Transitional Care Management

What it is

Transitional Care Management (TCM) is the 30-day post-discharge management of patients transitioning from an inpatient, observation, partial hospitalization, or SNF stay back to 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 newly-filed discharge summary in your EHR, and an encounter scan that flags a recent inpatient or ED stay the moment the chart opens. However it's detected, the patient lands on the worklist with the clocks already running — contact by day 2, visit by day 7 or 14 — and one click opens the episode.

Who qualifies

• Patient was discharged in the prior 30 days from inpatient, observation, partial hospitalization, or SNF.
• Interactive contact with the patient or caregiver within 2 business days of discharge.
• Face-to-face visit within 7 days (high-complexity, 99496) or 14 days (moderate-complexity, 99495).
• Medication reconciliation completed on or before the face-to-face visit date.
• One TCM service per patient per 30-day post-discharge period.

Codes & when to bill them

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

• 99495TCM with moderate-complexity MDM and face-to-face visit within 14 days of discharge.
  RequirementsModerate MDM; F2F by day 14; med rec by F2F date; interactive contact by day 2.
• 99496TCM with high-complexity MDM and face-to-face visit within 7 days of discharge.
  RequirementsHigh MDM; F2F by day 7; med rec by F2F date; interactive contact by day 2.

Documentation required every cycle

1. Discharge event with date, setting, and discharging facility.
2. Interactive contact timestamp + who completed it.
3. Face-to-face visit timestamp + practitioner.
4. Medication reconciliation note.
5. Discharge summary received and reviewed.
6. MDM level assigned (moderate vs high) with rationale.
7. Final practitioner sign-off.

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.