Transitional Care Management Requirements: 99495 and 99496

Updated October 2026. Written by Matteo Grassi, cofounder of HANA Health, trained in psychology.

Transitional care management (TCM) is a Medicare service that pays a practice for managing a patient's return to the community after a hospital or facility stay. To bill it, you need contact within 2 business days of discharge, a face to face visit within 7 or 14 days, and medical decision making over a 30 day period. In 2026 the national payment is $220.11 for 99495 and $298.60 for 99496.

Key facts

• TCM uses two CPT codes: 99495 (moderate complexity, visit within 14 calendar days) and 99496 (high complexity, visit within 7 calendar days), per the CMS Medicare Learning Network TCM booklet.
• The 30 day service period starts on the discharge date and runs for the next 29 days.
• The 2026 national non-facility payment is $220.11 for 99495 and $298.60 for 99496, using a $33.4009 conversion factor (CMS CY2026 final rule fact sheet).
• Medicare pays one practitioner per beneficiary per 30 day period, and it pays the first eligible claim it receives (CMS billing FAQ, 2016).
• Two or more timely, documented, unsuccessful contact attempts can still satisfy the 2 business day rule if the visit happens on time.
• In 2019, 11.3% of eligible Medicare discharges got TCM services (Anderson et al., JAMA Health Forum, 2024).
• The date of service on the claim is the date of the face to face visit, and you don't have to wait for day 30 to submit.

Who can bill TCM, and after which discharges?

Physicians of any specialty, nurse practitioners, physician assistants, clinical nurse specialists and certified nurse midwives can furnish the face to face part of TCM. Auxiliary staff can handle many of the other parts under general supervision, within state law and incident to rules.

The discharge has to be from one of these settings: an inpatient acute care hospital, inpatient psychiatric hospital, inpatient rehabilitation facility, long term care hospital, skilled nursing facility, hospital observation, or partial hospitalization (hospital or community mental health center). The patient then has to return to a community setting such as home, a group home, a nursing facility or an assisted living facility.

TCM also needs a practitioner who accepts responsibility for the patient's care at discharge, without a service gap. If nobody owns the patient on day one, the clock runs anyway.

What counts as the interactive contact within two business days?

It's a phone call, email or face to face contact with the patient or caregiver, made by you or by clinical staff who can address the patient's status and needs beyond scheduling a follow up. Business days are counted after the discharge date. CMS has said that for a Monday afternoon discharge, the deadline is the end of the day Wednesday.

A practical sequence looks like this:

1. Day of discharge: confirm the discharge date and the patient's current phone number.
2. Business day 1 and 2: reach the patient or caregiver. Cover symptoms, medicines, home needs and the follow up appointment.
3. If you can't reach them, make at least two separate attempts, document each one, and keep trying.
4. Book the visit so it lands inside the 7 or 14 day window.
5. Finish medication reconciliation on or before the visit date.

If the visit misses its window, you can't bill TCM, even when the calls were perfect.

What does the face to face visit have to include?

One face to face visit, inside the window for the code you want, plus medication reconciliation and management done on or before that visit date. The visit isn't billed separately, and Medicare allows 99495 and 99496 to be furnished by telehealth.

• 99495: at least moderate medical decision making, visit within 14 calendar days of discharge.
• 99496: high medical decision making, visit within 7 calendar days of discharge.

Medical decision making follows the CPT E/M guidelines, and the level you document has to be earned by the patient's problems, the data reviewed and the risk of management. A visit on day 5 doesn't make it a 99496 if the decision making was moderate. The booklet says to record the discharge date, the first contact date, the visit date and the decision making level at a minimum.

What non-face-to-face services does TCM require?

You have to provide medically reasonable and necessary services outside the visit during the 30 days. CMS splits them by who does the work.

• Practitioner: review discharge information, review the need for diagnostic tests and treatments, talk with other clinicians who will take over care, educate the patient or caregiver, arrange referrals and community resources, and help schedule follow up.
• Clinical staff under general supervision: communicate with the patient, communicate with community agencies the patient uses, educate to support self management, assess and support treatment adherence including medication management, identify community resources, and help the family access services.

This is where TCM is won or lost operationally. The 30 day work is calls, records, pharmacy checks and referrals that someone has to own and document.

How much does TCM pay in 2026, and how does billing work?

National averages for 2026 are $220.11 for 99495 and $298.60 for 99496 in the office setting, and $122.25 and $166.34 in the facility setting. Your locality adjusts these through geographic factors, so check the CMS PFS Look-Up Tool for your own rate.

The arithmetic ties to the final rule: 6.59 total relative value units times $33.4009 is $220.11, and 8.94 times $33.4009 is $298.60, per the CY2026 relative value table.

An illustrative month, using national non-facility averages and not a forecast:

• 6 episodes of 99495: 6 x $220.11 = $1,320.66
• 2 episodes of 99496: 2 x $298.60 = $597.20
• Monthly total: $1,917.86
• Over 12 months: $23,014.32

A few billing rules matter. If the patient is readmitted during the period, you can still report TCM. If the patient dies before day 30, you shouldn't report TCM, though you can report the visit as a regular E/M. CMS also lets certain other care management codes be billed alongside TCM when time isn't counted twice, which the booklet lists. If you run CCM, see the CCM code guide before you stack codes.

How common is TCM, and does it improve outcomes?

It's still underused. An analysis of 2010 to 2019 Medicare discharges found 11.3% of eligible patients received TCM by 2019. Timely primary care follow up rose from 31.5% in 2010 to 38.8% in 2019, and the authors say the TCM payment incentive likely drove part of that gain.

A 2015 to 2019 claims study found TCM in 10.9% of 1,556,347 eligible discharges, and it was less likely for patients at higher readmission risk, including those with frailty or dementia (Park et al., J Am Geriatr Soc, 2024).

On outcomes, the evidence is observational. A Northwell Health study linked TCM visits to lower 30 day readmissions (Kim et al., PLOS One, 2025). But practices that do TCM may differ in other ways, so these studies don't prove the code causes the drop. What they do show is that a timely visit after discharge is rare enough that most practices have room to improve.

What this means for your practice

Pick one owner for discharge notifications, and make the 2 business day call a daily task with a name next to it. Track three dates per episode: discharge, first contact, visit. Schedule the visit before you hang up on the first call.

Then decide who covers the 30 days. The hardest cases are the high risk patients who don't answer. Principal care management may fit better when one condition drives the stay.

HANA Health works with practices on structured outreach and follow up calls around Medicare care management programs, and you can see how on our care coordination page.

Frequently asked questions

Can a medical assistant make the two business day call?

Possibly. CMS says clinical staff must be allowed by law and facility policy to do the work, and they must be able to address patient status and needs beyond scheduling. State scope of practice and incident to rules decide who qualifies in your practice.

Can I bill TCM after an emergency department visit?

The CMS booklet lists inpatient settings, observation and partial hospitalization. An emergency department visit that doesn't become an observation or inpatient stay isn't on that list.

What if the patient is readmitted in the 30 days?

You can still report TCM if you furnish the described services during the period, including the time after the second discharge. Only one individual can report it once per patient within 30 days of discharge.

Can the visit be done by video?

Medicare allows 99495 and 99496 through telehealth under the booklet's guidance. Telehealth rules change, so confirm the current flexibilities with your MAC.

Who gets paid if two practices bill TCM?

Medicare pays only the first eligible claim received for the 30 day period. Other practitioners can still report other reasonable and necessary services.

Sources

1. Centers for Medicare & Medicaid Services, Medicare Learning Network. Transitional Care Management Services (MLN908628).
2. Centers for Medicare & Medicaid Services. Frequently Asked Questions about Billing the Medicare Physician Fee Schedule for Transitional Care Management Services, 2016.
3. Centers for Medicare & Medicaid Services. CY 2026 Medicare Physician Fee Schedule Final Rule fact sheet, 2025.
4. Centers for Medicare & Medicaid Services. PFS Look-Up Tool overview.
5. American Urological Association. CY 2026 MPFS final rule relative value table, evaluation and management.
6. Anderson TS et al. Medicare Transitional Care Management Program and Changes in Timely Postdischarge Follow-Up. JAMA Health Forum, 2024.
7. Park CM et al. Utilization of Transitional Care Management Service Among Medicare Beneficiaries at High Risk of Readmission. J Am Geriatr Soc, 2024.
8. Kim EJ et al. Utilization of transitional care management services and 30-day readmission. PLOS One, 2025.

This article is educational and isn't billing, coding, clinical or legal advice. Check current CMS guidance and your MAC before you bill. Want help building a discharge follow up workflow? Book a discovery call.