What CPT 99495 and 99496 are
99495 and 99496 are the two CPT codes for Transitional Care Management, the Medicare service covering the 30 days after a patient leaves an inpatient or observation setting and returns to the community. Both codes require the same interactive contact within 2 business days of discharge. They part ways on how fast the face-to-face visit has to happen and on the level of medical decision making the case involves.
CMS defines each code by required elements, not by time spent. There is no minute threshold to hit. Either the contact, the coordination work, and the visit all landed inside their windows, or the code is not billable.
One practitioner reports the service once per discharge. The 30-day period starts on the discharge date and runs for the next 29 days, and the claim carries the date of the face-to-face visit.
99495 and 99496 side by side
99496 buys a tighter visit deadline for a sicker patient and pays more for it. 99495 gives you 14 calendar days instead of 7. Everything else about the two codes matches, including the contact window, the service period, and the coordination work.
| Required element | CPT 99495 | CPT 99496 |
|---|---|---|
| Interactive contact with patient or caregiver | Within 2 business days of discharge | Within 2 business days of discharge |
| Face-to-face visit | Within 14 calendar days of discharge | Within 7 calendar days of discharge |
| Medical decision making during the service period | At least moderate complexity | High complexity |
| Service period | 30 days: discharge day plus the next 29 | 30 days: discharge day plus the next 29 |
| 2026 national non-facility payment | $220.11 | $298.60 |
| 2026 national facility payment | $122.25 | $166.34 |
The code descriptors come from the CMS Medicare Learning Network booklet Transitional Care Management Services (MLN908628, August 2025), which is the controlling operational spec for the service.
What Medicare pays in 2026
The 2026 national average is about $220 for 99495 and about $299 for 99496 in the non-facility setting, which is where most of these visits happen. In the facility setting the same codes pay about $122 and $166. Those are the figures for clinicians paid at the standard conversion factor.
2026 is the first year with two conversion factors. The CY2026 Physician Fee Schedule final rule set $33.5675 for clinicians who are qualifying participants in Advanced Alternative Payment Models and $33.4009 for everyone else, so a qualifying participant sees a little more: $221.21 for 99495 and $300.09 for 99496 in the office setting.
These are 2026 Medicare national averages, calculated from the CMS CY2026 Physician Fee Schedule Relative Value File (January release) and the CY2026 conversion factor. Actual payment varies by locality because of the geographic practice cost indices (GPCIs), so check your own locality's rate before you model TCM revenue off these figures.
The three required elements
CMS requires three things during the 30-day service period, and all three have to be documented. Miss any one and there is no TCM claim to submit.
- Interactive contact. You or clinical staff under your direction contact the patient or caregiver by phone, by email, or face-to-face within 2 business days of discharge. The person making the contact has to be able to address the patient's status and needs; a scheduler reading from a call list does not satisfy the element.
- Non-face-to-face services. The coordination work: reviewing the discharge summary, following up on pending tests, talking to the other clinicians involved, educating the patient and family, setting up referrals and community services, and getting the follow-up care scheduled.
- Face-to-face visit. One visit inside the 7 or 14 calendar day window, depending on the code. CMS is explicit that you do not report this visit separately as an E/M.
There is a fourth requirement that hides inside the second one. MLN908628 states: "You must provide medication reconciliation and management on or before the face-to-face visit date." Med rec is pegged to the visit, so if the visit lands on day 12, finishing reconciliation on day 20 puts the claim out of compliance.
What counts as the interactive contact
The contact has to be a two-way exchange. Noridian, the Part B MAC for Jurisdiction E, spells it out: "Merely leaving a voicemail or email without a response is not a direct exchange of information." The same page rules out an electronic digital assistant standing in for a person.
Clinical staff can make the contact under the billing practitioner's direction. CMS defines clinical staff as someone supervised by a physician or other qualified health care professional who is permitted to perform or assist in a specialized professional service but does not report that service themselves.
If the first attempts fail, the service can still be billed. CMS allows reporting after two or more unsuccessful separate contact attempts made in a timely manner, provided the other requirements including a timely face-to-face visit are met, the attempts are documented in the record, and the team keeps trying until it reaches the patient. The mechanics of counting the two business days are covered in the TCM requirements and workflow guide.
The 30-day service period
The service period begins the day the patient is discharged and continues for the next 29 days. CMS says it twice, in the MLN booklet and again in its TCM billing FAQ, because a lot of teams start counting the day after.
The 7 and 14 day visit clocks also start on the discharge day. The 2 business day contact clock is the exception: CMS counts the first business day after discharge as day one, so a patient discharged Monday afternoon has to be reached by the end of Wednesday.
What date of service goes on a TCM claim
Report the date of the required face-to-face visit, and submit the claim once that visit has happened. CMS made this change effective January 1, 2016 and states it directly in its TCM billing FAQ: "The date of service you report should be the date of the required face-to-face visit. You may submit the claim once the face-to-face visit is furnished and need not hold the claim until the end of the service period."
This is worth checking against whatever your billing team currently does, because the older rule is still in circulation. Guidance written before 2016 told practices to date the claim to the 7th or 14th day, or to hold it until day 30. Some widely read pages still carry that language. The place of service on the claim follows the same logic: it should match the setting where the face-to-face visit happened.
Who can bill TCM, and why only one claim gets paid
Physicians of any specialty can furnish the face-to-face visit and bill the service. So can non-physician practitioners who are legally authorized and qualified in their state: nurse practitioners, physician assistants, clinical nurse specialists, and certified nurse-midwives. Those same practitioners can also furnish the non-face-to-face work incident to a physician's services.
Supervision splits by component. CMS requires direct supervision for the face-to-face visit. All other TCM services may be furnished under general supervision, which is what lets auxiliary personnel do the coordination work.
Only one physician or non-physician practitioner may report TCM for a given discharge, once per patient during the period. If two practices both submit, CMS pays the first eligible claim and denies the second. Other practitioners can still bill their own reasonable and necessary E/M services during those 30 days. The practical consequence is a race: if the hospitalist group and the primary care practice both think they own the transition, one of them works the case for nothing.
Which discharges qualify
The 30-day period can start on discharge from an inpatient acute care hospital, an inpatient psychiatric hospital, an inpatient rehabilitation facility, a long-term care hospital, a skilled nursing facility, hospital outpatient observation or partial hospitalization, or partial hospitalization at a community mental health center. Observation stays count, which surprises people.
The patient also has to return to a community setting. CMS lists home, a domiciliary such as a group home or boarding house, a nursing facility, and an assisted living facility. A discharge to a skilled nursing facility is not a return to the community, so it does not start a TCM period even though a discharge from one does.
Can the TCM visit be done by telehealth
Yes. CMS lists both 99495 and 99496 on the CY2026 Medicare Telehealth Services List, and MLN908628 says outright that you can provide both codes through telehealth. The place of service is 02 for telehealth outside the patient's home and 10 for telehealth in the home, and home telehealth claims are paid at the non-facility rate.
The part to watch is the expiration date. The geographic and originating-site flexibilities that let a patient take the visit from home run through December 31, 2027 under current law. From January 1, 2028, unless Congress extends them again, most non-behavioral telehealth reverts to the rural-and-facility rule. CMS states the 2027 date in its Telehealth FAQ updated February 26, 2026.
Why TCM claims fail
There is no published CMS ranking of TCM denial reasons, so nothing below is ordered by frequency. Each row is a requirement that makes the claim unbillable when it is missed.
| What went wrong | Why the claim fails |
|---|---|
| Contact made after 2 business days, with no documented earlier attempts | Contact timing is a required element of both descriptors |
| A voicemail or unanswered email treated as the contact | Not a direct exchange of information |
| Face-to-face visit outside the 7 or 14 day window | CMS: if the visit is not within the required timeframe, you cannot bill TCM |
| Medical decision making does not support the code billed | 99496 requires high complexity, 99495 at least moderate |
| Medication reconciliation done after the visit | It must be on or before the face-to-face visit date |
| Wrong date of service, or a place of service that does not match the visit | Both are set by the face-to-face visit |
| Another practitioner already billed TCM for that discharge | Only one may report, and Medicare pays the first eligible claim |
| Any part of the 30 days falls in a post-operative global period billed by the same practitioner | TCM is not payable inside a global surgical period |
| The required visit reported separately as an E/M | CMS: do not report the TCM face-to-face visit separately |
| The visit billed on the same day as discharge day management | Explicitly prohibited |
| Patient died before day 30 and TCM was still reported | Report the face-to-face visits under the appropriate E/M instead |
Billing TCM and CCM in the same month
You can. CMS says in its Chronic Care Management FAQs that "TCM may be billed concurrently with CCM codes when relevant and medically necessary," a position it set in the CY2020 and CY2021 Physician Fee Schedule final rules. MLN909188, the June 2025 CCM booklet, repeats it: CCM codes 99487, 99489, 99490, and 99491 can be reported for services provided during the 30-day TCM period.
The condition is that time and effort cannot be counted twice. Minutes that support the TCM claim do not also count toward the CCM time threshold. RHCs and FQHCs can bill both for the same patient in the same period as well.
Plenty of billing guidance still repeats the 2016 position, which was narrower. If your policy says the two cannot share a month, it is out of date.
How Pelica keeps the TCM clock from running out
Almost every TCM failure traces back to the same root cause: the team found out about the discharge too late. The claim posts weeks after the fact, the faxed discharge summary sits in a shared inbox, and the weekly census report lands after the 2 business day window has already closed.
Pelica ingests ADT feeds live and turns each discharge into a task on the member's record the moment the message arrives, with the contact deadline and the 7 or 14 day visit deadline already on the clock. The Care Management copilot then works the queue: it makes the outreach, documents the attempts, books the visit inside the window, and escalates to a coordinator when a person is genuinely needed. Customers close 70%+ of transitions-of-care gaps within 30 days, and teams get back roughly 10 hours per user per week.
Related terms
TCM covers the service itself and how it fits the transitions-of-care cluster. The TCM requirements guide walks the workflow that gets the contact and the visit done on time. ADT is the discharge signal that starts all of it.
Sources
- CMS Medicare Learning Network: Transitional Care Management Services (MLN908628, August 2025)
- CMS: Billing FAQs for Transitional Care Management (March 17, 2016)
- CMS: CY2026 Physician Fee Schedule Relative Value Files (January release)
- CMS: CY2026 Physician Fee Schedule Final Rule fact sheet (CMS-1832-F)
- CMS: List of Medicare Telehealth Services (CY2026)
- CMS: Telehealth FAQ, updated February 26, 2026
- CMS: Chronic Care Management FAQs
- Noridian Medicare: Transitional Care Management