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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that required patient transitional care management (TCM) services include: 
 
Supporting the patients transition to the community setting 
Health care professionals who accept patient care at post-facility discharge without a service gap 
Health care professionals taking responsibility for patients care 
Moderate or high complexity medical decision making for patients who have medical or 
psychosocial problems 
The 30-day TCM period begins on a patients inpatient discharge date and continues for the next 29 days. 
TCM services begin the day of discharge from 1 of these inpatient or partial hospitalization settings: 
Inpatient Acute Care Hospital 
 Inpatient Psychiatric Hospital 
 Long-Term Care Hospital 
 Skilled Nursing Facility 
 Inpatient Rehabilitation Facility 
 Hospital outpatient observation or partial hospitalization 
 Partial hospitalization at a Community Mental Health Center 
After inpatient discharge, the patient must return to their community setting. These could include: 
 Home 
 Domiciliary 
 Nursing home 
 Assisted living facility 
 When a patient is discharged from an approved inpatient setting, you must provide at least these 
TCM components over the course of the 30-day service period: 
An Interactive Contact 
Within 2 business days following the patients discharge, you must contact the patient or their caregiver via 
phone, email, or face-to-face. You or your clinical staff (A person who works under the supervision of a 
physician or other qualified health care professional and is allowed by law, regulation, and facility policy to 
perform or assist in the performance of a specialized professional service, but who doesnt individually report 
that professional service) can address patient status and needs beyond scheduling follow-up care. Get more 
information about interactive contacts in the CPT Codebook at the American Medical Association Store. 
Report the service if you make 2 or more unsuccessful separate attempts in a timely manner. Document your 
attempts in the medical record if you meet all other TCM criteria. Continue trying to communicate with the 
patient until successful. If the face-to-face visit isnt within the required timeframe, you cant bill TCM 
services (see the Face-to-Face Visit section).  
 
Face-to-Face Visit 
You must provide 1 face-to-face visit within the timeframes described by these 2 CPT codes: 
CPT Code 99495  Transitional Care Management services with the following required elements: 
Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days 
of discharge; Medical decision making of at least moderate complexity during the service period; Face-to-face 
visit, within 14 calendar days of discharge 
CPT Code 99496  Transitional Care Management services with the following required elements: 
Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days 
of discharge; Medical decision making of high complexity during the service period; Face-to-face visit, within 
7 calendar days of discharge. You shouldnt report the TCM face-to-face visit separately. 
 
Billing TCM Services 
This list offers TCM services billing tips: 
 Only 1 physician or NPP may report TCM services. 
 Report services once per patient during the TCM period. 
 The same health care professional may discharge the patient from the hospital, report hospital or 
observation discharge services, and bill TCM services. The required face-to-face visit cant take 
place on the same day you report discharge day management services. 
 Report reasonable and necessary Evaluation and Management (E/M) services (except required 
face-to-face visit) to manage the patients clinical issues separately. 
 You cant bill TCM services and services within a post-operative global surgery period (Medicare 
doesnt pay TCM services if any of the 30-day TCM period falls within a global surgery period for a 
procedure code billed by the same practitioner). 
 At a minimum, document this information in the patients medical record: 
 Patient discharge date 
 Patient or caregiver first interactive contact date 
 Face-to-face visit date 
 Medical complexity decision making (moderate or high) 
 
You can find this information in the Medicare Learning Network (MLN): Transitional Care Management 
Services MLN908628. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.