OnCare360
Aug 14, 2025
Transitional Care Management (TCM) is designed to improve outcomes and reduce readmissions during the first 30 days after a patient is discharged from an inpatient or skilled nursing facility. While TCM is often the primary reimbursable service for this period, it may overlap with other care management programs such as Chronic Care Management (CCM), Remote Patient Monitoring (RPM), Principal Care Management (PCM), and Behavioral Health Integration (BHI).
Billing TCM concurrently requires careful compliance, as CMS restricts duplication of services while still permitting distinct, non-overlapping billing. This guide outlines when and how TCM can be billed alongside other services, with documentation and workflow strategies to maximize both patient benefit and revenue integrity.
Executive Summary
TCM is billable once per 30-day transition period using CPT 99495 (moderate MDM, visit ≤14 days) or CPT 99496 (high MDM, visit ≤7 days).
Concurrent billing with CCM, RPM, or PCM may be possible if time, scope, and documentation are clearly distinct.
Practices must implement structured workflows for timely contact, role allocation, and care plan documentation to ensure compliance.
Table of Contents
TCM Overview in the Billing Context
Common Concurrent Billing Combinations
CMS Guidelines: Allowable vs. Restricted Combinations
Time Segmentation and Role Differentiation
Documentation Examples
Frequent Denials and How to Prevent Them
Compliance Checklist
1. TCM Overview in the Billing Context
TCM codes:
99495 Moderate complexity medical decision making, interactive contact within 2 business days, face-to-face visit within 14 days.
99496 High complexity medical decision making, interactive contact within 2 business days, face-to-face visit within 7 days.
Requirements include:
Discharge from hospital, SNF, or observation status.
Interactive patient/caregiver contact within 2 business days.
Non-face-to-face services such as medication reconciliation, coordination, and patient education.
2. Common Concurrent Billing Combinations
TCM + CCM
Permissible if:
TCM covers the transition period while CCM covers chronic care beyond 30 days.
Documented activities and time are non-duplicative.
TCM + RPM
Permissible if:
RPM device monitoring supports physiologic tracking (e.g., glucose, BP) during the transition.
RPM time and documentation are separate from TCM outreach and care planning.
TCM + PCM
Permissible if:
PCM is focused on one condition, while TCM addresses the post-discharge transition across conditions.
Distinct documentation of PCM vs TCM tasks.
TCM + BHI
Permissible if:
Behavioral health needs are managed distinctly from the transitional episode.
BHI activities documented separately.
3. CMS Guidelines: Allowable vs. Restricted Combinations
TCM may not be billed by more than one provider during the 30-day period.
Only one TCM claim is payable per patient per 30-day discharge episode.
TCM may be billed concurrently with CCM, RPM, or PCM, provided the services are non-overlapping.
TCM services cannot be duplicated under other evaluation and management visits during the same transition window.
4. Time Segmentation and Role Differentiation
Service | Time Requirement | Distinction Needed | Example Task |
|---|---|---|---|
TCM 99495/99496 | 30-day episode | Transitional contact & follow-up | Post-discharge phone call, medication reconciliation, face-to-face visit |
CCM 99490 | 20 min/month | Chronic ongoing care management | Long-term care plan update, lifestyle coaching |
RPM 99457 | 20 min/month | Device data review | Reviewing BP/glucose uploads, contacting patient on device alerts |
PCM 99426 | 30 min/month | Condition-specific care | Single-condition follow-up (e.g., CHF) |
Role assignment example:
TCM outreach & reconciliation – nurse coordinator
CCM care planning – chronic care nurse
RPM device monitoring – care technician
PCM condition follow-up – specialist NP
5. Documentation Examples
TCM 99495:
“Patient discharged from hospital on 07/20/25. Contacted by RN on 07/22/25. Medication reconciliation completed, follow-up scheduled. Face-to-face visit on 07/29/25. Moderate MDM due to diabetes + CHF. Documented transition plan and care coordination.”
CCM 99490 (Concurrent Month):
“Reviewed patient’s diabetes and hypertension care plan, coordinated endocrinology referral, adjusted diet recommendations. 25 minutes of clinical staff time.”
RPM 99457 (Concurrent Month):
“Reviewed 17 days of glucose monitoring data. Called patient for 9 minutes to discuss hypoglycemia prevention. Total interactive time this month: 22 minutes.”
6. Frequent Denials and How to Prevent Them
Denial Reason | Prevention Tip |
|---|---|
Missing 2-day contact | Document date/time and method of patient contact |
Duplicate TCM claims | Ensure only one provider submits claim per 30-day episode |
Overlapping time | Maintain separate time logs for TCM vs CCM/RPM/PCM |
Insufficient documentation | Note clinical decision-making complexity and specific interventions |
7. Compliance Checklist
TCM billed only once per 30-day episode per patient
Interactive contact documented within 2 business days of discharge
Face-to-face visit within 7 or 14 days based on CPT code used
Non-face-to-face care coordination tasks documented (e.g., med reconciliation, referrals)
Distinct documentation for TCM vs CCM, RPM, or PCM
Separate time logs for concurrent services
Patient consent on file for all billed programs
Provider and staff roles clearly delineated in documentation
Internal audit of TCM claims monthly for compliance
CMS and payer-specific rules reviewed annually
Final Note
Concurrent billing for TCM requires precision but offers significant value. By combining structured post-discharge support with ongoing chronic care, practices can reduce readmissions, enhance patient safety, and sustain revenue streams. With clear workflows, time segmentation, and documentation rigor, TCM can coexist with CCM, RPM, and PCM in a compliant, patient-centered model.
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