Programs / TCM
Transitional Care

Transitional Care Management

TCM Period: Per 30-day post-discharge episode Source: CMS-1832-F (CY 2026 PFS Final Rule)

What it is

Transitional Care Management (TCM) is the 30-day post-discharge management of patients transitioning from an inpatient hospital, observation, partial hospitalization, skilled nursing facility, inpatient rehabilitation or long-term care hospital stay back to the community. It bills one of two CPT codes per episode based on medical decision-making complexity and timeliness of the face-to-face visit.

Most practices lose TCM before it starts — nobody notices the discharge until the windows are gone. willowbridge watches for the discharge three ways: a real-time ADT feed from your regional HIE or notification vendor; a chart watcher that spots a discharge summary newly filed to the athenaOne chart for enrolled patients; and an encounter scan that shows a recent inpatient or observation stay on the athenaOne chart. An emergency department visit on its own is not a TCM discharge, so willowbridge never starts an episode from one — unless the patient was kept in observation. A discharge from the ADT feed or a filed summary lands on the worklist with the clocks already running — contact within 2 business days, visit by day 7 or 14 — and one click opens the episode.

Who qualifies

Codes & when to bill them

How the minutes add upOne code per 30-day episode — there are no minute tiers, and TCM is not timed. The code follows the face-to-face visit's day: a visit by day 7 bills 99496 (high-complexity MDM), a visit on days 8–14 bills 99495 (at least moderate MDM), and after day 14 there is no TCM. The windows are calendar days on your practice's clock, with the discharge day as day 0 — a visit at any hour of day 7 or day 14 counts. willowbridge checks your athena schedule against the open episodes and tells the people who code the visit which code goes on its claim.

Each billable code, with the requirements that must be on file to bill it.

Documentation required every cycle

  1. Discharge event with date, setting, discharging facility, and where the patient went.
  2. Interactive contact date, what was discussed, and who made it.
  3. Face-to-face visit date, the practitioner who performed it, and how (in person or telehealth).
  4. Medication reconciliation date, no later than the visit.
  5. Discharge summary received and reviewed.
  6. The non-face-to-face services furnished in the 30 days (documentation only).
  7. The practitioner's sign-off: the medical decision making the code requires, and what the visit's claim carries.

Built-in patient consentwillowbridge exclusive

Every program ships with compliant, CY-2026 patient consent language — read verbatim into the in-app consent capture flow, captured with date + modality, and version-pinned to each claim, so the consent on file always matches the consent that was billed. No more chasing signatures or re-papering when the rule changes.

Note: TCM is a Medicare benefit that does not require separate patient written consent, and willowbridge asks the patient for none.

If your practice prefers to capture written acknowledgement, the following text may be used:

See the full TCM consent flow
Book a 20-minute demo — we'll walk you through consent capture, the audit packet, and the billing flow on a live demo tenant. No data of yours, no setup on your end.
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Common questions

Who qualifies for Transitional Care Management (TCM)?

Patient was discharged from an inpatient hospital stay, observation, partial hospitalization, a skilled nursing facility, an inpatient rehabilitation facility or a long-term care hospital, back to the community (home, assisted living, a domiciliary or a nursing facility). Interactive contact with the patient or caregiver within 2 business days of discharge, by clinical staff or the practitioner — or two attempts dated inside those two days. Face-to-face visit by the billing practitioner within 7 days (high-complexity, 99496) or 14 days (moderate-complexity, 99495). Medication reconciliation completed no later than the face-to-face visit date. One TCM service per patient per 30-day post-discharge period.

Which codes does willowbridge bill for TCM, and when?

One code per 30-day episode — there are no minute tiers, and TCM is not timed. The code follows the face-to-face visit's day: a visit by day 7 bills 99496 (high-complexity MDM), a visit on days 8–14 bills 99495 (at least moderate MDM), and after day 14 there is no TCM. The windows are calendar days on your practice's clock, with the discharge day as day 0 — a visit at any hour of day 7 or day 14 counts. willowbridge checks your athena schedule against the open episodes and tells the people who code the visit which code goes on its claim.

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CCMChronic Care Management APCMAdvanced Primary Care Management HHHome Health Certification & Oversight

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