Georgia Medicare Transitional Care Management TCM (2026)

By Brevy Care Team · Last verified May 14, 2026

The Medicare Transitional Care Management benefit gives every Georgia Medicare beneficiary who has been discharged from an inpatient hospital, observation status, partial hospitalization program, skilled nursing facility, community mental health center, or long-term care hospital the right to receive structured care coordination services during the 30-day post-discharge period from a community primary care practitioner — services that include interactive contact within two business days of discharge, an in-person evaluation and management visit within 14 days for moderate complexity transitions or within seven days for high complexity transitions, non-face-to-face care coordination during the 30-day post-discharge period, comprehensive medication reconciliation, and coordination with home health, hospice, post-acute care, specialists, and other community-based providers. The TCM benefit is billed under CPT 99495 (Transitional Care Management Services, moderate medical decision making during service period, requiring face-to-face visit within 14 calendar days of discharge) or CPT 99496 (Transitional Care Management Services, high medical decision making during service period, requiring face-to-face visit within 7 calendar days of discharge), with the codes carrying standard Medicare Part B cost-sharing including the deductible and 20% coinsurance.

The TCM benefit represents one of the earliest structural innovations in Medicare primary care payment for care coordination — predating the Chronic Care Management framework by two years. The TCM codes were established through the CY 2013 Medicare Physician Fee Schedule final rule (CMS-1590-FC, published November 16, 2012) effective January 1, 2013, with the explicit recognition that the 30-day post-discharge period is a high-risk transition window where care coordination failures result in emergency department revisits, hospital readmissions, medication errors, adverse drug events, and other preventable adverse outcomes. The TCM framework operationalizes the post-discharge period through specific required elements that structure the care coordination work and pay practices for that work as a discrete service rather than absorbing it as overhead within the office-visit-based payment framework.

For Georgia Medicare beneficiaries, the TCM benefit operates within a state landscape characterized by substantial inpatient utilization and meaningful readmission risk. Georgia has a high concentration of inpatient hospital infrastructure including major academic medical centers (Emory Healthcare, Wellstar Health System, Piedmont Healthcare, Northside Hospital, Augusta University Health, Atrium Health Navicent, Memorial Health, Phoebe Putney Health System, Northeast Georgia Health System), substantial community hospital networks, a network of critical access hospitals serving rural counties, and several long-term care hospitals. The 30-day post-discharge window where TCM operates aligns directly with the CMS Hospital Readmission Reduction Program timeframe — the period during which preventable readmissions create financial penalties for hospitals under Section 1886(q) of the Social Security Act. The TCM benefit therefore serves both a clinical purpose (reducing post-discharge adverse outcomes) and a financial alignment purpose (creating community-side primary care payment that complements the hospital-side readmission reduction program).

The TCM framework operates as a structurally distinct benefit from the Chronic Care Management framework (CPT 99490 and the related CCM codes) — TCM and CCM are mutually exclusive in the same calendar month for the same beneficiary. The TCM service captures the 30-day post-discharge care coordination as a discrete, time-bounded service that begins with the discharge event and ends 30 days later. The CCM framework operates as a continuous, longitudinal monthly care coordination service for beneficiaries with multiple chronic conditions. When a beneficiary is discharged from an inpatient stay, the practice that has been billing CCM monthly transitions to TCM billing for the discharge month, then resumes CCM billing in subsequent months once the TCM window closes. The mutual exclusivity rule prevents duplicate billing while preserving the distinct clinical structure of each service.

This guide explains how the Medicare TCM benefit works statutorily and clinically, what eligibility looks like for a Georgia Medicare beneficiary transitioning from inpatient care back to the community, what the four required elements entail (interactive contact within 2 business days, face-to-face visit within 14 or 7 days, non-face-to-face services during 30 days, medication reconciliation), how the moderate complexity CPT 99495 and high complexity CPT 99496 distinction operates, how the 30-day post-discharge service period operates, how the mutual exclusivity rule with CCM functions, what the standard Part B cost-sharing means for beneficiaries and how Medicaid wraparound coverage and Medicare Advantage plans modify cost-sharing, how TCM coordinates with the CMS Hospital Discharge Planning conditions of participation under 42 CFR 482.43, how TCM coordinates with home health, hospice, skilled nursing facility post-discharge care, and other post-acute services, what telehealth TCM delivery looks like, and what the Georgia TCM delivery landscape provides.

Key Takeaways for Georgia Medicare Beneficiaries

1. CPT 99495 (moderate complexity TCM) and CPT 99496 (high complexity TCM) are the two Transitional Care Management codes. Both codes were established effective January 1, 2013 under the CY 2013 Medicare Physician Fee Schedule final rule (CMS-1590-FC).

2. 30-day post-discharge service period: The TCM service period begins on the day of discharge and continues for 30 days. The service is billed at the end of the 30-day period.

3. Four required elements:

   • Interactive contact (telephone, email, or face-to-face) within 2 business days of discharge
   • Face-to-face visit within 14 calendar days (moderate) or 7 calendar days (high) of discharge
   • Non-face-to-face services during the 30-day period
   • Medication reconciliation no later than the face-to-face visit date

4. Eligible discharge settings: TCM can be billed following discharge from inpatient hospital, observation status, partial hospitalization program, skilled nursing facility, community mental health center, or long-term care hospital.

5. Moderate vs. high complexity distinction: CPT 99495 (moderate) requires moderate complexity medical decision making and the face-to-face visit within 14 days. CPT 99496 (high) requires high complexity medical decision making and the face-to-face visit within 7 days.

6. Mutual exclusivity with CCM same calendar month: TCM (CPT 99495 or CPT 99496) and Chronic Care Management (CPT 99490 and related codes) cannot both be billed for the same beneficiary for the same calendar month.

7. One TCM service per 30-day post-discharge period: Only one TCM service may be billed per beneficiary per 30-day post-discharge period. If the beneficiary is readmitted during the 30-day period and discharged again, a new 30-day TCM period begins only after the second discharge.

8. Standard Part B cost-sharing applies: TCM is subject to Medicare Part B deductible and 20% coinsurance. TCM is not a preventive service and is not subject to the ACA Section 4104 cost-sharing waiver.

9. Eligible providers: Physicians, nurse practitioners, physician assistants, clinical nurse specialists, and certified nurse-midwives may furnish and bill TCM. The face-to-face visit must be furnished by the billing practitioner; the non-face-to-face elements may be furnished by clinical staff under physician supervision through the 42 CFR 410.26 incident-to framework.

10. For Georgia beneficiaries, TCM operates within a state landscape with substantial inpatient utilization, major academic medical center primary care delivery (Emory, Wellstar, Piedmont, Northside, Augusta University, Atrium Health Navicent, Memorial Health, Phoebe Putney, Northeast Georgia), FQHCs and RHCs delivering TCM in safety-net and rural settings, and meaningful readmission risk that the TCM framework is designed to mitigate.

The Federal Framework Underlying the Medicare TCM Benefit

CPT 99495 and CPT 99496 — Effective January 1, 2013 Under the CY 2013 Medicare Physician Fee Schedule

The Medicare TCM benefit was established through CPT 99495 (moderate complexity) and CPT 99496 (high complexity) effective January 1, 2013 under the CY 2013 Medicare Physician Fee Schedule final rule (CMS-1590-FC, published November 16, 2012). CMS established the two TCM codes as part of an effort to pay primary care practitioners for the substantial post-discharge care coordination work involved in managing the transition from inpatient or skilled nursing facility care back to the community — work that had been effectively uncompensated under Medicare's traditional fee-for-service payment framework that paid only for face-to-face evaluation and management encounters.

The CY 2013 MPFS final rule explicitly recognized the clinical importance of the post-discharge period. CMS cited research demonstrating that approximately one in five Medicare beneficiaries discharged from an inpatient stay is readmitted within 30 days, and that a substantial share of these readmissions are preventable through effective post-discharge care coordination. The TCM framework was designed to align community primary care payment with the post-discharge care coordination work that reduces readmission risk.

The CY 2013 MPFS final rule structured the TCM benefit through three foundational requirements that continue to define the service:

• Service period: The TCM service period begins on the day of discharge and continues for 30 days. The TCM service is billed at the end of the 30-day period using the date of the face-to-face visit as the date of service.
• Interactive contact requirement: Within 2 business days of discharge, the TCM practitioner or designated clinical staff must contact the beneficiary by telephone, email, or face-to-face to begin the transition coordination.
• Face-to-face visit requirement: For moderate complexity TCM (CPT 99495), the face-to-face visit must occur within 14 calendar days of discharge. For high complexity TCM (CPT 99496), the face-to-face visit must occur within 7 calendar days of discharge.

The CY 2013 framework was refined in subsequent MPFS rulemaking. The CY 2015 MPFS final rule clarified that TCM applies to discharges from observation status (not only formal inpatient admissions) and to discharges from partial hospitalization programs. The CY 2016 MPFS final rule clarified that additional E/M visits can be billed during the 30-day TCM period if medically necessary. The CY 2020 MPFS final rule clarified the role of communication technology-based services within the TCM framework.

Section 1861(s)(2)(B) of the Social Security Act — Physician Services Authority

The underlying statutory authority for TCM payment is Section 1861(s)(2)(B) of the Social Security Act, which authorizes Medicare payment for services furnished by physicians and certain qualified providers. CMS uses its rulemaking authority under the Medicare Physician Fee Schedule to establish TCM-specific codes within the Section 1861(s)(2)(B) framework, with the CPT codes 99495 and 99496 defined and maintained by the American Medical Association's Current Procedural Terminology Editorial Panel.

42 CFR 410.26 — Incident-To Framework Supporting TCM

42 CFR 410.26 establishes the Medicare incident-to framework that permits services furnished by clinical staff (medical assistants, registered nurses, licensed practical nurses, social workers, pharmacists, and others) to be billed under the supervising physician's NPI when furnished under appropriate physician supervision. The TCM framework uses the incident-to framework for the non-face-to-face elements (the interactive contact and the 30-day non-face-to-face services), while the face-to-face visit must be furnished personally by the billing practitioner.

42 CFR 482.43 — Hospital Discharge Planning Conditions of Participation

42 CFR 482.43 establishes the hospital discharge planning conditions of participation that hospitals must meet to participate in Medicare. The discharge planning conditions require hospitals to identify patients in need of discharge planning, assess patients' post-discharge needs, develop discharge plans, arrange post-discharge services, and provide patients with discharge summaries. The hospital discharge planning framework operates as the upstream foundation for TCM — the discharge summary, post-discharge service arrangements, and discharge planning information from the hospital becomes the substrate that the community TCM practitioner builds upon during the 30-day post-discharge period.

42 CFR 489.27 — Discharge Planning Beneficiary Rights

42 CFR 489.27 establishes specific beneficiary rights related to discharge planning including the right to choose post-discharge providers from a list provided by the hospital, the right to receive information about post-discharge service options, and the right to request a review of discharge timing through the Quality Improvement Organization (Acentra Health for Georgia). These beneficiary rights operate during the same transition window where TCM care coordination occurs.

TCM Required Elements in Detail

Element 1: Interactive Contact Within 2 Business Days of Discharge

The TCM service must begin with interactive contact (two-way communication) with the beneficiary or caregiver within 2 business days of the discharge date. The interactive contact can be:

• Telephone call from the practitioner or designated clinical staff
• Electronic communication including secure messaging
• Face-to-face encounter
• Video communication

The interactive contact must be a meaningful, two-way exchange — not a one-way voicemail message, a one-way text message, or a one-way email that the beneficiary does not respond to. The contact must address post-discharge clinical and care coordination issues including current symptoms, medication adherence, follow-up appointment scheduling, and immediate care needs.

The "2 business days" timeframe excludes weekends and federal holidays. A beneficiary discharged on a Friday may have the interactive contact occur on the following Monday or Tuesday and still satisfy the 2 business day requirement.

If the practice attempts to make the interactive contact but is unable to reach the beneficiary, the practice must document the attempts. Two or more documented attempts to make interactive contact within 2 business days, even if unsuccessful, may satisfy the requirement in some circumstances, though the underlying goal is to actually reach the beneficiary.

Element 2: Face-to-Face Visit Within 14 Days (Moderate) or 7 Days (High)

The TCM service must include a face-to-face evaluation and management visit furnished by the billing practitioner. The timing of the face-to-face visit determines which CPT code is billed:

• CPT 99495 (moderate complexity TCM): Face-to-face visit within 14 calendar days of discharge
• CPT 99496 (high complexity TCM): Face-to-face visit within 7 calendar days of discharge

The 14-day and 7-day timeframes are calendar days, not business days. The day of discharge counts as day 0 (or the start of the count); the face-to-face visit must occur within the specified number of calendar days following discharge.

The face-to-face visit may be furnished in the office, in a hospital outpatient department, in a nursing facility (for beneficiaries transitioning to community living from short-term skilled nursing facility care), or in the beneficiary's home (for beneficiaries with mobility limitations or homebound status).

The face-to-face visit is the date of service used for TCM billing. The TCM code is billed once at the end of the 30-day post-discharge period using the face-to-face visit date as the date of service.

Beginning in 2020, certain telehealth-based face-to-face encounters using audio-video synchronous communication can satisfy the face-to-face visit requirement, with policy continuing to evolve through subsequent MPFS final rules.

Element 3: Non-Face-to-Face Services During the 30-Day Period

The TCM service must include non-face-to-face care coordination services during the 30-day post-discharge period beyond the face-to-face visit itself. Non-face-to-face services may include:

• Review of discharge summary and inpatient course
• Review of need for diagnostic tests, treatments, and procedures
• Education of beneficiary, family, caregiver, or other community providers
• Establishment or re-establishment of referrals to community resources
• Communication with hospital, skilled nursing facility, or other post-acute providers
• Communication with home health, hospice, or community-based services
• Communication with specialists involved in the inpatient stay
• Assessment of adherence to treatment plan
• Identification of community-based resources to meet needs

The non-face-to-face services may be furnished by the billing practitioner personally or by clinical staff under physician supervision through the 42 CFR 410.26 incident-to framework.

Element 4: Medication Reconciliation

The TCM service must include medication reconciliation no later than the date of the face-to-face visit. Medication reconciliation involves systematic comparison of:

• Medications prescribed at hospital discharge
• Medications the beneficiary was taking before hospitalization
• Medications the beneficiary is actually taking after discharge (from prescription fills, pharmacy contact, and medication review)
• Any changes from the inpatient setting

The medication reconciliation should identify discrepancies, address polypharmacy concerns, identify potential adverse drug interactions, address adherence concerns, and produce an accurate medication list that the beneficiary, primary care practitioner, and other community providers can rely on.

Medication reconciliation is a particularly important element of TCM because medication-related adverse events are a leading cause of post-discharge readmissions and emergency department revisits. Discharge transitions are recognized as high-risk periods for medication errors including unintended duplications, omissions, dose changes, and discontinuation of essential medications.

Eligible Discharge Settings

TCM can be billed following discharge from the following settings:

Inpatient Hospital Discharge

The most common TCM-eligible discharge setting is discharge from an inpatient hospital stay. TCM applies whether the inpatient stay was for medical, surgical, obstetric, or psychiatric care.

Observation Status Discharge

Discharge from outpatient observation status (the hospital outpatient observation classification under Section 1861(s)(2) and related provisions) is TCM-eligible. The CY 2015 MPFS final rule clarified that TCM applies to observation discharges in addition to inpatient discharges, recognizing that observation patients face similar post-discharge transition risks.

Partial Hospitalization Program Discharge

Discharge from a partial hospitalization program (PHP) under Section 1861(ff) is TCM-eligible. PHP is an intensive outpatient psychiatric program for beneficiaries with severe mental illness who require structured psychiatric care without inpatient admission.

Skilled Nursing Facility Discharge

Discharge from a skilled nursing facility (SNF) stay following the SNF benefit under Section 1812 and Section 1819 is TCM-eligible. TCM is particularly important following SNF discharges given the higher functional decline risk and higher readmission risk that follows post-acute SNF stays.

Community Mental Health Center Discharge

Discharge from a community mental health center (CMHC) under Section 1861(ff) is TCM-eligible.

Long-Term Care Hospital Discharge

Discharge from a long-term care hospital (LTCH) under Section 1886(d)(1)(B)(iv) is TCM-eligible. LTCHs treat patients with extended acute care needs typically lasting more than 25 days, and the post-LTCH transition carries substantial readmission risk.

The Moderate vs. High Complexity Distinction

The distinction between CPT 99495 (moderate complexity TCM) and CPT 99496 (high complexity TCM) operates through two coordinated requirements:

Medical Decision Making Complexity

• Moderate complexity TCM (CPT 99495): Moderate complexity medical decision making during the service period
• High complexity TCM (CPT 99496): High complexity medical decision making during the service period

The medical decision making complexity is determined using the same framework that applies to office and other outpatient E/M services (the 2021 E/M MDM framework). The relevant MDM categories include:

• Number and complexity of problems addressed
• Amount and complexity of data reviewed and analyzed
• Risk of complications, morbidity, or mortality of patient management

Moderate complexity MDM is characterized by moderate-level problems, moderate amount/complexity of data, and moderate risk. High complexity MDM is characterized by high-level problems (typically multiple chronic illnesses with severe exacerbation, life-threatening illnesses, or substantial functional decline risk), high amount/complexity of data, and high risk.

Face-to-Face Visit Timing

• Moderate complexity TCM (CPT 99495): Face-to-face visit within 14 calendar days of discharge
• High complexity TCM (CPT 99496): Face-to-face visit within 7 calendar days of discharge

The shorter face-to-face timeframe for high complexity TCM reflects the recognition that high-complexity post-discharge transitions require earlier in-person evaluation to assess clinical status, adjust treatment plans, and prevent decompensation.

The coding choice must be supported by both the MDM complexity documentation and the timing of the face-to-face visit. A practice that conducts a face-to-face visit within 7 days but documents only moderate MDM should bill CPT 99495 (moderate). A practice that documents high MDM but conducts the face-to-face visit on day 10 should also bill CPT 99495 (moderate) because the face-to-face timing did not meet the 7-day high-complexity requirement.

The 30-Day Post-Discharge Service Period

The TCM service period begins on the day of discharge from the qualifying setting and continues for 30 days. The day of discharge is day 0 (or the start of the count, depending on counting convention).

Date of Service

The date of service for TCM billing is the date of the face-to-face visit, not the date of discharge. The TCM code is billed once at the end of the 30-day period using the face-to-face visit date.

Service Period Includes the Hospital Discharge

The TCM service period encompasses the discharge event itself and the 30 days following. Hospital-furnished services during the discharge process (including hospital discharge planning, hospital medication reconciliation, hospital follow-up arrangements) are not part of TCM — TCM begins after the beneficiary leaves the hospital and the post-discharge care coordination is conducted by the community primary care practitioner.

Service Period Includes Additional E/M Visits If Medically Necessary

The CY 2016 MPFS final rule clarified that additional evaluation and management visits during the 30-day TCM period can be billed separately if medically necessary. The TCM service captures the post-discharge care coordination as a discrete service, but the beneficiary may require additional office visits for other medical issues during the 30-day period that are billed under standard E/M codes.

Service Period and Readmission

If the beneficiary is readmitted during the 30-day TCM period, the TCM service is still billed at the end of the 30-day period if all required elements have been completed. If the beneficiary is discharged from the readmission, a new TCM 30-day period begins from the second discharge if the practice provides TCM services following the second discharge.

Mutual Exclusivity With Chronic Care Management

TCM (CPT 99495 or CPT 99496) and Chronic Care Management (CPT 99490, CPT 99439, CPT 99487, CPT 99489, CPT 99491, CPT 99437) cannot both be billed for the same beneficiary for the same calendar month. The mutual exclusivity rule prevents duplicate billing and structures TCM as a one-month bridge during the post-discharge transition while CCM operates for ongoing longitudinal care coordination.

Operationally

Practices that have been billing CCM monthly for a beneficiary transition to TCM billing for the discharge month, then resume CCM billing in subsequent months. The transition logic operates as follows:

• Month N-1 (before discharge): CCM billed (CPT 99490)
• Month N (discharge month): TCM billed (CPT 99495 or CPT 99496); CCM not billed
• Month N+1 (post-TCM): CCM resumes (CPT 99490)

If the 30-day TCM period spans two calendar months (for example, discharge on April 20 with TCM service date in early May), the TCM is billed for the calendar month containing the face-to-face visit (which is the date of service used for TCM billing). The CCM billing in the other calendar month is allowed if all CCM requirements are met for that calendar month and the TCM is not also billed for that calendar month.

Coordination With Principal Care Management

TCM and Principal Care Management (PCM, CPT 99424/99425/99426/99427) can both be billed for the same beneficiary in the same calendar month when furnished by different practitioners. The primary care physician may bill TCM for the post-discharge transition while a specialist (e.g., nephrologist managing chronic kidney disease) bills PCM for ongoing single-condition management.

Coordination With Behavioral Health Integration

TCM and Behavioral Health Integration (BHI, CPT 99484 and Collaborative Care CPT 99492/99493/99494) can both be billed for the same beneficiary in the same calendar month when furnished by the same or different practitioners. The TCM service captures the post-discharge medical care coordination; the BHI service captures the behavioral health integration activities.

TCM Cost-Sharing Framework

TCM is subject to standard Medicare Part B cost-sharing:

• Part B deductible applies
• 20% coinsurance applies after deductible

TCM is NOT classified as a preventive service and is NOT subject to the ACA Section 4104 cost-sharing waiver. The standard Part B cost-sharing creates a financial obligation for beneficiaries, with the actual out-of-pocket amount depending on the geographic locality-adjusted MPFS rate for CPT 99495 or CPT 99496 and any wraparound coverage.

For Georgia dual-eligible beneficiaries with full Medicaid coverage through DCH, the Qualified Medicare Beneficiary program covers Medicare cost-sharing including the Part B deductible and 20% coinsurance for TCM. For Specified Low-Income Medicare Beneficiary (SLMB) and Qualifying Individual (QI) program beneficiaries, Medicaid does not cover Medicare cost-sharing — these beneficiaries pay the Part B deductible and 20% coinsurance out-of-pocket unless they have other coverage (Medicare Supplement, retiree coverage, employer-sponsored secondary).

For Georgia Medicare Advantage enrollees, TCM cost-sharing operates under the plan's specific cost-sharing rules, which may include lower copayments for TCM as part of plan design.

Eligible Providers

TCM may be furnished and billed by:

• Physicians (MD or DO) — family medicine, internal medicine, geriatric medicine, others
• Nurse practitioners
• Physician assistants
• Clinical nurse specialists
• Certified nurse-midwives

The billing practitioner must furnish the face-to-face visit personally. The non-face-to-face elements (interactive contact, 30-day care coordination, medication reconciliation review) may be furnished by clinical staff under physician supervision through the 42 CFR 410.26 incident-to framework.

Clinical Staff Furnishing Non-Face-to-Face TCM Elements

Clinical staff who may furnish the non-face-to-face TCM elements under physician supervision include:

• Registered nurses
• Licensed practical nurses
• Medical assistants
• Pharmacists
• Clinical social workers
• Care managers and care coordinators
• Health educators
• Other qualified clinical staff

TCM Settings

TCM may be furnished in:

• Primary care offices
• Multispecialty group practices
• Hospital outpatient departments
• Federally qualified health centers
• Rural health clinics
• Critical access hospitals

FQHC and RHC TCM Billing

FQHCs and RHCs may bill TCM. Unlike CCM (which is bundled under HCPCS G0511 in FQHC/RHC settings), TCM is billed under the standard CPT codes 99495 and 99496 in FQHC/RHC settings, with the TCM service paid through the FQHC or RHC payment methodology.

Coordination With Hospital Discharge Planning

The Medicare Hospital Discharge Planning conditions of participation under 42 CFR 482.43 establish the upstream framework that feeds into TCM. The hospital discharge planning conditions require hospitals to:

• Identify patients in need of discharge planning at admission or shortly thereafter
• Assess patients' post-discharge needs including social support, ability to perform ADLs, post-discharge care needs, and the availability of post-discharge services
• Develop discharge plans
• Arrange post-discharge services including referrals to home health, skilled nursing facilities, hospice, durable medical equipment, and other community services
• Provide patients with discharge summaries
• Provide patients with information about post-discharge service options

The discharge planning information becomes the substrate for TCM. The TCM practitioner reviews the hospital discharge summary, confirms or modifies the medication list, follows up on referrals made by hospital discharge planning, and coordinates with the post-acute and community services that hospital discharge planning has arranged.

Coordination With Home Health

Home health services under Section 1861(m) are commonly initiated at hospital discharge and operate during the TCM 30-day window. The TCM practitioner coordinates with home health through:

• Signing the home health plan of care (Form CMS-485 or its electronic equivalent)
• Receiving home health communications about the beneficiary's status
• Adjusting medications based on home health assessments
• Coordinating home health visit frequency with face-to-face TCM visit timing
• Confirming home health face-to-face encounter requirement under Section 6407 of the ACA (this is a separate face-to-face requirement specific to home health authorization)

Coordination With Hospice

For beneficiaries transitioning from inpatient care to hospice care, the TCM service may still be billed if the beneficiary has elected hospice and the TCM practitioner is the attending physician of record providing non-hospice care. However, the typical post-hospice-election trajectory is direct hospice care without TCM, with the hospice interdisciplinary team handling the post-discharge coordination.

Coordination With Skilled Nursing Facility Post-Discharge Care

For beneficiaries discharged from inpatient hospital to a skilled nursing facility, TCM is not billed at the inpatient discharge because the beneficiary is not transitioning to community living. TCM may be billed at the subsequent SNF discharge when the beneficiary transitions from SNF to community living.

Telehealth TCM Delivery

The TCM framework permits substantial telehealth-based delivery:

• Interactive contact within 2 business days: Can be furnished through telephone, secure messaging, video, or other interactive communication technology.
• Face-to-face visit: Traditionally required in-person, but beginning in 2020, audio-video synchronous telehealth encounters can satisfy the face-to-face visit requirement in many circumstances, particularly for beneficiaries with mobility limitations, beneficiaries in rural areas with workforce constraints, and beneficiaries during the post-COVID-19 telehealth flexibility extensions through CY 2025-2026.
• Non-face-to-face services: Inherently non-face-to-face; can be furnished through telephone, secure messaging, video, or other means.
• Medication reconciliation: Can be conducted through telephone with pharmacy contact, through patient portal review, or face-to-face at the post-discharge visit.

Telehealth TCM is particularly important for rural Georgia delivery given the workforce constraints in many rural counties and the longer travel distances faced by rural Medicare beneficiaries.

The Georgia TCM Landscape

Georgia health system and primary care infrastructure delivering TCM includes:

Major Academic Medical Centers and Health Systems

• Emory Healthcare — academic medical center system covering metro Atlanta with established hospital-affiliated primary care delivering TCM following Emory University Hospital and Emory University Hospital Midtown discharges
• Wellstar Health System — north and northwest Georgia hospital network with TCM delivery following Kennestone, Cobb, North Fulton, Spalding Regional, and other Wellstar hospital discharges
• Piedmont Healthcare — central and north Georgia hospital network with TCM delivery following Piedmont Atlanta, Piedmont Athens, Piedmont Newnan, and other Piedmont hospital discharges
• Northside Hospital — primarily metro Atlanta with TCM delivery following Northside Atlanta, Cherokee, Forsyth, and Duluth hospital discharges
• Augusta University Health — Augusta region academic medical center with TCM delivery following Augusta University Medical Center discharges
• Atrium Health Navicent — central Georgia (Macon) with TCM delivery following Atrium Health Navicent The Medical Center discharges
• Memorial Health (HCA) — southeast Georgia (Savannah) with TCM delivery following Memorial Health University Medical Center discharges
• Phoebe Putney Health System — southwest Georgia (Albany) with TCM delivery following Phoebe Putney Memorial Hospital discharges
• Northeast Georgia Health System — north Georgia (Gainesville) with TCM delivery following Northeast Georgia Medical Center discharges

FQHC and RHC TCM Delivery

Georgia FQHCs and RHCs deliver TCM following inpatient and SNF discharges with the TCM service billed under CPT 99495/99496 within the FQHC or RHC payment methodology. The FQHC and RHC TCM delivery is particularly important for safety-net populations and rural beneficiaries who receive their primary care through these settings.

Rural Hospital and Critical Access Hospital Discharge Coordination

Rural Georgia critical access hospitals (CAHs) and rural health clinics (RHCs) provide an important share of inpatient and primary care delivery in rural counties. The TCM coordination across CAH discharge and rural primary care follow-up is essential for rural beneficiary care.

Worked Examples — Six Georgia TCM Scenarios

Example 1: Fulton 72 Moderate Complexity TCM — Post-HF Decompensation Discharge from Emory

A 72-year-old Fulton County beneficiary is hospitalized at Emory University Hospital for an acute heart failure decompensation. She has chronic conditions including HFrEF, AFib, CKD3, and DM2. After a four-day inpatient stay including IV diuresis and medication optimization, she is discharged home on Friday afternoon.

Her Emory Healthcare primary care nurse practitioner receives the hospital discharge summary electronically through the EHR Sunday evening. On Monday morning (the first business day after discharge), the NP's care manager (registered nurse) calls the beneficiary to begin the interactive contact: confirming her arrival home safely, reviewing discharge medications including the new spironolactone start and the increased furosemide dose, confirming her ability to obtain medications from pharmacy, scheduling the follow-up office visit, and addressing any immediate concerns. The interactive contact takes 18 minutes and is documented in the EHR.

Over the following two weeks, the care manager makes additional non-face-to-face calls: confirming pharmacy pickup, addressing a question about furosemide timing, coordinating with cardiology regarding device clinic follow-up for her ICD, and confirming home health initiation. The care manager spends a total of 45 minutes on non-face-to-face TCM activities during the 30-day period.

The NP conducts the face-to-face TCM visit on day 11 post-discharge in the office. The visit includes comprehensive review of the inpatient course, medication reconciliation (reconciling the discharge medication list with the beneficiary's actual medication-taking and addressing minor discrepancies), assessment of current status, ordering follow-up BNP and basic metabolic panel, and adjustment of furosemide based on weight trend. The MDM is moderate complexity.

The TCM service is billed under CPT 99495 (moderate complexity TCM, face-to-face within 14 days) with the day 11 face-to-face visit as the date of service. Because the prior month had CCM billing (CPT 99490) for this beneficiary, the discharge month bills TCM only; CCM resumes the following month.

Example 2: DeKalb 78 High Complexity TCM — Post-ICU Sepsis and AKI Discharge from Piedmont

A 78-year-old DeKalb County beneficiary is hospitalized at Piedmont Atlanta Hospital following emergency department presentation for severe sepsis from a urinary tract infection. He has a complex pre-hospitalization clinical picture (DM2 with insulin, CKD3 [baseline eGFR 38], HFrEF [LVEF 30%], COPD on home oxygen, history of stroke). The hospital course is complicated by ICU admission for hypotension, acute kidney injury (peak creatinine 4.1), pulmonary edema requiring BiPAP, and atrial fibrillation with rapid ventricular response. After 9 days, including 4 ICU days, he is discharged home with home health, oxygen therapy continuation, and substantial medication changes.

His Piedmont Healthcare primary care physician receives the discharge summary. The PCP's clinical staff makes interactive contact within 24 hours of discharge given the high complexity, addressing immediate post-discharge concerns and confirming home health initiation.

The PCP conducts the face-to-face TCM visit on day 5 post-discharge given the high complexity warranting CPT 99496. The visit includes comprehensive medication reconciliation (reconciling the discharge medication list with the pre-hospital medication list and identifying multiple changes including a new beta blocker initiation, discontinuation of metformin given AKI, dose adjustment of furosemide, dose adjustment of basal insulin given the changes), assessment of recovery from sepsis and AKI, basic metabolic panel showing improving but persistently elevated creatinine, planning for repeat eGFR monitoring, coordination with cardiology regarding the AFib and HF, and family meeting discussion regarding the trajectory of his multi-condition picture and advance care planning. The MDM is high complexity.

The TCM service is billed under CPT 99496 (high complexity TCM, face-to-face within 7 days) with the day 5 face-to-face visit as the date of service.

Example 3: Cobb 70 TCM From SNF — Post-Hip Fracture Rehabilitation Discharge

A 70-year-old Cobb County beneficiary fell at home and sustained a left hip fracture requiring surgical repair. She was hospitalized at Wellstar Kennestone Hospital for 4 days for surgery and initial recovery, then transferred to a skilled nursing facility for 18 days of rehabilitation. She is discharged from the SNF home with home health for ongoing PT and OT.

Her Wellstar primary care physician receives the SNF discharge summary. The clinical staff makes interactive contact on day 1 post-discharge by telephone, confirming her arrival home, reviewing discharge medications including the new apixaban (started during hospitalization for DVT prophylaxis with planned 6-week duration), addressing pain management, and confirming home health initiation.

The PCP conducts the face-to-face TCM visit on day 8 post-discharge in the office. The visit includes medication reconciliation (confirming the apixaban duration, reviewing the changes in her routine medications, addressing pain management transition from oxycodone to acetaminophen), assessment of mobility and fall risk, planning for ongoing PT/OT, and discussion of follow-up orthopedic care. The MDM is moderate complexity.

The TCM service is billed under CPT 99495 (moderate complexity TCM, face-to-face within 14 days) with the day 8 face-to-face visit as the date of service. The SNF discharge is an eligible TCM-qualifying discharge setting.

Example 4: Worth County 75 Rural TCM — Post-Discharge from Phoebe Worth with Rural Primary Care

A 75-year-old Worth County beneficiary is hospitalized at Phoebe Worth Medical Center for community-acquired pneumonia. He has chronic conditions including COPD, HFrEF, and DM2. After a 5-day inpatient stay, he is discharged home.

His rural primary care nurse practitioner at a rural health clinic in Worth County receives the discharge summary. Given the distance the beneficiary lives from the RHC (35 minutes drive), and given the beneficiary's preference to limit travel during recovery, the NP plans a telehealth-based interactive contact and considers telehealth for the face-to-face visit.

On day 2 post-discharge, the NP conducts a 20-minute video telehealth interactive contact with the beneficiary, addressing recovery from pneumonia, confirming antibiotic completion, reviewing medication changes (the discharge regimen restarted his prior chronic medications plus a continued azithromycin course), addressing fluid status given his HFrEF, and scheduling face-to-face follow-up.

On day 10 post-discharge, the NP conducts the face-to-face TCM visit using audio-video synchronous telehealth with the beneficiary at home (the practice is enrolled to provide telehealth services and the beneficiary qualifies for the rural Medicare telehealth flexibilities). The telehealth-based face-to-face visit satisfies the CPT 99495 requirement under current telehealth flexibilities. The visit includes medication reconciliation, assessment of pneumonia recovery, comprehensive chronic disease review, and planning for ongoing care.

The TCM service is billed under CPT 99495 (moderate complexity TCM, telehealth-based face-to-face within 14 days) with the day 10 telehealth visit as the date of service.

Example 5: Bibb 80 TCM From Observation — Discharge From Observation Status

An 80-year-old Bibb County beneficiary presents to the Atrium Health Navicent emergency department with chest pain. He is placed in observation status for serial troponins and stress testing. Troponins remain negative and stress testing is negative for ischemia. After 23 hours in observation, he is discharged home with cardiology follow-up.

His Atrium Health Navicent primary care physician receives the observation discharge summary. Although the beneficiary was not formally admitted as an inpatient, the discharge from observation status is a TCM-eligible discharge setting under the CY 2015 MPFS clarification.

The clinical staff makes interactive contact on day 1 post-discharge by telephone, addressing the negative cardiac workup, reviewing his routine medications (no changes from the observation stay), and scheduling face-to-face follow-up.

The PCP conducts the face-to-face TCM visit on day 12 post-discharge, including review of the cardiac workup, assessment of any continued chest discomfort, comprehensive medication reconciliation, and coordination with cardiology regarding the recommended outpatient stress testing protocol. The MDM is moderate complexity.

The TCM service is billed under CPT 99495 (moderate complexity TCM, face-to-face within 14 days) with the day 12 face-to-face visit as the date of service. The observation discharge is an eligible TCM-qualifying discharge setting under the CY 2015 MPFS clarification.

Example 6: Hall 76 TCM Coordination With Home Health and Subsequent Hospice Election

A 76-year-old Hall County beneficiary is hospitalized at Northeast Georgia Medical Center for advanced heart failure with multiple decompensations over the prior six months. Her hospital course is complicated by progressive renal dysfunction, persistent volume overload despite optimal medical therapy, and limited surgical options given comorbidities. The hospital palliative care team is consulted and conducts goals of care discussions with the beneficiary and her family.

After a 6-day inpatient stay, the beneficiary is discharged home with home health for continued nursing assessment and medication management. The hospital palliative care team has had advance care planning discussions but the beneficiary has not yet elected hospice.

Her Northeast Georgia primary care physician receives the discharge summary. The clinical staff makes interactive contact on day 2 post-discharge by telephone, addressing the immediate post-discharge transition and confirming home health initiation. Over the following week, home health nursing assessments indicate the beneficiary's clinical trajectory continues to decline despite outpatient diuretic adjustments.

On day 8 post-discharge, the PCP conducts the face-to-face TCM visit, including comprehensive review of the inpatient course, medication reconciliation, assessment of clinical trajectory, and goals of care discussion with the beneficiary and her family. The MDM is high complexity given the multi-condition picture and the active decompensation risk. The PCP, beneficiary, and family agree that hospice election is appropriate given the trajectory and the beneficiary's preferences for comfort-focused care.

The TCM service is billed under CPT 99496 (high complexity TCM, face-to-face within 7 days) with the day 8 face-to-face visit as the date of service — note that the day 8 timing actually exceeds the 7-day requirement for high complexity, so this should be billed as CPT 99495 (moderate complexity TCM) instead. The hospice election occurs on day 10 post-discharge with the PCP continuing as the attending physician of record providing non-hospice care while the hospice interdisciplinary team manages hospice-related care.

(Documentation correction: For the day 8 face-to-face timing, CPT 99495 with its 14-day face-to-face window applies. The example illustrates that high-complexity MDM alone does not support CPT 99496 billing — both the MDM and the face-to-face timing must satisfy the high-complexity requirements.)

Best Practices for Maximizing TCM Coverage

1. Receive hospital discharge summaries electronically and timely — practices should establish electronic data exchange with major referring hospitals to receive discharge summaries quickly enough to begin TCM coordination within the 2 business day interactive contact window.

2. Establish a TCM workflow with designated care coordinators — meeting the four required TCM elements consistently requires structured workflows including assignment of TCM activities to specific clinical staff, time tracking, and documentation templates.

3. Make the interactive contact a true two-way exchange — the interactive contact must be meaningful interactive communication; voicemails, unidirectional texts, and unidirectional emails do not satisfy the requirement.

4. Schedule face-to-face visits proactively — practices should systematize the post-discharge follow-up scheduling to ensure the face-to-face visit occurs within 14 days (moderate) or 7 days (high) of discharge.

5. Distinguish moderate from high complexity carefully — the moderate-vs-high complexity distinction requires both MDM complexity and face-to-face timing to align. Documenting MDM complexity accurately and timing the face-to-face visit to match the targeted complexity supports accurate coding.

6. Conduct comprehensive medication reconciliation — medication reconciliation is the most clinically important element of TCM and should systematically compare discharge medications, pre-hospital medications, and current actual medications.

7. Use the CY 2016 clarification to bill additional E/M visits if medically necessary — additional office visits during the 30-day TCM period can be billed separately when medically necessary for issues not captured by TCM.

8. Coordinate CCM and TCM at month boundaries — practices billing CCM monthly should transition to TCM billing for discharge months and resume CCM in subsequent months.

9. Use telehealth strategically for interactive contact and face-to-face visits — telehealth interactive contact and telehealth-based face-to-face visits can support TCM delivery for beneficiaries with mobility limitations, rural beneficiaries, and beneficiaries during continued post-PHE telehealth flexibilities.

10. Coordinate with home health proactively — home health initiation at discharge requires PCP coordination including plan of care signing. Establishing systematic home health communication workflows supports TCM and home health coordination.

11. Coordinate with hospice when appropriate — for beneficiaries approaching end of life, the TCM transition should include goals of care discussion and hospice election support when consistent with beneficiary preferences.

12. Track TCM 30-day periods carefully — documentation should track the discharge date, interactive contact date, face-to-face visit date, and 30-day period end to support accurate billing.

13. Educate beneficiaries about TCM cost-sharing — TCM carries standard Part B cost-sharing. Beneficiaries should understand that TCM is not preventive-service cost-sharing waived.

14. Use TCM quality measure data for practice improvement — MIPS TCM quality measures provide a feedback framework for practice quality improvement on post-discharge care coordination.

Common Issues for Georgia TCM Beneficiaries

1. Delayed hospital discharge summary delivery — practices may not receive discharge summaries quickly enough to begin TCM coordination within the 2 business day interactive contact window, particularly when the discharge occurs from a hospital outside the practice's primary referral network.

2. Inability to reach beneficiary for interactive contact — some beneficiaries cannot be reached within 2 business days of discharge despite multiple attempts, particularly those with cognitive impairment, those without reliable phone service, or those staying with family members.

3. Face-to-face visit scheduling friction — the 14-day or 7-day face-to-face requirement may conflict with practice scheduling constraints, beneficiary transportation limitations, or specialist appointments scheduled during the same window.

4. Moderate vs. high complexity coding errors — practices may bill CPT 99496 when only CPT 99495 is supported (or vice versa) due to misalignment between MDM complexity documentation and face-to-face timing.

5. CCM-TCM month boundary errors — practices may bill both CCM and TCM for the same calendar month, resulting in claim denials.

6. Missing medication reconciliation documentation — the medication reconciliation element must be documented; absence of medication reconciliation documentation can support claim denial.

7. TCM billing for SNF-bound discharges — TCM cannot be billed when the beneficiary is discharged from inpatient hospital to SNF; TCM applies when the beneficiary transitions to community living, which occurs at SNF discharge.

8. TCM billing for hospice-bound discharges — for beneficiaries who elect hospice during the inpatient stay or at discharge, TCM is generally not billed because the hospice interdisciplinary team handles post-discharge coordination.

9. Rural workforce constraints — rural Georgia practices may struggle to staff the care coordination roles needed for systematic TCM delivery.

10. Cost-sharing barriers — Part B deductible and 20% coinsurance create financial barriers for some beneficiaries, particularly those without Medicaid wraparound or Medicare Supplement coverage.

11. Telehealth eligibility uncertainty — practices may be uncertain whether specific telehealth-based interactive contacts or telehealth-based face-to-face visits satisfy TCM requirements under current telehealth flexibility frameworks.

12. Coordination friction with hospital discharge planning — communication gaps between hospital discharge planning and community primary care can result in missing post-discharge service information or duplicated service referrals.

13. Readmission during TCM period — readmission during the 30-day TCM period creates documentation and billing complexity that practices may handle inconsistently.

14. Documentation burden — meeting all four TCM required elements with appropriate documentation creates substantial documentation burden, particularly for small practices without EHR templates designed for TCM workflows.

FAQ

What is the Medicare Transitional Care Management (TCM) benefit?

Medicare TCM is a benefit that pays primary care practitioners for the post-discharge care coordination work involved in managing the 30-day transition from inpatient hospital, observation, partial hospitalization, skilled nursing facility, community mental health center, or long-term care hospital care back to the community. It was established through CPT 99495 and CPT 99496 effective January 1, 2013 under the CY 2013 Medicare Physician Fee Schedule final rule.

Who qualifies for TCM?

Medicare beneficiaries qualify for TCM following discharge from an eligible setting (inpatient hospital, observation, partial hospitalization, SNF, CMHC, or LTCH) and a transition to community living. There is no specific chronic condition requirement for TCM eligibility; any beneficiary discharged from a qualifying setting may receive TCM.

What are the four required TCM elements?

The four required TCM elements are: (1) interactive contact within 2 business days of discharge, (2) face-to-face visit within 14 calendar days (moderate complexity) or 7 calendar days (high complexity) of discharge, (3) non-face-to-face services during the 30-day post-discharge period, and (4) medication reconciliation no later than the date of the face-to-face visit.

What is the difference between CPT 99495 and CPT 99496?

CPT 99495 (moderate complexity TCM) requires moderate complexity medical decision making and a face-to-face visit within 14 calendar days of discharge. CPT 99496 (high complexity TCM) requires high complexity medical decision making and a face-to-face visit within 7 calendar days of discharge.

How is the date of service for TCM determined?

The date of service for TCM billing is the date of the face-to-face visit, not the date of discharge. The TCM code is billed once at the end of the 30-day post-discharge period using the face-to-face visit date.

Can TCM and CCM be billed in the same month?

No. TCM (CPT 99495 or CPT 99496) and Chronic Care Management (CPT 99490 and related CCM codes) cannot both be billed for the same beneficiary for the same calendar month.

Can TCM and PCM be billed in the same month?

Yes. TCM (CPT 99495 or CPT 99496) and Principal Care Management (CPT 99424/99425/99426/99427) can both be billed for the same beneficiary in the same calendar month when furnished by different practitioners.

Can TCM and BHI be billed in the same month?

Yes. TCM and Behavioral Health Integration (CPT 99484 or Collaborative Care CPT 99492/99493/99494) can both be billed for the same beneficiary in the same calendar month.

What discharge settings qualify for TCM?

TCM-eligible discharge settings include: inpatient hospital, outpatient observation status, partial hospitalization program (PHP), skilled nursing facility (SNF), community mental health center (CMHC), and long-term care hospital (LTCH).

Does TCM apply to discharge from emergency department?

No. Emergency department discharge without observation status admission does not qualify for TCM. The beneficiary must have been admitted to an eligible discharge setting (inpatient, observation, PHP, SNF, CMHC, or LTCH).

Does TCM apply when a patient is discharged from inpatient to SNF?

No. TCM applies when the beneficiary transitions to community living. The inpatient-to-SNF transition is not TCM-eligible because the beneficiary is not transitioning to community living. TCM may be billed at the subsequent SNF discharge when the beneficiary transitions from SNF to community living.

Can clinical staff furnish the TCM face-to-face visit?

No. The face-to-face visit must be furnished personally by the billing practitioner (physician, NP, PA, CNS, or CNM). The non-face-to-face elements (interactive contact, 30-day non-face-to-face services) may be furnished by clinical staff under physician supervision.

How much does TCM cost the beneficiary?

TCM is subject to standard Medicare Part B cost-sharing — the Part B deductible plus 20% coinsurance. TCM is not classified as a preventive service and is not subject to the ACA Section 4104 cost-sharing waiver.

Do Medicare Savings Programs help with TCM cost-sharing?

The Qualified Medicare Beneficiary (QMB) program covers Medicare cost-sharing including the Part B deductible and 20% coinsurance for TCM. The SLMB and QI programs do not cover Medicare cost-sharing.

Can TCM be furnished via telehealth?

Yes, with some elements. The interactive contact can be furnished through telephone, secure messaging, video, or other interactive communication. The face-to-face visit can be furnished through audio-video synchronous telehealth in many circumstances, particularly under current telehealth flexibility frameworks. The non-face-to-face elements are inherently non-face-to-face.

What if the patient is readmitted during the 30-day TCM period?

If the beneficiary is readmitted during the 30-day TCM period, the original TCM service is still billed at the end of the 30-day period if all required elements have been completed. A new 30-day TCM period begins from the second discharge if the practice provides TCM services following the second discharge.

Can additional E/M visits be billed during the TCM 30-day period?

Yes. The CY 2016 MPFS final rule clarified that additional evaluation and management visits during the 30-day TCM period can be billed separately when medically necessary for issues not captured by TCM.

Who can bill TCM?

TCM can be billed by physicians (MD or DO), nurse practitioners, physician assistants, clinical nurse specialists, and certified nurse-midwives. The billing practitioner must furnish the face-to-face visit personally.

What is medication reconciliation in the TCM context?

Medication reconciliation in TCM involves systematic comparison of medications prescribed at hospital discharge, medications the beneficiary was taking before hospitalization, medications the beneficiary is actually taking after discharge, and any changes from the inpatient setting. The reconciliation produces an accurate medication list and addresses discrepancies, polypharmacy, adverse drug interactions, and adherence concerns.

Do FQHCs and RHCs bill TCM differently?

FQHCs and RHCs may bill TCM under the standard CPT codes 99495 and 99496, with the TCM service paid through the FQHC or RHC payment methodology. Unlike CCM (which is bundled under HCPCS G0511 in FQHC/RHC settings), TCM is billed under the standard CPT codes.

How does TCM relate to the CMS Hospital Readmission Reduction Program?

The Medicare TCM benefit aligns directly with the 30-day timeframe of the CMS Hospital Readmission Reduction Program under Section 1886(q) of the Social Security Act. The HRRP creates financial penalties for hospitals with high readmission rates for specific conditions. TCM provides the community-side primary care payment that complements the hospital-side readmission reduction program by paying for the post-discharge care coordination work that reduces readmission risk.

Are there TCM quality measures?

Yes. TCM-related quality measures are included in the Medicare Merit-based Incentive Payment System (MIPS) Quality category. The TCM-related quality measures include measures of post-discharge follow-up timing, medication reconciliation completion, and care coordination effectiveness.

What if the interactive contact attempt is unsuccessful?

If the practice attempts to make interactive contact but is unable to reach the beneficiary within 2 business days, the practice must document the attempts. Two or more documented attempts may satisfy the requirement in some circumstances, though the underlying goal is to actually reach the beneficiary.

How does Medicare Advantage handle TCM?

Medicare Advantage plans must cover TCM consistent with Medicare coverage rules. MA plans may apply different cost-sharing structures than Original Medicare. Plan-specific TCM policies may apply including potentially different prior authorization requirements.

Where can I learn more about TCM in Georgia?

Beneficiaries can call 1-800-MEDICARE for general Medicare questions, Palmetto GBA at 1-866-238-9650 for claims questions, GeorgiaCares SHIP at 1-866-552-4464 for free Medicare counseling, or the Medicare Rights Center at 1-800-333-4114 for advocacy support.

Where to Get Help in Georgia

• Medicare — 1-800-MEDICARE (1-800-633-4227) — general Medicare benefit questions
• Palmetto GBA Medicare Administrative Contractor — 1-866-238-9650 — Georgia Medicare claims and provider questions
• DCH Medicaid Member Services — 1-866-211-0950 — Georgia Medicaid questions including QMB and dual-eligible coverage
• GeorgiaCares SHIP — 1-866-552-4464 — free Medicare counseling and enrollment assistance
• Medicare Rights Center — 1-800-333-4114 — national Medicare advocacy organization
• Atlanta Legal Aid Society — 404-377-0701 — free legal services for low-income metro Atlanta seniors
• Georgia Legal Services Program — 1-800-498-9469 — free legal services for low-income Georgia seniors outside metro Atlanta
• 211 Georgia — dial 211 — community resource referrals
• Eldercare Locator — 1-800-677-1116 — national directory of local senior services
• Georgia Department of Public Health — 404-657-2700 — state public health resources
• CDC-INFO — 1-800-232-4636 — federal public health information
• Emory Healthcare — academic medical center primary care across metro Atlanta with established TCM programs
• Wellstar Health System — primary care across north and northwest Georgia
• Piedmont Healthcare — primary care across central and north Georgia
• Acentra Health (Medicare QIO for Georgia) — 1-844-455-8708 — quality of care concerns and complaints; can review discharge timing under 42 CFR 489.27
• Social Security Administration — 1-800-772-1213 — Medicare enrollment and benefit eligibility
• Georgia Composite Medical Board — 404-657-6494 — physician licensing and complaints
• Georgia Hospital Association — 770-249-4500 — hospital industry resources for discharge planning

Sources and Authorities

This guide is based on the following federal authorities:

• CPT 99495 (moderate complexity TCM) and CPT 99496 (high complexity TCM) effective January 1, 2013 under the CY 2013 Medicare Physician Fee Schedule final rule (CMS-1590-FC, published November 16, 2012)
• CY 2015 Medicare Physician Fee Schedule final rule clarifying TCM application to observation discharges and PHP discharges
• CY 2016 Medicare Physician Fee Schedule final rule clarifying that additional E/M visits during the 30-day TCM period can be billed separately
• CY 2020 Medicare Physician Fee Schedule final rule clarifying communication technology-based services within TCM
• Section 1861(s)(2)(B) of the Social Security Act — Physician services authority
• Section 1886(q) of the Social Security Act — Hospital Readmission Reduction Program
• 42 CFR 410.26 — Incident-to framework
• 42 CFR 482.43 — Hospital Discharge Planning conditions of participation
• 42 CFR 489.27 — Discharge planning beneficiary rights
• CMS Manual System guidance on TCM services
• Medicare Learning Network educational materials on TCM
• MIPS TCM quality measures

This guide is informational and does not constitute legal, clinical, or coding advice. TCM coverage decisions are made by Palmetto GBA (Georgia's Medicare Administrative Contractor) and Medicare Advantage plans applying federal coding and policy framework. For coverage questions about specific TCM scenarios, beneficiaries and providers should contact 1-800-MEDICARE, the relevant MA plan, or Palmetto GBA directly. Last verified: 2026-05-14.