Transitional Care Management (TCM) is a Medicare service that supports patients during the 30 days that begin on the day they are discharged from an inpatient stay and return to a community setting. Those weeks matter because problems after discharge can lead to a return hospital stay. The Agency for Healthcare Research and Quality (AHRQ) reports 13.9 readmissions within 30 days for every 100 hospital stays in 2020, and 17.0 when Medicare is the expected payer. The required TCM steps happen at set points in that window, and the days between them often rely on what the patient or caregiver reports.
This article explains what TCM requires, how CPT 99495 and CPT 99496 differ, what care teams do during the 30 days, and what research says about readmissions. It also shows how Remote Patient Monitoring (RPM) readings can add information between those steps, and where DrKumo’s technology fits.
The short answer TCM is a Medicare service for the 30 days that begin on the day a patient is discharged to a community setting. The practice reaches the patient within 2 business days, holds a face to face visit within 7 or 14 days, reconciles medications, and coordinates follow up. These steps are designed to reduce readmission risk, though no service removes it. |
TCM at a glance
Contact Reach the patient or caregiver within 2 business days of discharge. | Visit Hold a face to face visit within 7 days (CPT 99496) or 14 days (CPT 99495). | Coordinate Provide non face to face services through the 30 day period. |
Sources: the CMS MLN booklet on TCM (August 2025) and CMS’s TCM billing FAQs. Current as of October 2026. This article summarizes CMS guidance and is not medical or billing advice. Health care professionals should confirm requirements with their Medicare Administrative Contractor (MAC).
What Is Transitional Care Management
CMS lists “taking responsibility for a patient’s care” among the required elements of TCM. The practitioner accepts the patient after discharge without a gap in service, supports the move to a community setting, and manages medical decision making that is at least moderate in complexity.
Discharged from
| Returns to a community setting
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Who Can Provide and Bill TCM
Physicians of any specialty and certain non physician practitioners (NPPs) can provide TCM: certified nurse midwives, clinical nurse specialists, nurse practitioners, and physician assistants. Clinical staff can carry out parts of the service under their direction. Only one physician or NPP may report TCM for a patient during the 30 days.
Why the 30 Days After Discharge Matter
13.9 Readmissions within 30 days per 100 hospital stays, all payers, 2020 | 17.0 Per 100 stays when Medicare is the expected payer, 2020 | 16.8% Share of all readmissions that followed a circulatory system diagnosis, 2020 |
Source: AHRQ, Healthcare Cost and Utilization Project Statistical Brief #304 (2023).
AHRQ notes that in most cases readmissions are necessary, but “a significant portion may be preventable.” That is the gap TCM is designed to address.
Research on health outcomes offers cautious support. A national Medicare study published in JAMA Internal Medicine found that TCM was associated with lower adjusted costs and lower mortality in the 31 to 60 days after discharge. The study was observational, so it shows an association and not a cause. TCM was also billed after only 7.0 percent of eligible discharges in 2015, the last year the study covered.
The TCM 2, 7, and 14 Day Timeline
| Day 1 | The day of discharge. The 30 day period starts here and runs for the next 29 days. |
| Within 2 business days | Interactive contact with the patient or caregiver by phone, email, or face to face. CMS gives an example: for a discharge on Monday, the deadline is the end of the day on Wednesday. |
| On or before the visit | Medication reconciliation and management. |
| Within 7 calendar days | The face to face visit for CPT 99496, which requires high medical decision making. |
| Within 14 calendar days | The face to face visit for CPT 99495, which requires at least moderate medical decision making. |
| Through day 30 | Non face to face services continue until the service period ends. |
For TCM, business days are Monday through Friday, except holidays, without regard to normal practice hours or the date the practice learned of the discharge, according to Noridian, a MAC. The day of discharge is not counted, as the Monday to Wednesday example above shows.
The gaps between the required steps The contact, the visit, and the close of the 30 days are three points in time. Between them, the care team often relies on what the patient or caregiver reports. RPM can add measured readings during those days, which is where the later sections connect to DrKumo. |
What the Care Team Does During the 30 Days
CMS divides the non face to face work between the billing practitioner and clinical staff working under general supervision. Together they coordinate care across the hospital, the community, and the practice. Patient education, medication management, and follow up are at the center of that work.
Physician or NPP
| Clinical staff
|
The 2 business day contact must be made by clinical staff who can address the patient’s status and needs beyond scheduling follow up care. If two or more separate attempts in a timely manner are unsuccessful and documented, the service may still be reported, provided the face to face visit happens on time. Teams are expected to keep trying until they reach the patient.
CPT 99495 vs 99496: Which Code Applies
| Element | CPT 99495 | CPT 99496 |
|---|---|---|
| Interactive contact | Within 2 business days of discharge | Within 2 business days of discharge |
| Medical decision making | At least moderate | High |
| Face to face visit | Within 14 calendar days of discharge | Within 7 calendar days of discharge |
| Service period | 30 days, beginning on the day of discharge | 30 days, beginning on the day of discharge |
Medical decision making is defined by three elements: the number and complexity of problems addressed, the amount and complexity of data reviewed, and the risk of complications and morbidity or mortality of patient management. CMS says TCM can be provided through telehealth services, and the TCM face to face visit is not reported separately.
How to Reduce the Risk of Readmission During the 30 Days
No service removes the risk of readmission. The steps below turn the CMS requirements into a workflow a practice can build around. The first step is a practical suggestion, and the rest follow CMS’s requirements.
Step 1 | Learn about the discharge quickly The 2 business day clock starts at discharge, so someone in the practice needs a way to learn when patients are discharged. |
Step 2 | Make and document the contact Clinical staff can make the call. Record the date of first contact, or the dates of unsuccessful attempts, in the medical record. |
Step 3 | Reconcile medications early CMS requires medication reconciliation and management on or before the date of the face to face visit. |
Step 4 | Hold the visit inside the window Schedule the visit within 7 or 14 calendar days based on the expected level of medical decision making. A telehealth visit is allowed. The visit cannot take place on the same day as discharge day management services. |
Step 5 | Use the rest of the 30 days Review pending tests and treatments, arrange referrals and community resources, educate the patient and caregiver, and support adherence. |
TCM vs CCM vs RPM: What Is the Difference
TCM, chronic care management (CCM), and RPM are separate services. CMS’s TCM booklet lists the code descriptors for all three, which the table summarizes.
| Feature | TCM | CCM | RPM |
|---|---|---|---|
| What it covers | Care after discharge from a qualifying inpatient or partial hospitalization setting | Care for two or more chronic conditions expected to last at least 12 months | Remote monitoring of physiologic data, such as weight, blood pressure, pulse oximetry, or respiratory flow rate |
| Time frame | 30 days, beginning on the day of discharge | Reported by calendar month | Device supply reported for each 30 days, with treatment management by calendar month |
| What the descriptors require | Contact within 2 business days, a face to face visit within 7 or 14 days, and at least moderate medical decision making | A comprehensive care plan that is established, implemented, revised, or monitored | Interactive communication with the patient or caregiver during the month for treatment management |
Can TCM Be Billed With CCM, RPM, and Other Services
CMS says certain other care management services can be billed concurrently with TCM when medically reasonable and necessary and if time and effort are not counted more than once. The table shows the service families the booklet lists. It was published in August 2025, before the 2026 RPM code changes that added CPT 99445 and CPT 99470 (Noridian summary). Confirm with your MAC how those codes apply during a TCM period. These allowances reflect Medicare policy, and other payers may follow CPT guidelines or their own rules, which can differ.
| Service | Example codes listed by CMS |
|---|---|
| Remote physiologic monitoring | 99453, 99454, 99457, 99458 |
| Chronic care management | 99490, 99491, 99439, 99487, 99489 |
| Remote therapeutic monitoring | 98975, 98976, 98977, 98978, 98980, 98981 |
| Physiologic data interpretation | 99091 |
| Other listed services | 99358 and 99359 (prolonged services), 93792 and 93793 (INR monitoring), end stage renal disease services, G0181, G0182 |
| Topic | What CMS says |
|---|---|
| Who can report | Only 1 physician or NPP may report TCM, and only once per patient during the TCM period. |
| Same practitioner | The practitioner who discharges the patient may also bill TCM, but the required face to face visit cannot take place on the same day as discharge day management services. |
| Global surgery | CMS does not pay TCM if any of the 30 day period falls within a global surgery period for a procedure billed by the same practitioner. |
| First eligible claim | Medicare pays the first eligible claim submitted for the 30 day period. |
| Readmission | TCM can still be reported if the patient is readmitted, provided the services are furnished. The same individual or group cannot report a second TCM for a later discharge within the same 30 days. |
| APCM | The same practitioner cannot report APCM (HCPCS G0556, G0557, G0558) and TCM for the same patient in the same month, according to the AAFP’s summary of CMS policy. |
| Death before day 30 | Do not report TCM. Face to face visits can be reported under the appropriate evaluation and management (E/M) code. |
When to Submit the Claim and What to Document
According to CMS’s billing FAQs, the date of service is the date of the required face to face visit, and the practitioner “need not hold the claim until the end of the service period.” The place of service matches the face to face visit. These FAQs date from 2016, so confirm current claim handling with your MAC.
TCM documentation checklist
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TCM at Rural Health Clinics and FQHCs
CMS’s FAQs explain that Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) are not paid separately under the Physician Fee Schedule, but the face to face visit component of TCM could qualify as a billable visit in an RHC or FQHC. Practitioners with a separate fee for service practice outside the clinic may bill the TCM codes under the usual requirements. FQHCs and RHCs should confirm details with their MAC.
Where RPM Can Add Information During the 30 Days
CMS lists RPM codes 99453, 99454, 99457, and 99458 among the services billable alongside TCM when medically reasonable and necessary. RPM adds health data from the patient’s home to the patient information the team already has, and it is one way to monitor patients between contacts. The table shows where RPM readings could support each TCM element. RPM is for monitoring only, clinicians decide what to do with the data, and it does not replace emergency care.
| TCM element | What CMS describes | Where RPM readings can help |
|---|---|---|
| Contact within 2 business days | Clinical staff address the patient’s status and needs beyond scheduling follow up care. | If the patient has already started RPM, staff can discuss recent readings. Timing depends on when the patient is enrolled. |
| Face to face visit within 7 or 14 days | The practitioner assesses the patient with moderate or high medical decision making. | The practitioner can review readings collected since discharge alongside the visit. |
| Non face to face services through day 30 | Review of tests and treatments, education, adherence support, and arranging follow up. | Staff can review readings between contacts and use them in education and adherence conversations. |
| Patients without a smartphone or home internet | The TCM booklet does not address how patients connect. | RPM that transmits over cellular connectivity does not depend on WiFi or a phone app. |
AHRQ’s data show why chronic conditions such as congestive heart failure, COPD, and diabetes are often discussed in this setting. Circulatory system diagnoses accounted for the largest share of readmissions in 2020, and readmission rates after respiratory and endocrine diagnoses were above the overall rate. RPM coding changes periodically, and CMS has proposed further changes for CY 2027 that are not final. DrKumo summarizes them in an article on the CY 2027 RPM proposal.
How DrKumo Supports RPM After Discharge
The table above describes RPM in general. DrKumo’s role is the technology that moves readings from the patient’s home to the care team. DrKumo provides secure, HIPAA compliant digital health technology that supports RPM programs operated by healthcare providers, using medical devices as defined by the FDA, such as blood pressure monitors, glucometers, and weight scales. Data travels over cellular connectivity, with no WiFi or smartphone app required, so a patient who returns home without a smartphone or home internet is not left out of the design. That includes patients served by FQHCs and RHCs, rural health organizations, and community providers.
DrKumo also supports provider led, evidence based Disease Management Protocols for hypertension, diabetes, heart failure, and COPD, and applies healthcare cybersecurity practices to patient data. Whether RPM suits a patient, and which TCM code to report, remain decisions for the care team and the billing practitioner. Practices can review DrKumo’s comprehensive guide to RPM. DrKumo is a technology provider and is not a clinical entity. Providers retain full clinical responsibility for patient care decisions, and RPM supports monitoring between visits rather than replacing emergency care.
Key Takeaways
TCM covers the 30 days that begin on the day of discharge. It requires contact within 2 business days, a face to face visit within 7 or 14 calendar days, medication reconciliation, and non face to face coordination, with at least moderate medical decision making.
Research links TCM to lower costs and mortality, and AHRQ notes that some readmissions may be avoidable. No service removes the risk of readmission, and the evidence is observational.
RPM can add readings between the required TCM steps, and CMS lists RPM codes among services billable alongside TCM, subject to the usual conditions. DrKumo’s technology supports RPM programs. DrKumo is a technology provider and is not a clinical entity, and RPM does not replace emergency care.
Data driven care starts here Considering RPM for patients in the 30 days after discharge? To learn how DrKumo can help your organization deliver secure, HIPAA compliant RPM, contact us today. Our team is ready to support your journey toward better patient care.
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Frequently Asked Questions About Transitional Care Management
Questions health care teams ask about TCM and the 30 days after discharge.
What is transitional care management?
TCM is a Medicare service for the 30 days that begin on the day a patient is discharged from a qualifying inpatient or partial hospitalization setting to a community setting. It includes interactive contact within 2 business days, a face to face visit within 7 or 14 calendar days, medication reconciliation, and non face to face coordination.
Who can bill transitional care management?
Physicians of any specialty and certain non physician practitioners can bill TCM: certified nurse midwives, clinical nurse specialists, nurse practitioners, and physician assistants. Only one physician or NPP may report TCM for a patient during the 30 days. Clinical staff can carry out parts of the service under their direction.
How do you count the 2 business days for TCM contact?
Business days are Monday through Friday, except holidays, and the day of discharge is not counted. CMS gives an example: for a Monday discharge, the practice must communicate with the patient by the end of the day Wednesday. If two or more separate, timely attempts are unsuccessful and documented, TCM may still be reported when the other requirements are met.
Can TCM be billed with CCM or RPM?
CMS’s MLN booklet says certain other care management services can be billed concurrently with TCM when medically reasonable and necessary and if time and effort are not counted more than once. It lists CCM codes such as 99490 and RPM codes 99453, 99454, 99457, and 99458. APCM is different: the same practitioner cannot report APCM and TCM for the same patient in the same month. Confirm newer codes with your MAC.
When can a TCM claim be submitted?
CMS’s billing FAQs say the date of service is the date of the required face to face visit, and the practitioner may submit the claim once that visit is furnished instead of waiting until the end of the 30 days. The FAQs date from 2016, so confirm current handling with your MAC.
References
Sources and method: this article was prepared from primary sources, namely CMS’s MLN booklet MLN908628 (August 2025), CMS’s TCM billing FAQs, AHRQ’s HCUP Statistical Brief #304, and peer reviewed research. Every CPT and HCPCS code named in the article was checked against CMS’s booklet or the source cited next to it. Information is current as of October 2026.
Centers for Medicare & Medicaid Services. (2025). Transitional Care Management Services (MLN908628). HHS.gov.
Centers for Medicare & Medicaid Services. (2016). Frequently Asked Questions About Billing the Medicare Physician Fee Schedule for Transitional Care Management Services. CMS.gov.
Jiang, H. J., & Hensche, M. K. (2023). Characteristics of 30 Day All Cause Hospital Readmissions, 2016 to 2020 (HCUP Statistical Brief #304). Agency for Healthcare Research and Quality.
American Academy of Family Physicians. Using advanced primary care management services codes G0556, G0557 and G0558. AAFP.org.
Noridian Healthcare Solutions. (2025). Remote Physiologic Monitoring (RPM): 2026 Evaluation and Management (E/M) Updates. Medicare Administrative Contractor, Jurisdiction F Part B.
Noridian Healthcare Solutions. (2023). Transitional Care Management (TCM) Direct Contact. Medicare Administrative Contractor, Jurisdiction E Part B.
Bindman, A. B., & Cox, D. F. (2018). Changes in health care costs and mortality associated with transitional care management services after a discharge among Medicare beneficiaries. JAMA Internal Medicine.
Disclaimer: This article is intended for informational purposes only and does not constitute medical, legal, billing, coding, or financial advice. It summarizes CMS’s MLN booklet MLN908628 (August 2025) and CMS’s transitional care management billing FAQs, which are dated 2016. Medicare coverage, coding, and payment requirements are subject to change. Always consult official CMS sources and your Medicare Administrative Contractor for current requirements. DrKumo is a technology provider and is not a clinical entity. It does not provide clinical services or replace a licensed provider’s clinical judgment. Always consult with a licensed healthcare provider for guidance on diagnosis, treatment, or medical decisions. References to CMS, HHS, AHRQ, and the National Institutes of Health do not constitute or imply an endorsement by those agencies or the U.S. Government. |
