Home/Services/Transitional Care Management
TCM · Service Detail

The 30 days after discharge are where readmissions are won or lost

Structured post-discharge follow-up: contact within two business days, a face-to-face visit within the required window, medication reconciliation, and coordinated handoffs that keep patients from bouncing back to the hospital.

CPT 99495CPT 99496
Talk to us about TCM All 11 services
What It Is

Transitional Care Management covers the 30-day period after a patient is discharged from a hospital, skilled nursing facility, or similar setting. Medicare requires interactive contact within two business days of discharge, a face-to-face visit within a set window, and medication reconciliation — all aimed at the highest-risk moment in a patient's care.

The two-business-day contact rule is unforgiving: miss it, and the entire TCM billing opportunity for that discharge is gone. That's a staffing and process problem more than a clinical one, and it's exactly the kind of relentless, no-excuses workflow Elixir is built to run.

What's included

  • Discharge feed monitoring so no patient is missed
  • Contact attempted within 2 business days of discharge, every time
  • Medication reconciliation & discrepancy flagging
  • Scheduling support for the required face-to-face visit
  • Coordination with discharging facility & specialists
  • Complexity-level documentation for correct code selection
Who Qualifies
  • Patient discharged from an inpatient hospital, SNF, or qualifying facility
  • Patient returns to community setting (home, domiciliary, assisted living)
  • Contact within 2 business days is feasible and documented
  • A face-to-face visit occurs within the required timeframe
Eligibility is confirmed by your clinical team — Elixir verifies documentation, not medical necessity.
CodeDescription
99495Moderate complexity — face-to-face visit within 14 days
99496High complexity — face-to-face visit within 7 days
Common Questions

Transitional Care Management, answered plainly

What if we don't get a discharge notification in time?+
Part of the Elixir setup process is establishing a reliable discharge-notification feed — from your EHR, a HIE connection, or direct facility relationships — specifically so the 2-day contact window is never missed for lack of information.
Who has to do the face-to-face visit?+
The billing provider or a qualified clinician on your team performs the visit; Elixir handles scheduling, reminders, and the coordination work around it.
Can TCM and CCM overlap for the same patient?+
TCM and CCM can't be billed for the same patient in the same service period, but a patient often moves from a TCM episode into an ongoing CCM program once they're stabilized post-discharge.
Pairs Well With

Related services

CCM

Chronic Care Management

Monthly care your patients feel — documented so your practice can bill it

PCM

Principal Care Management

Focused management of the one condition driving a patient's risk

RCM

Medical Billing & RCM

Clean claims, faster reimbursement, fewer denials.

Next Step

See TCM modeled on your own patient panel

Bring your panel size and payer mix to a 60-minute opportunity session and leave with a specific, numbers-based program design.

Book the Session info@elixirhc.com

Session Agenda

  1. Patient population & payer mix
  2. Current TCM activity, if any
  3. EHR & documentation workflow
  4. Staffing & device strategy
  5. Pilot design for this service
  6. Your clinic-specific opportunity model