What does Transitional Care Management pay in 2026?
| Code | What it covers | CY2026 national non-facility |
|---|---|---|
| 99495 | moderate complexity, face-to-face within 14 days | $220.11 |
| 99496 | high complexity, face-to-face within 7 days | $298.60 |
National averages from our verified CY2026 fee-schedule config (source: CMS Physician Fee Schedule). Actual payment varies by locality, payer, and site of service.
Who can bill it?
Physicians and NP/PA/CNS/CNM practitioners. One practitioner bills the episode — the one who furnishes the face-to-face visit and takes responsibility for the transition.
Clinical staff can make the interactive contact and do care-coordination work during the 30 days under the billing practitioner's direction.
One discharge, one TCM claim, one practitioner. A second practitioner claiming the same discharge — or a second discharge within 30 days of a billable one — does not create a second claim.
What are the deadlines?
- Interactive contact with the patient or caregiver within 2 business days of discharge — or at least two documented, timely attempts when the patient can't be reached.
- Face-to-face visit within 7 days of discharge for 99496 (high MDM) or within 14 days for 99495 (moderate MDM) — the deadline follows the code being billed.
- Medication reconciliation completed on or before the date of the face-to-face visit.
- The service period runs 30 days from discharge; the claim reflects the whole period.
What has to be in place first?
- A qualifying discharge setting
- The episode starts with a discharge from an inpatient hospital stay, observation, SNF, or partial hospitalization — not every facility exit qualifies.
- Return to a community setting
- The patient must return to home, assisted living, or another community setting. A transfer to another facility is not a TCM episode.
- Medication reconciliation, dated
- Med rec has to be done — and done by the face-to-face visit, not after it.
- The complexity level matches the visit window
- High-complexity MDM with a visit on day 10 doesn't bill 99496 — the 7-day window has passed; it bills 99495 if the 14-day window holds.
What gets claims denied?
- A second discharge within 30 days
- Two discharges close together don't make two TCM claims — a later discharge within 30 days of an already-billable TCM period cannot generate a second claim.
- A global surgery period
- If the discharge falls inside a procedure's global surgery period the practitioner is already being paid for, TCM doesn't stack on top.
- The patient dies before day 30
- TCM covers a 30-day service period; if the patient dies before day 30, the TCM codes as defined aren't billable for that episode.
- Missing the contact window
- No interactive contact (or two documented attempts) within 2 business days ends the claim before it starts.
- APCM exclusivity
- A confirmed APCM bundle for the patient-month blocks TCM, like it blocks CCM and PCM.
- Treating the rates as gospel
- The CY2026 TCM dollar values here are national figures computed from the CMS relative value file at the standard conversion factor — your MAC applies locality adjustment and the 2% sequestration, so verify your locality's exact amount before building projections on them.
What could this look like for your panel?
Estimates only, not billing advice. Actual Medicare reimbursement varies by region, payer, and year. Figures approximate CY2026 national non-facility averages from our verified fee-schedule config.
Frequently asked questions
- What decides 99495 vs 99496?
- Two things together: the medical decision-making complexity AND the face-to-face timing. 99496 needs high-complexity MDM and a visit within 7 days of discharge. Moderate complexity — or a later visit within 14 days — is 99495.
- What if we can't reach the patient in 2 business days?
- CMS allows the claim when at least two timely, documented attempts were made even if contact wasn't achieved — the attempts must be in the record.
- Can TCM and CCM be billed in the same month?
- Yes, since CY2022 — they're separate programs. The same minute can't count toward both, but the same patient can have both in a month.
- Who bills when two practitioners see the patient after discharge?
- One. TCM is a single claim per discharge, billed by the practitioner who furnishes the face-to-face visit and manages the transition.
- How were the TCM rates verified?
- Against the CMS national PFS relative value file itself (RVU26C, the same data the PFS Look-Up Tool displays): 99495 and 99496 are computed from their published CY2026 RVUs at the national conversion factor. National figures — your MAC applies locality adjustment and the 2% sequestration.
This page is general information, not billing, coding, or legal advice. Verify current requirements with the relevant payer before billing. Mallowa helps practices capture and document coordination time and generates claim-ready superbills; it does not submit claims or determine eligibility.