.jpg)
$298.60.
That’s what a single high-complexity TCM service can be worth at 2026 national rates, and it takes seven checked boxes to collect it. Miss one and the claim is at risk.
This checklist covers all seven requirements in four parts: patient eligibility, the three required service components, timing, and documentation. It’s written for the practice teams that run TCM, from the clinician who sees the patient to the biller who submits the claim, and it works best as the run-through before you bill.
For code selection, check out our TCM CPT codes guide, or read our Transitional Care Management guide to get a full breakdown.
The TCM Requirements Checklist
TCM has several moving parts, but the rules themselves are clear. Make sure you check every box before billing:
- Eligible medical discharge: The patient was medically discharged from a qualifying inpatient setting and returned to a community setting.
- Interactive contact: The patient or caregiver was reached in a two-way exchange within two business days of hospital discharge (or two or more separate, timely attempts were made and documented).
- Face-to-face visit: The patient was seen within 14 calendar days for moderate-complexity MDM or 7 calendar days for high-complexity MDM.
- Medication reconciliation: Medications were reconciled no later than the date of the face-to-face visit.
- 30-day coordination: Required non-face-to-face care and coordination continued throughout the TCM service period.
- Medical decision-making: The patient’s care supported the moderate or high complexity level required for the code.
- Documentation: The chart supports the medical discharge, reason for admission, contact, visit, medication reconciliation, coordination, and medical decision-making.
Seven boxes. The rest of this guide breaks down each requirement, so jump to the one you need.
Patient Eligibility Requirements
Start here, because everything else depends on it. A patient qualifies for TCM when two conditions are met: they were medically discharged from a qualifying setting, and they are returning to a community setting.
Qualifying Medical Discharge Settings
TCM eligibility can follow medical discharge from:
- Inpatient acute care hospitals
- Inpatient psychiatric hospitals
- Long-term care hospitals
- Inpatient rehabilitation facilities
- Skilled nursing facilities
- Hospital outpatient observation or partial hospitalization
- Partial hospitalization at a community mental health center
This list follows CMS’s TCM booklet (August 2025). It’s easy to summarize inaccurately, so check CMS directly before you build a workflow around it.
Qualifying Community Settings
A qualifying discharge is only half of it. The patient also has to return to a community setting, which CMS lists as a home, a group home, a nursing facility, or an assisted living facility.
A transfer from one inpatient facility to another doesn’t qualify. TCM begins once the patient leaves institutional care and recovery in the community starts.
Medical Complexity
The patient’s care also has to support at least moderate-complexity medical decision-making during the TCM period. A routine hospital discharge with no meaningful management needs rarely clears that bar.
Complexity does double duty: it decides whether the patient qualifies and which code applies, 99495 for moderate or 99496 for high.
Requirement 1 - Interactive Contact Within 2 Business Days
The countdown clock begins the second the patient is medically discharged. Someone on the care team must reach the patient, or their caregiver, within two business days, by phone, email, or in person. CMS also expects that person to be clinical staff who can address the patient’s needs and status, not simply book the follow-up.
Contact means contact. An interactive, two-way exchange. Leaving a voicemail or unanswered text doesn’t count.
If you can’t reach the patient, all is not lost. CMS allows you to report TCM after two or more separate, timely contact attempts, provided they are documented and the face-to-face visit still happens on time. The safest approach is to make both attempts inside the two business days, and CMS expects you to keep trying until you reach the patient.
The important word here is documented. Make sure you keep a record of everything. If there is no record of the attempt, then as far as the claim is concerned, it never happened.
Requirement 2 - The Face-to-Face Visit
The face-to-face visit comes next, and its deadline depends on medical complexity:
- Moderate complexity: Within 14 calendar days of medical discharge.
- High complexity: Within 7 calendar days of medical discharge.
The face-to-face visit is already part of the TCM service, so it can’t be billed separately as an office visit. The visit must be performed by a physician or qualified non-physician provider, such as a nurse practitioner (NP) or physician assistant (PA). Clinical staff cannot perform it instead.
The visit can be done by telehealth. CMS lists 99495 and 99496 as services you can provide that way, and Medicare’s telehealth flexibilities, which let patients be seen from home, are extended through December 31, 2027. They’ve lapsed and returned before, so confirm the current rules before you bill.
Requirement 3 - Medication Reconciliation and Non-Face-to-Face Services
Medication reconciliation needs to be completed no later than the date of the face-to-face visit. This is a hard TCM requirement, and missing or failing to document it can put the claim at risk.
It’s also where TCM proves its clinical value. The care team reconciles the patient’s hospital discharge medication list against what they’re taking at home, which catches discrepancies before they evolve into bigger problems.
Much of the work happens between visits. Across the 30-day TCM period, non-face-to-face services can include:
- Reviewing hospital discharge summaries and following up on diagnostic tests.
- Coordinating with other providers, home health agencies, and the community services the patient uses.
- Scheduling necessary follow-up appointments.
- Educating the patient or caregiver about self-management.
- Checking that the patient is taking medications as prescribed.
Clinical staff can carry out a lot of this work under the billing provider’s supervision. The visit is one part of the service. The other is 30 days of coordinated transitional care.
The 30-Day Service Period and Billing Timing
TCM runs on a 30-day clock, and Medicare doesn’t stop to let your workflow catch up. Day one is the date of hospital discharge, followed by a further 29 days. All three service components have to fit inside that window.
Billing timing often provides the stumbling block. Older CMS guidance had practices wait the full 30 days before they submitted. That’s no longer the case. CMS’s billing FAQs let you submit once the face-to-face visit has happened and you report the visit date, with no need to hold the claim for 30 days.
A lot of published advice still reflects the old rule, so check current CMS guidance before you submit.
Who Can Provide and Bill TCM?
Not everyone involved in TCM can bill for it. Physicians and qualified non-physician providers can report TCM, including:
- Nurse practitioners
- Physician assistants
- Clinical nurse specialists
- Certified nurse midwives
Clinical staff can handle the interactive contact and much of the non-face-to-face work under appropriate supervision. The face-to-face visit is different. That needs to be carried out by the billing physician or qualified non-physician provider.
One more restriction matters: only one provider can bill TCM for a patient across that 30-day window, even if the patient is readmitted or sees several practices. If several providers are involved after hospital discharge, decide who owns TCM early.
Documentation Requirements
Good care alone doesn’t get a TCM claim paid. The chart needs to prove it happened.
CMS’s minimum is the discharge date, the date of the first interactive contact with the patient, the face-to-face visit date, and the level of medical decision-making. The rest of this list is what supports the claim if it’s reviewed. Before billing, you need to make sure the documentation shows:
- Medical discharge: The patient’s medical discharge date.
- Reason for admission: Why the patient was hospitalized (drives diagnosis code selection).
- Interactive contact: The date and method of contact, plus any unsuccessful attempts.
- Face-to-face visit: The date the required visit took place.
- Medication reconciliation: Evidence it was completed and the date it happened.
- Non-face-to-face services: A record of the coordination and other services provided.
- Medical decision-making: Documentation supporting the complexity level billed.
Medical decision-making is where charts can run thin. The paperwork needs to show the problems managed, data reviewed, and risk involved. Without that, an auditor has no basis for the complexity level billed.
If the chart can’t support the code, the claim can’t either.
Where TCM Claims Fall Apart
A TCM claim can unravel fast. Miss a deadline or leave a gap in your documentation, and reimbursement can be at risk.
Common failure points include:
- Missing the two-business-day contact, or failing to document contact attempts.
- Scheduling the face-to-face visit outside of the 7- or 14-day window for the code billed.
- Skipping medication reconciliation or failing to document when it happened.
- Billing a complexity level the clinical note does not support.
- Two providers attempting to bill TCM for the same 30-day period.
- Billing TCM when any part of the 30-day period falls within a post-operative global surgery period for a procedure billed by the same practitioner.
The clinical work typically happens. What can slip is timing and paperwork, which makes TCM as much a workflow problem as a clinical one.
How Dimer Health Handles TCM Requirements
TCM operates on strict deadlines. Dimer Health builds the workflow around meeting them.
Dimer Health works alongside the practices that bill TCM, not in their place. Where a practice wants support, Dimer Health’s physician-led care team can handle outreach after hospital discharge. Where a practice wants to keep the work in-house, Dimer Connect, Dimer Health’s platform, can drive the patient straight back to the practice’s own care team, so they can run targeted outreach for patients who need it.
Based on Dimer Health’s own reported outcomes, patients have seen a 42% readmission reduction (at time of writing). First appointments happen within 24 hours of hospital discharge, and more than 6,000 patients have received care across eight states.
Meet Every Requirement, Every Time
Taken individually, TCM requirements are manageable. The deadlines are what make them hard, and these arrive whether the chart is ready or not.
If you want to collect consistently, build a repeatable process. Keep the checklist at the top of this guide to hand so all requirements become a part of your workflow.
FAQs
What are the requirements for transitional care management?
TCM requires an eligible medical discharge, interactive contact within two business days, a timely face-to-face visit, medication reconciliation, ongoing care coordination, appropriate medical decision-making, and documentation across the 30-day period.
Who qualifies for TCM services?
Patients may qualify after medical discharge from an eligible setting to a community setting when their care requires at least moderate complexity medical decision-making.
What counts as interactive contact for TCM?
Interactive contact is a two-way exchange with the patient or caregiver by phone, in person, or electronically, within two business days of their hospital discharge.
What if you cannot reach the patient within two business days?
TCM can still be reported if you make two or more separate, timely contact attempts, document them, and meet all the other CMS guidance requirements, including a timely face-to-face visit.
How soon does the TCM face-to-face visit have to happen?
The face-to-face visit has to occur within 14 days for moderate-complexity TCM or 7 days for high-complexity TCM.
Can the TCM visit be done by telehealth?
Yes. CMS lists 99495 and 99496 as services you can provide via telehealth, and Medicare’s telehealth flexibilities are extended through December 31, 2027. The rules have shifted before, so confirm the current requirements before you bill.
When does medication reconciliation have to be completed?
Medication reconciliation must be completed no later than the date of the required face-to-face visit.
Which discharge settings qualify for TCM?
Qualifying settings are inpatient acute care hospitals, inpatient psychiatric hospitals, inpatient rehabilitation facilities, long-term care hospitals, skilled nursing facilities, hospital outpatient observation, and partial hospitalization, including at a community mental health center.
Can two providers bill TCM for the same patient?
No. Only a single eligible provider can report TCM for the same patient during a single 30-day service period.
What date of service should be used for TCM billing?
Current CMS guidance allows your TCM to be reported using the date of your required face-to-face visit. But it’s crucial to verify current billing guidance before you submit your claim.
What documentation is required for a TCM claim?
The chart needs to document the hospital discharge process, reason for admission, interactive contact and any attempts, face-to-face visit, medication reconciliation, non-face-to-face services, and medical decision-making supporting the code billed.
Why do TCM claims get denied?
TCM claims can often be denied for missed deadlines, missing documentation, unsupported medical decision-making, missing medication reconciliation, overlap with a surgical global period, or conflicting claims for the same service period.
Sources:
