What Transitional Care Management is
TCM pays a practice to manage a patient's move from a facility back to the community. The service period is 30 days, starting on the discharge day. Qualifying discharges include inpatient acute, psychiatric, and rehab hospitals, long-term care hospitals, skilled nursing facilities, observation stays, and partial hospitalization.
The practice must make interactive contact within 2 business days, by phone, email, or face-to-face. Two or more timely unsuccessful attempts still count. CPT 99495 needs a visit within 14 days and moderate medical decision making, about $220 in 2026. CPT 99496 needs a visit within 7 days and high medical decision making, about $299.
Those are 2026 national non-facility amounts, and locality varies. The hard part is the 2-business-day clock, because discharge notices arrive late or in bulk. Rivvi's action layer can call newly discharged patients and record each contact attempt. It warm-transfers them to a nurse or creates a scheduling task for staff.