TCM Services & Workflow Support
Transitional Care Management Services and Workflow Support
HealthArc helps physician practices and care teams deliver structured post-discharge follow-up, automate TCM documentation, reconcile medications and bill CPT 99495 and 99496 accurately — reducing readmissions and closing gaps in post-acute care.
Built for primary care, hospitalist groups and multi-specialty practices managing Medicare and Medicaid patients transitioning from hospital, SNF or inpatient rehab back to the community.
HIPAA Compliant
AICPA SOC 2 Type II
Audit-ready documentation
Primary care, hospitalists, FQHCs & ACOs
2 business daysthe contact window that decides the claim
TCM CPT codes30-day episode from discharge
99495Moderate complexity — visit within 14 days~$215
99496High complexity — visit within 7 days~$295
Interactive contactWithin 2 business days — non-waivableRequired
Episode length30 days from date of discharge1 claim
1 in 5Medicare patients readmitted within 30 days
up to 76%reduction in preventable readmissions with structured TCM
2 codes99495 and 99496
2–4 wkstypical time to go live
Program Overview
What Is Transitional Care Management?
Transitional care management (TCM) is a Medicare and Medicaid program that supports patients during the high-risk period immediately after discharge from a hospital, skilled nursing facility, inpatient psychiatric facility, long-term care hospital or inpatient rehabilitation facility. The goal is to get patients home safely and keep them from being readmitted.
TCM services are delivered over a 30-day period beginning on the date of discharge. The program requires at least one interactive contact — phone, electronic or face-to-face — with the patient or caregiver within two business days of discharge, followed by a face-to-face visit within either 7 days (moderate-to-high complexity, CPT 99496) or 14 days (moderate complexity, CPT 99495). Between those touchpoints the care team performs non-face-to-face work: discharge summary review, medication reconciliation, care coordination and patient education.
CMS introduced TCM as part of its broader chronic care strategy because care transitions are among the most clinically vulnerable windows in a patient’s continuum. One in five Medicare beneficiaries is readmitted within 30 days of discharge, and structured TCM programs have been shown to reduce preventable readmissions substantially. Despite the clinical and financial case, many practices forgo TCM billing because the documentation and workflow requirements are difficult to manage without dedicated software.
HealthArc’s TCM platform operationalises every step of this workflow — from the discharge trigger to the billing submission — so care teams spend their time on patient care rather than administrative tracking.
Episode
30 days beginning on the date of discharge — one TCM claim per episode
Interactive contact
Within 2 business days of discharge — non-waivable for both codes
Face-to-face visit
Within 7 days for 99496, 14 days for 99495
Qualifying discharge
Hospital (inpatient or observation), SNF, inpatient psych, LTCH or IRF
CPT codes
99495 (moderate) and 99496 (high complexity) — see the full TCM code reference
Not billable with
A second TCM claim, or CCM, for the same patient in the same period
The 2-business-day contact is where TCM claims are won or lost. If contact is not achieved within the window, the episode cannot be billed — regardless of how well the rest of the workflow was executed. HealthArc drives the outreach attempts, timestamps every one, and flags a slipping window while there is still time to act on it.
Who It’s For
Who Uses HealthArc for Transitional Care Management?
TCM is built for clinical and administrative teams responsible for what happens after a patient leaves a facility — and for the readmission that follows if nobody does.
Practice Types
- Primary care and internal medicine practices with high-volume Medicare panels
- Hospitalist and hospital medicine groups coordinating post-discharge follow-up
- Multi-specialty groups and federally qualified health centers
- ACOs and value-based care networks with readmission reduction targets
- Independent physician associations and clinically integrated networks
Provider Roles
- Physicians (MD/DO) billing under their own NPI
- Nurse practitioners and physician assistants — who can bill TCM independently
- Care coordinators and RNs performing non-face-to-face work under the supervising provider
- Licensed clinical social workers managing community resource coordination
- Billing staff managing claim submission and denial follow-up
Which Discharges Qualify
A patient qualifies for a TCM episode when they are discharged from:
- A hospital — inpatient or observation status
- A skilled nursing facility (SNF)
- An inpatient psychiatric facility
- A long-term care hospital (LTCH)
- An inpatient rehabilitation facility (IRF)
- … and is returning to a community setting — home, assisted living or similar
Observation status discharges qualify. Emergency department visits without an admission do not. If your practice is seeing readmissions, missing the 2-day contact window or leaving 99495 and 99496 uncaptured, this is the workflow HealthArc was built for.
The Platform
HealthArc TCM Platform: Built for Every Step of the Workflow
Managing transitional care through spreadsheets, sticky notes or generic EHR task lists leads to missed contact windows, undocumented encounters and lost reimbursement. HealthArc replaces that patchwork with a purpose-built TCM workflow engine.
Automated Discharge Intake
- Receive and log discharge alerts from hospitals and SNFs
- Each discharge triggers a structured workflow checklist
- No patient enters the 30-day window without an owner
- Duplicate and re-admission detection within an open episode
2-Day Interactive Contact Tracking
- The platform prompts the care team inside the required 2-business-day window
- Every contact attempt is timestamped for billing documentation
- Missed attempts are flagged and queued for retry
- Escalation when the window is about to close
Discharge Summary Review
- Upload or pull in discharge summaries against the patient’s TCM record
- Flag discrepancies in medication lists, pending follow-up orders and specialist referrals
- Document resolution of each discrepancy
- Retain the reviewed summary in the audit trail
Medication Reconciliation Workflow
- Side-by-side comparison of pre-admission and post-discharge medication lists
- Prompts to resolve conflicts, document rationale and notify the patient
- Reconciliation completion recorded against the episode
- High-risk medication flags for pharmacist or clinician review
Non-Face-to-Face Service Logging
- Track every asynchronous touchpoint — coordinator calls, portal messages, referral coordination, education delivery
- Timestamps and provider attribution on each entry
- Activity types mapped to CMS documentation requirements
- Full episode timeline in one view
Face-to-Face Visit Scheduling
- Automated outreach for the 7-day or 14-day visit
- Reminders by SMS, email or patient portal based on preference
- Visit-date tracking against the code being billed
- Alerts when a visit deadline is at risk
CPT Code Assignment Logic
- Completed activities mapped to 99495 or 99496 by complexity and visit timing
- Reduces billing errors and upcoding risk
- Incomplete records flagged before submission
- Billing-ready export for your RCM system or clearinghouse
Real-Time Dashboard & Alerts
- Open TCM cases, upcoming deadlines and overdue tasks across the full panel
- Filter by care coordinator, discharge facility or days remaining
- Role-based views for coordinators, clinicians and billers
- Daily digest of what needs attention
Care Team Model
How HealthArc Structures the TCM Care Workflow
The platform is designed around the three-phase TCM workflow CMS defines — and gives each member of the care team a clear, documented role inside it.
1
Within 2 business days of discharge
Interactive Contact
A member of the care team — physician, NP, PA or a supervised care coordinator — makes direct contact with the patient or an authorised caregiver, by telephone, secure electronic message or face-to-face. The purpose is to confirm the patient arrived home safely, identify urgent concerns, confirm the follow-up visit is scheduled and begin the medication review. HealthArc logs the contact with provider attribution, method, date and summary note — all of it required for billing.
2
Days 2–14
Non-Face-to-Face Services
Between the initial contact and the required visit the care team reviews the hospital discharge summary for accuracy, reconciles the medication list, coordinates referrals to specialists or community services, educates the patient and caregiver about the discharge diagnosis and self-management, and communicates with receiving providers or home health agencies. HealthArc structures these as a checklist tied to the episode, each item timestamped and documented.
3
Within 7 days (99496) or 14 days (99495)
Face-to-Face Visit
A face-to-face visit with a physician, NP or PA must occur within 7 days of discharge for CPT 99496 (high complexity) or within 14 days for CPT 99495 (moderate complexity). The visit closes the active TCM case and the platform generates the documentation package needed to submit the claim. The 30-day TCM period ends on day 30 from discharge; no second TCM claim may be submitted for the same patient within it.
Option 1
Software only
Your coordinators and clinicians run the episodes in HealthArc. The platform owns the clock, the checklist and the documentation; your team owns every patient interaction.
Best for: practices with care coordination staff
Option 2
Managed post-discharge outreach
HealthArc’s team drives the 2-day contact attempts and non-face-to-face work under your providers’ direction; your clinicians perform the face-to-face visit that closes the case.
Best for: practices with high discharge volume
Option 3
Hybrid
HealthArc absorbs overflow and after-hours contact attempts — the window does not respect clinic hours — while your team keeps the patients it knows.
Best for: weekend and holiday discharges
Role-based permissions mean each user sees only the tasks relevant to their function: coordinators manage outreach and scheduling, clinical staff manage documentation and medication review, billing staff manage claim submission.
Billing & Reimbursement
TCM Billing: CPT Codes 99495 and 99496
Transitional care management is billed using two CPT codes. Which one applies depends on the complexity of medical decision-making and the timing of the face-to-face visit. Both cover a 30-day episode beginning on the discharge date.
~$215
99495
Moderate Complexity
- Moderate medical decision-making complexity
- Face-to-face visit within 14 calendar days of discharge
- Interactive contact within 2 business days
- Stable chronic conditions without urgent complications
~$295
99496
High Complexity
- High medical decision-making complexity
- Face-to-face visit within 7 calendar days of discharge
- Interactive contact within 2 business days
- Complex, unstable or multiple conditions needing close management
| Requirement | CPT 99495 — moderate complexity | CPT 99496 — high complexity |
|---|---|---|
| Medical decision-making | Moderate | High |
| Face-to-face visit | Within 14 calendar days of discharge | Within 7 calendar days of discharge |
| Interactive contact | Within 2 business days of discharge | Within 2 business days of discharge |
| Episode length | 30 days from date of discharge | 30 days from date of discharge |
| Avg. Medicare reimbursement | ~$215 | ~$295 |
| Typical patient profile | Stable chronic conditions requiring post-discharge follow-up without urgent complications | Complex, unstable or multiple chronic conditions requiring close post-discharge management |
Documentation Requirements for Both Codes
- Date of discharge and the qualifying inpatient facility type
- Date and method of the 2-business-day interactive contact — or documented failed attempts
- All non-face-to-face services performed between discharge and the visit, including medication reconciliation and care coordination
- Date of the face-to-face visit and the provider who performed it
- The medical decision-making level supporting the selected code
- A completed or updated care plan
Common Billing Errors to Avoid
- Billing TCM and a separately billable E&M visit for the same face-to-face encounter on the same date — the TCM code includes the E&M
- A missing or undocumented 2-business-day contact attempt
- Failing to document complexity sufficient to support 99496 over 99495
- Billing a second TCM claim inside the same 30-day episode
- Billing TCM and CCM for the same patient in the same month
The Monthly Billing Workflow in HealthArc
1
A discharge notification opens a TCM episode and starts the 2-business-day clock
2
Outreach attempts are prompted, logged and timestamped until interactive contact is achieved
3
Non-face-to-face work is completed against a structured checklist, each item attributed and dated
4
The face-to-face visit is scheduled, reminded and recorded against the applicable deadline
5
HealthArc maps the documented activity to 99495 or 99496 and flags incomplete records before submission
6
A billing-ready documentation package is exported to your RCM system or clearinghouse
A practice with 30 qualifying discharges a month represents an estimated $77,000–$106,000 a year in TCM reimbursement (30 × $215–$295 × 12). Most practices have more qualifying patients than they are currently tracking.
Calculate Your RevenueReimbursement figures are approximate national non-facility Medicare averages and vary by geographic locality, facility status, payer and calendar year. CMS updates them annually in the Physician Fee Schedule — verify current rates at cms.gov or with your MAC before you bill.
Implementation
Implementing HealthArc TCM: What Onboarding Looks Like
Most practices launch within two to four weeks. Implementation minimises disruption to existing workflows and does not require an EHR migration.
1
Week 1
Practice Configuration
Your implementation specialist configures the platform to your structure — provider roster, care team roles, patient panel parameters and billing preferences. You define which staff perform which TCM tasks and set alert and escalation thresholds.
2
Weeks 1–2
EHR & Discharge Feed Connection
HealthArc connects to your EHR and, where available, to hospital or SNF discharge notification feeds — so discharge events are captured automatically rather than depending on a coordinator noticing them.
3
Week 2
Staff Training
Role-based training for care coordinators, clinical staff and billing personnel, delivered live or via on-demand modules. Typically two to three hours per role.
4
Week 3
Pilot Case Review
Your team runs a cohort of active TCM cases through the platform with HealthArc support on hand. Workflow gaps are identified and resolved before full-volume launch.
5
Week 4+
Go-Live & Ongoing Support
The full patient panel goes live. HealthArc provides monthly billing reconciliation reviews, compliance check-ins and platform updates aligned to CMS policy changes.
Interoperability
EHR Integration and Interoperability
HealthArc works alongside your existing EHR rather than replacing it, connecting via HL7 FHIR and direct API integrations for bidirectional flow of demographics, problem lists, medication records and encounter notes.
- What integrates automatically — patient demographics and insurance on discharge notification; medication lists for the reconciliation workflow; care plan notes back to the EHR encounter record; billing-ready documentation for your existing RCM system
- What stays in HealthArc — the TCM case management dashboard, task assignment across care team roles, compliance documentation and audit trail, and program-level reporting
- Discharge feeds — inbound ADT where a hospital or SNF can provide it, so episodes open without manual entry
- Custom integration — supported for enterprise and health system clients
Discharge Triggers
ADT feeds open the episode and start the clock without manual entry.
Medication Lists
Pre-admission and post-discharge lists land side by side for reconciliation.
Notes Back to Chart
Care plan notes and episode documentation write back to the encounter.
RCM Handoff
Billing-ready packages export to the clearinghouse you already use.
Commonly Integrated Systems
Epic
Cerner (Oracle Health)
athenahealth
eClinicalWorks
NextGen Healthcare
Allscripts / Veradigm
DrChrono
HL7 FHIR R4 API
If your EHR is not listed, contact HealthArc’s integration team at sales@healtharc.io to discuss API connectivity options.
Reporting & Analytics
TCM Reporting, Analytics and Program Performance
Running a successful TCM program takes more than completing individual episodes — it takes visibility into billing capture rates, contact performance and population-level outcomes.
Open Case Dashboard
- Every active TCM patient with discharge date and case stage
- 2-day contact status and visit deadline per patient
- Days remaining in each 30-day episode
- Filter by coordinator, facility or risk
Contact Attempt Tracking
- Every outreach attempt per patient with outcome and timestamp
- Staff attribution on each attempt
- Supports documentation in the event of an audit
- Contact-rate trend by coordinator and by method
Billing Capture
- Monthly summary of completed cases by CPT code
- Estimated reimbursement, submitted claims and denial rates
- Episodes that failed to bill, with the reason
- Revenue trend month over month
Readmission Tracking
- Patients readmitted within 30 days of discharge
- Enables quality review and workflow adjustment
- Segmented by discharge facility and diagnosis
- Supports value-based contract reporting for ACOs
Staff Productivity
- TCM cases managed per coordinator or provider
- Completion rates and average time-to-contact
- Workload balance across the team
- Bottleneck identification by workflow stage
Program Growth
- Month-over-month enrolled patients and cases completed
- Revenue generated and readmissions avoided
- Capture rate against total qualifying discharges
- Exportable to CSV or PDF and schedulable to leadership
HealthArc’s reporting module also supports value-based care contract reporting for ACOs and other risk-bearing entities.
Compliance & Security
Compliance, Security and Audit Readiness
TCM is a federally defined program with specific CMS documentation requirements. Practices that bill TCM without adequate documentation are exposed to claim denial, post-payment audit recovery and compliance liability.
HIPAA Compliance
- HealthArc operates as a HIPAA-compliant Business Associate
- Patient data encrypted in transit and at rest
- Role-based access controls across the care team
- A signed BAA is provided to every HealthArc customer
CMS Documentation Standards
- CMS TCM documentation requirements enforced at the point of care
- Required fields cannot be left blank during claim generation
- Verification that the 2-day contact window was met
- Medical decision-making complexity and visit timing validated against the code billed
Audit Trail
- Every action — contact attempts, documentation edits, task completions, note revisions — timestamped and attributed
- A complete trail supporting internal quality review and external audit response
- Failed contact attempts preserved as evidence of the required effort
- Episode-level export on demand
Data Residency & Security
- HIPAA-eligible cloud infrastructure with SOC 2 Type II certification
- Data residency within the United States
- Regular penetration testing and vulnerability assessment
- MFA required for all platform users
Results
TCM Outcomes: The Case for Running the Program Properly
TCM is one of the highest-value programs available to primary care and hospitalist practices under Medicare — in clinical outcomes and in reimbursement. The figures below are published research and CMS rate arithmetic.
1 in 5Medicare beneficiaries readmitted within 30 days of discharge
up to 76%reduction in preventable readmissions with structured TCM programs
$215–$295Average Medicare reimbursement per completed TCM episode
$100K+Est. annual TCM revenue at 30 qualifying discharges per month
The revenue case is unusually simple. A practice with 30 qualifying discharges per month can generate over $100,000 a year in TCM reimbursement alone — 30 episodes × $215–$295 × 12 months. The harder question is how many qualifying discharges you are not currently tracking. Calculate your TCM revenue.
Readmission reduction figures are from published literature on structured transitional care programs. Practice-level results from HealthArc programs are shared under NDA during evaluation rather than published here.
FAQ
Frequently Asked Questions About Transitional Care Management
The questions practices ask most when evaluating TCM programs and software vendors.
What is the difference between transitional care management (TCM) and chronic care management (CCM)?
TCM is a time-limited, episode-based program covering the 30 days immediately following discharge from an inpatient setting, triggered by a specific discharge event. CCM is an ongoing monthly program for patients with two or more chronic conditions who are not necessarily transitioning from a facility.
A patient can receive CCM continuously but cannot receive TCM and CCM during the same calendar month. Practices often use TCM to manage the acute post-discharge period and then transition eligible patients to ongoing CCM.
Which patients qualify for transitional care management services?
Patients qualify if they have been discharged from a hospital (inpatient or observation status), skilled nursing facility, inpatient psychiatric facility, long-term care hospital or inpatient rehabilitation facility, and are returning to a community setting such as home or assisted living.
The patient must be a Medicare Part B beneficiary and the discharging facility must be a qualifying inpatient setting. Observation status discharges qualify; emergency department visits without an admission do not.
Can nurse practitioners and physician assistants bill for transitional care management?
Yes. CMS allows nurse practitioners and physician assistants to bill CPT 99495 and 99496 independently, provided there is an established or new patient relationship, the face-to-face visit is performed by the NP or PA, and the non-face-to-face services are conducted under the supervising physician’s practice. Billing must be under the NP’s or PA’s own NPI.
Many practices extend TCM capacity significantly by letting NPs and PAs manage their own TCM panels.
What does TCM stand for in medical terms?
TCM stands for Transitional Care Management. In a clinical context it refers specifically to the CMS-defined program covering the post-discharge care transition period.
The abbreviation is also used informally for Traditional Chinese Medicine, an entirely separate field. In a healthcare billing or CMS context, TCM always means Transitional Care Management.
What happens if the 2-day interactive contact is not made within the required window?
If the care team cannot make contact within two business days of discharge, it must document all attempts made — date, time, method and outcome — in the patient record. If contact is ultimately not achieved within the required window, the TCM claim cannot be billed for that episode. The 2-day contact is a non-waivable requirement for both 99495 and 99496.
HealthArc automates the outreach attempt workflow and flags missed windows immediately, which gives teams the best available chance of achieving contact before the deadline.
How is the 30-day TCM period calculated?
The 30-day period begins on the date of discharge (day 1) and ends on day 30. The claim covers all TCM services provided in that window. A second TCM claim cannot be billed for the same patient within the period, even if the patient is discharged from a different facility.
If the patient is discharged again after the 30-day period ends, a new TCM episode may be initiated. CMS does not limit the number of TCM episodes a patient may have over a year.
How much does HealthArc’s TCM software cost?
Pricing is structured around practice size, enrolled patient volume and the modules you select. Because TCM reimbursement scales with discharge volume, most practices find the platform pays for itself within the first one to two billing cycles.
For a proposal tailored to your discharge volume and payer mix, contact sales@healtharc.io or schedule a discovery call.
Get Started
Ready to Launch a Transitional Care Management Program?
If your practice is seeing preventable readmissions, missing the 2-day contact window or leaving CPT 99495 and 99496 reimbursement uncaptured, HealthArc can close those gaps. Most practices go from zero TCM billing to active claim submission within 30 days of launch.
- How HealthArc tracks and manages your open TCM cases in real time
- How the 2-day contact workflow operates — and what happens when a patient does not answer
- How completed cases generate billing-ready documentation for 99495 or 99496
- What your monthly and annual TCM revenue opportunity looks like at your discharge volume
- Which EHR and discharge feed connections are available for your systems
Schedule a Demo
Calculate Your TCM Revenue
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sales@healtharc.io • +1-201-885-5571
sales@healtharc.io • +1-201-885-5571
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Resources
Latest on Transitional Care Management
Guidance on post-discharge workflows, the 2-day contact requirement and 99495 / 99496 billing.
May 13, 2026
HealthArc vs Cadence: User Experience Compared
Compare HealthArc vs Cadence user experience, usability, navigation, and workflow efficiency for remote patient monitoring and chronic care management teams.
Read articleOctober 30, 2025
Closing the Care Gaps in Elderly Transitions with Transitional Care Management (TCM)
Learn how Transitional Care Management (TCM) bridges care gaps for seniors, reduces readmissions, and supports Medicare’s 2026 value-based care goals.
Read articleMay 27, 2024
What Is Transitional Care Management (TCM) & How It Works?
We have shed some light on transitional care management, its components, its work process, and billing guidelines. For more details, get in touch with us.
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