We made an appt for Mom at her PCP within seven days of her d/c from the hospital. That is just good practice.

He didn’t even know she was in the hospital until we called and talked with his nurse when Mom got home. So when I flew home the following Monday, we went into the PCP office.

He really is an excellent doctor. My Mom has been going to him for YEARS! My Mom has great confidence in him.

He completed a physical exam and reviewed her hospital discharge report. He kept asking Mom when did she get out of the hospital. She couldn’t remember. I couldn’t either. We managed to narrow it down to 2 days.

My brother had been with her during that time, so I texted him. The doctor found it on the paperwork, started counting on his fingers, and said, ” Okay, great, six days ago!”

…And then said:

“Alright, great, I can click this and say it was less than seven days ago.” And a light bulb went off – Transitional Care Management – TCM!

So I asked.

“Are you asking that for TCM?” He said. “I don’t know what that is, but if you click this button if the patient is in the office before seven days d/c, the billers are happy.”

What is Medicare Transitional Care Management (TCM)?


According to AAFP: Transitional Care Management (TCM) services address 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 services are:

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


If you have a patient or client discharged from the hospital, you can be a HUGE asset to that PCP to prompt them that their patient has been D/C’d from a hospital and may be eligible for TCM billing.

How many times do PCPs not even know a patient was in the hospital?

My Moms PCP didn’t know.

We called him!

Imagine all the bonus points you would get if you alerted your PCPs to patients or clients who have recently D/C’d so they could make that appointment in the office within 7 or 14 days from D/C?

You would be the HERO!


Isn’t that so cool!

We have a whole module on TCM and how to help position you as the agency of choice when you help your PCPs PRODUCE MORE REVENUE!

This is your time to be a true care partner!

Ready to go deeper in TCM?

Reach out to Mike and discover the module!


Together We Grow!


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