the table. The "Transitional Care Management: Getting Paid for What We Do Best!" webcast, presented by Marc Price, D.O., provides an overview of the benefits of offering TCM services to Medicare beneficiaries.