Transition Care Management
TCM covers the fragile 30 days after a hospital, observation or SNF stay. With ADT alerts from the HIE, ZOC surfaces the discharge, prompts the 2-day interactive contact, tracks medication reconciliation and readies the qualifying face-to-face visit — cutting readmissions and capturing 99495/99496 revenue.
What it means for patients
Highest-value 30-day service — one billable window per discharge.
The safety net when a patient leaves the hospital.
Eligibility
Medicare — post-discharge from inpatient, observation or SNF
Billing model
One-time post-discharge CPT
Time required
Interactive contact ≤ 2 business days · face-to-face ≤ 7 or 14 days
Medicare reimbursement
$204 – $281 / discharge
Billing codes
The 30-day window
A guided timeline, every discharge.
HIE-driven · fully documented
Day 0
Discharge detected
ADT feed from the HIE flags the discharge — automatically.
Day 1–2
Interactive contact
Care coordinator reaches out within 2 business days.
Day 2–14
Med reconciliation
Prior meds are pulled, reconciled and reviewed with the patient.
Day 7 or 14
Face-to-face visit
High-complexity ≤ 7 days · moderate ≤ 14 days. 99495/99496 documented.
Day 30
Service period closes
Full documentation and billing packet ready for submission.
Stay audit-ready
Documentation requirements
Each concurrently billed program requires independent, separately documented evidence.
Compatible combinations
Valid stacking
Never bill together