Talk with us CARE PROGRAM GUIDE · TCM
Transitional Care Management
After a qualifying hospital or facility stay, the care team helps a patient get safely settled, understand medicine changes, and see the right clinician.
FIRST, THE SHORT ANSWER
What would TCM add to care?
TCM is a time-limited transition service after a qualifying discharge to a community setting. It combines prompt contact, ongoing coordination, medication reconciliation, an appropriately timed visit, and medical decision-making.
No special device is required. The essentials are discharge notification, task deadlines, medication reconciliation, and a closed-loop handoff into the clinical record.
PATIENT & PRACTICE FIT
Could this help people you treat?
Potential fit
An eligible discharge to a community setting from an acute, psychiatric, rehabilitation, or long-term-care hospital; skilled nursing facility; qualifying hospital observation or partial hospitalization; or community mental health center partial hospitalization—with the practice able to meet contact, visit, decision-making, and 30-day requirements.
Check before enrolling
Routine ASC discharge; prohibited global-surgery overlap; missed contact or visit windows without a valid exception; no medication reconciliation; or another practitioner already claiming the transition.
PATIENT EXPERIENCE
A timely post-discharge contact, medication clarification, help securing services, and a follow-up visit with the clinician responsible for the transition.
SEE IT IN PRACTICE
A transition from discharge to follow-through.
Meet Robert: he returns home after a qualifying hospital stay with changed medicines and several follow-up appointments.
The goal: Resolve discharge questions and complete a coordinated 30-day transition.
Choose a stage to see what the patient, treating practice, and PrimeVital’s agreed team each do.
Receive discharge
Day of discharge- Patient / caregiver
- Returns to a community setting after a qualifying stay.
- Treating practice
- Accepts transition responsibility and checks global-surgery and other-biller issues.
- PrimeVital’s agreed role
- Helps obtain the discharge notice and organize deadlines.
- What gets recorded
- Eligible setting, discharge date, destination, summary, and clinical owner.
Illustrative scenario, not a patient record or clinical protocol. Clinical targets, review frequency, staff qualifications, escalation, and service hours are agreed with the treating practice. Clinical decisions stay with qualified personnel.
SAMPLE CARE PLAN
A plan the patient and the team can understand.
Resolve discharge questions and complete a coordinated 30-day transition.
- Patient task
- Share discharge instructions, medicines, concerns, and caregiver needs.
- Clinical owner
- The practitioner accepting the transition performs the required visit and clinical decision-making.
- Team follow-up
- Arrange timely clinical contact, clarify medication information, and coordinate needed services.
- Review
- Complete the required visit and follow unresolved needs through the transition period.
After the transition
TCM is a transition episode, not an automatic recurring monthly claim. Afterward, assess whether a separately qualifying ongoing care program would help.
YOUR INVOLVEMENT
Clinical ownership stays with the treating practice.
The agreement names the people, work, coverage hours, records access, and handoffs. Technology and operational support do not transfer clinical or billing authority.
What your clinician does
The eligible billing practitioner takes responsibility for the transition and performs the required face-to-face visit and medical decision-making.
What supporting staff can do
Clinical or auxiliary staff may perform specified non-face-to-face work under the practitioner’s direction and applicable supervision rules.
What we can organize with you
PrimeVital can help capture discharge alerts, manage the contact clock, coordinate medication and service tasks, and prepare documentation for the practice’s review.
PrimeVital’s full care arrangement includes applicable devices and a care-management team. The program determines which resources and professional qualifications are needed. Interactly can support front-desk tasks within the agreed scope; 24/7 PrimeVital clinical coverage is not assumed.
REQUIREMENTS BEFORE LAUNCH
Make the pathway ready before enrolling patients.
- Capture the qualifying discharge, date, destination, and practitioner.
- Make timely interactive contact or document the CMS-recognized unsuccessful-attempt pathway.
- Reconcile medication and complete the correct 7- or 14-day visit with required decision-making.
- Confirm no other practitioner reports the same transition and no included visit is separately billed.
Detailed operating workflow and technology
- 1
Notify
Capture the eligible discharge date and setting, summary, and responsible practitioner.
- 2
Contact
Reach the patient or caregiver within two business days; document attempts and issues.
- 3
Visit
Reconcile medications on or before the visit and complete the 7- or 14-day visit as appropriate.
- 4
Close
Coordinate unresolved needs through the 30-day period and confirm the correct single TCM claim.
Technology and records: No special device is required. The essentials are discharge notification, task deadlines, medication reconciliation, and a closed-loop handoff into the clinical record.
GETTING PAID
Who receives payment, and what earns it?
Care need, completed services, evidence, and the actual payer determine the claim. A covered service or an enrollment is not the same as collected revenue.
An eligible practitioner—not the surgical center merely because it discharged a patient—reports a supported TCM service. Routine ASC discharge does not qualify. A global surgical period for a procedure billed by that practitioner can prevent TCM payment.
Original Medicare Part B may pay one eligible TCM service for the 30-day transition. The qualifying visit is included in the TCM service rather than billed separately.
Medicare Advantage, Medicaid, and commercial contracts may use their own transition programs, authorization terms, or bundled payments. Check the actual contract and attribution.
Part B deductible and coinsurance may apply under Original Medicare; the patient’s supplemental coverage or plan may change the amount.
Payment boundaryRoutine ambulatory surgical center discharge does not qualify for TCM. Medicare does not pay TCM if any of its 30-day period overlaps a global surgery period for a procedure billed by the same practitioner. Only one practitioner reports the transition; do not duplicate time or included work.
2026 code reference and an illustrative service check
A qualifying transition with moderate decision-making and a visit within 14 calendar days may fit 99495. High decision-making plus a visit within 7 calendar days may fit 99496. Both also need timely clinical contact and the other service elements. The required visit is included, not a separate charge.
These are code-family summaries, not complete descriptors or payment estimates. Check the current code set, payer, clinician, setting, date, unit edits, and required add-on base code.
| Code / pathway | What it describes | Before billing |
|---|---|---|
| 99495 | Moderate-complexity TCM | Contact within two business days and qualifying visit within 14 calendar days, plus required decision-making. |
| 99496 | High-complexity TCM | Contact within two business days and qualifying visit within 7 calendar days, plus required decision-making. |
Questions before a claim
Is a post-discharge phone call TCM?
No. TCM requires the full transition service, including the visit and medical decision-making. CMS permits two or more timely, documented unsuccessful contact attempts when other requirements are met; continue trying to reach the patient.
Can we bill the follow-up visit separately?
CMS says the required TCM face-to-face visit is included in the TCM service.
FINANCIAL PICTURE
See how participation, collections, and costs change the result.
Start with one supported pathway. Do not multiply every patient by every possible code. Use verified payer terms and the written PrimeVital scope before making a business decision.
Illustrative TCM model
These starting figures are hypothetical. They are not Medicare rates, a PrimeVital quote, or a payment forecast. PrimeVital pilot terms are not modelled automatically. Replace them with your verified contract, service mix, and cost assumptions.
Estimate net after your agreed service fee and other costs
Enter the total fees from your written agreement. No fee is prefilled. Pilot service fees are paid from collections; treatment of denied or insufficient collections must be agreed before launch.
Leave at zero if already included in the service fee. Avoid counting it twice.
Shown separately from recurring operating costs.
35 of 50 patients meet the assumed service requirements.
Illustrative collections before service and practice costs: $3,500. This uses the hypothetical per-patient amount and collection rate above; it is not a code-specific Medicare estimate.
To estimate the amount remaining for the practice, open the cost section and enter the total service fee from a written proposal. We do not invent a PrimeVital price or show a misleading net amount before that is known.
Contribution is before other overhead and taxes. Actual billing uses service-level evidence and rules; this simplified model does not select codes, approve eligibility, or guarantee outcomes. Patient cost sharing and QMB protections must be checked separately.
BENEFITS TO MEASURE
Define success before the first patient starts.
Agree on a baseline and review period. These are measures to track, not promised results or guaranteed payment.
Timeliness
Discharge alerts, clinical contact, and visit completion.
Safety and continuity
Medication questions resolved and services arranged.
Follow-through
Unresolved discharge needs and unplanned returns tracked against a baseline.
PRIMARY SOURCES
Check the rule before a real claim.
Reviewed October 7, 2026 against current CMS guidance. These guides describe 2026 pathways; proposals for later years are not effective requirements. Coverage, contracts, scope, and patient facts can change the answer.
APPLY THIS TO YOUR PRACTICE
Start with a patient group and a clear question.
Tell us your practice type, payer mix, and workflow. We can map clinical fit, your involvement, available support, launch requirements, and financial assumptions to verify.
DESIGN A PRACTICAL STARTING POINT
Tell us where the workflow is breaking. We’ll show you where to begin.
Send us a message
Continue on your phoneScan to open a pre-addressed email draft.Email contact@theprimevital.com