The weeks following hospital discharge represent one of the highest-risk stages in a patient’s care journey; at the same time, it is a period during which primary care centers often bill less than they are entitled to. Transitional Care Management (TCM) allows for reimbursement for the coordination efforts that take place immediately after a patient returns home such as phone calls, medication reviews, follow-up visits, and the ongoing support necessary to prevent hospital readmission. For centers serving Medicaid beneficiaries in New York, accurate billing for TCM services requires an understanding of CPT codes, strict requirements regarding timelines, and knowledge of where to find current payment rates. This guide details these three aspects for the year 2026.

What Is Transitional Care Management?

TCM (Transitional Care Management) encompasses a 30-day period that begins on the day a patient is discharged from a qualifying facility such as a hospital (inpatient admission), an observation unit, or a skilled nursing facility and returns to a community setting, such as their home or an assisted living facility. During this period, a single professional assumes responsibility for coordinating the patient’s care. A single claim, submitted under one of the two applicable CPT codes, covers the entire suite of services: the initial contact, the in-person visit, medication reconciliation, and subsequent non-face-to-face management.

The TCM CPT Codes: 99495 vs. 99496

The TCM family consists of two codes, and the difference between them lies in the complexity of the medical decision-making (MDM) and the promptness with which the patient is seen.
 

There are certain details that often cause issues for billing teams. An in-person visit is included as part of the TCM code and is not billed separately. Only one professional may report TCM services for a given discharge, and only one TCM claim per patient is permitted within a 30-day period. Furthermore, if a patient with high-complexity needs does not receive care until the tenth day, the claim must be filed under code 99495, as the 7-day timeframe required for code 99496 has already expired.

TCM Requirements Checklist for Your Documentation

Auditors and payers look for evidence of each required element. Before submitting a claim for Transitional Care Management (TCM) services, ensure that the medical record includes:

1. The discharge date and the type of facility, confirming that the patient transitioned from a qualifying setting to a community setting.
2. An interactive contact made within 2 business days, specifying the date, the method used (telephone, electronic, or in-person), and the individual with whom contact was established.
3. Medication reconciliation and management, completed on or before the date of the in-person visit.
4. The date of the in-person visit, which must fall within the 7-day or 14-day timeframe corresponding to the code billed.
5. The level of Medical Decision Making (MDM), appropriately supported by the problems addressed, the data reviewed, and the risk associated with the case.
6. Non-face-to-face services, such as reviewing discharge information, managing referrals, educating the patient or their caregiver, and coordinating community resources.

The absence of any of these elements is the most frequent reason why a claim for TCM services is denied or subject to "downcoding" (a reduction in the billed service level).

How to Find the NY Medicaid TCM Fee Schedule Rate

Here is a detail that most blogs overlook: New York’s Medicaid program does not publish a universal fee schedule. Payment amounts are found in provider manuals available on eMedNY the state’s Medicaid portal for providers which maintains separate fee schedules based on the category of service. TCM codes are included in the fee schedules for medical services; in fact, the most recent eMedNY listings include a fee schedule for medical services updated on August 31, 2026, along with a medical procedure code manual updated in April 2026. Since these documents are revised several times a year, always be sure to verify which version corresponds to the date the service was provided.

To check your reimbursement rate:

1. Access the section for physicians within the eMedNY provider manuals.
2. Select the fee schedule that covers evaluation and management (E&M) services, as well as care management services.
3. Locate CPT codes 99495 and 99496.
4. Verify the effective date and any applicable modifiers, provider types, or restrictions based on the place of service.
5. Note the specific rate that applies to your provider type and the date the service was rendered; do not simply rely on the most recently published file.

If a code does not appear for your provider type, or if a rate seems unusual, consider this an issue that should be clarified with the Department of Health before using it as a basis for any revenue projections.

Medicare Rates as a Benchmark

Many medical practices use the "Medicare Physician Fee Schedule" as a rough benchmark for planning purposes. For 2026, published national estimates for non-hospital settings for code 99495 generally fall within the range of approximately $190 to $220; for code 99496, they range from $266 to $300, depending on the source and the conversion factor used. These figures are adjusted based on geographic location and should be viewed strictly as an upper limit for comparative purposes. New York’s Medicaid program utilizes its own fee schedule, with rates that are typically lower than those of Medicare; therefore, never apply Medicare figures to a Medicaid revenue projection.

NY Medicaid Timely Billing Rules You Cannot Miss

A claim for Transitional Care Management (TCM) services even if perfectly documented—will not be paid if it is submitted past the deadline. Under New York’s Medicaid program (within the fee-for-service model), current eMedNY guidelines and 18 NYCRR 540.6 regulations establish the following timeframes:

1. 90 days from the date the service was provided to submit the initial claim.
2. 30 days to submit a late claim—once the circumstance that caused the delay is resolved including a code justifying the delay.
3. 60 days to correct and resubmit a claim that was returned due to insufficient data or billing errors; this period begins on the date the provider receives notification.

An absolute maximum limit of two years for the submission and payment of a claim.

Since TCM services are billed only after the full care period has concluded, healthcare facilities must pay close attention to when the 90-day window begins. It is recommended to incorporate a tracking mechanism into the workflow so that TCM claims are scheduled for submission as soon as all necessary information is available, rather than waiting for a batch processing cycle.

Medicaid Managed Care: Verify Plan by Plan

Most Medicaid enrollees in New York are covered under managed care plans, which may establish their own policies. The 90-day rule applicable to the fee-for-service model should not be applied automatically or indiscriminately to claims from managed care plans. Deadlines for claim submissions, prior authorization requirements, billing criteria, and reimbursement rates for Targeted Case Management (TCM) services may differ from those established under the state’s fee-for-service program. Consult each plan’s provider manual, confirm your network participation, and verify the specific plan in which the beneficiary was enrolled on the date the service was provided.

Eligibility and Enrollment Checks Before You Bill

Two initial checks help safeguard TCM revenue. First, verify the eligibility of both the member and the payer as of the date of service not the date of discharge or the date the visit was scheduled. Federal changes to Medicaid matching rules for certain categories of non-citizens take effect on October 1, 2026; as states are currently re-evaluating some members, assumptions about coverage made earlier in the year may no longer be valid. Second, confirm your own status as an enrolled provider. New York now handles enrollment and revalidation through the Provider Services Portal, and providers generally have 123 calendar days from the date of official notification to complete the revalidation process. Failure to meet this deadline can result in the termination of your Medicaid enrollment, rendering all claims uncollectible.

Common TCM Denial Reasons and How to Prevent Them

1. Delayed contact: the contact scheduled to take place within 2 business days either did not occur or was not documented. Solution: implement a discharge notification system and assign a task to clinical staff to ensure the contact is made on the same day.
2. Visit outside the established timeframe: the in-person visit took place on the ninth day, but was billed under code 99496. Solution: configure scheduling alerts linked to the seventh and fourteenth days.
3. Duplicate billing: another professional has already reported Transitional Care Management (TCM) services for the same discharge. Solution: verify whether any prior claims exist before submission.
4. Discrepancy in Medical Decision Making (MDM): the documentation supports a moderate level of complexity, yet the claim indicates a high level (or vice versa). Solution: have a coding specialist review the MDM before submitting the claim.
5. Separate billing for the visit: the in-person visit has also been reported as a standard office consultation; however, this is already included within the TCM code.
6. Late submission: the claim was submitted after the 90-day period had elapsed, without including a valid justification for the delay.

TCM and Chronic Care Management

Healthcare facilities that offer Chronic Care Management (CCM) services often ask whether both programs can coexist. Under Medicare, the Centers for Medicare & Medicaid Services (CMS) allow for the billing of certain CCM codes during a Transitional Care Management (TCM) period, provided that the requirements for each service are met and the same time or effort is not counted twice. Medicaid and managed care plans may have stricter policies; therefore, verify the regulations with each payer before billing for both services for the same patient during the same period.

A Simple Workflow That Keeps TCM Claims on Track

Practices that consistently generate revenue from Transitional Care Management (TCM) services tend to follow a set routine. Each morning, a designated team member reviews hospital discharge notifications to identify eligible patients covered by Medicaid. Clinical staff conduct and document the follow-up call that same day, while front-office staff schedule the appointment, clearly marking the 7-day and 14-day deadlines in the schedule. Following the visit, a coding specialist confirms the level of Medical Decision Making (MDM) and verifies that the medical record contains all required elements. Finally, the billing staff submits the claim promptly and monitors its status, ensuring that any denials can be addressed well within the 60-day window allowed for corrections.

The Takeaway

Transitional Care Management (TCM) rewards medical practices that approach the 30-day period following a hospital discharge as a structured workflow, rather than as a series of ad-hoc tasks. This entails managing the discharge promptly, making initial contact within two business days, scheduling the follow-up appointment within the required timeframe, documenting every aspect, verifying the current reimbursement rate via eMedNY for the date of service, and submitting the claim well in advance of the 90-day filing deadline. Practices that integrate these steps into their daily operations transform routine follow-up care into a reliable revenue stream, while simultaneously helping to prevent hospital readmissions.

ESOFTX, Inc., a medical billing company based in Levittown, New York, assists medical practices in establishing compliant TCM workflows, tracking deadlines related to hospital discharges, and reducing avoidable claim denials both within the New York Medicaid program and with private insurance carriers. If you would like a review of your current Transitional Care Management billing process, our team is here to help.