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What Is Transitional Care Management (TCM) & How Does It Compare to CCM & APCM?

To support patient health today, healthcare providers must think beyond the traditional exam room visit. As patient needs become more complex and chronic conditions more prevalent, delivering continuous, coordinated care has never been more critical. One of the biggest challenges healthcare practices face is ensuring consistent follow-up after a patient is discharged from the hospital, a critical period where gaps in care can lead to complications and hospital readmissions.

That’s where Transitional Care Management (TCM) proves beneficial. Designed to support patients as they move from inpatient to outpatient care, TCM helps bridge the gap between hospital and home, providing essential follow-up care that reduces readmission rates and improves long-term health outcomes. By coordinating care, facilitating communication between healthcare providers, and ensuring patients receive timely follow-up visits, TCM offers a structured approach to managing post-discharge recovery.

From 2013 to 2025, Transitional Care Management was the only care management program tailored to the high-risk period immediately after discharge. Other value-based care programs, like Chronic Care Management (CCM) and Principal Care Management, focused primarily on ongoing, preventative care, and were therefore often paired with TCM. Advanced Primary Care Management (APCM), introduced in 2025, is the first program to combine ongoing, preventative care with discharge management services and support after leaving the hospital.

Understanding how TCM or APCM fits into your care strategy can help your practice deliver more comprehensive, patient-centered care while maximizing reimbursement.

In this article, we’ll explore the unique features of TCM, its role in reducing hospital readmissions, and how those features compare to the newly introduced discharge management features of APCM. You’ll gain insights into when and how to implement TCM or APCM effectively to optimize patient outcomes and streamline your practice workflows.

What is Transitional Care Management?

Transitional Care Management (TCM) is a Medicare-reimbursed service designed to support patients transitioning from an acute care setting, such as a hospital, to a community healthcare setting, like their home. TCM aims to prevent readmission in the 30 days following discharge. During this critical period, patients are particularly vulnerable to readmission due to post-treatment complications, medication-related issues, or gaps in care. 

More specifically, transitional care supports better patient outcomes following discharge via the following key mechanisms:

• Patient contact, via phone, face-to-face conversation, or electronic communication, within two days of discharge 
• Face-to-face visit with a provider within 7 days for high complexity patients and within 14 days for moderate complexity patients 
• Medication reconciliation and management services 
• Care coordination services with specialists 
• Patient and caregiver education and self-management support 
• Connection to community resources 

TCM is typically billed using one of two CPT codes, either 99495 for moderate complexity or 99496 for high complexity. 

How TCM compares to other care management programs

TCM vs. CCM

While TCM and CCM both involve care management, they have different aims and methods for achieving their respective goals. The scope of transitional care extends only to the moment of discharge and the 30 days after it and includes support, such as connection to community resources and patient education, to prevent hospital readmissions. 

Chronic Care Management, by contrast, is an ongoing model of care designed around Medicare beneficiaries with two or more qualifying conditions. It aims to improve quality of life, reduce adverse outcomes, support patient self-management, and coordinate care across care providers and settings. CCM includes personalized care plans, medication management, 24/7 access to healthcare support, constant provider and patient access to health information via an electronic health record (EHR), as well as monthly patient touchpoints, and self-management support.

Key differences

To understand the distinct role of TCM and CCM in supporting better health outcomes, you must first see how they differ. 

• Billing cadence: TCM can be billed once during the 30 days following discharge. CCM is ongoing and can be billed monthly as long as the patient qualifies and the 20-minute monthly care coordination service requirement is met. 
• Service duration: The billing differences between the TCM and CCM highlight a key distinction in the length of each. Whereas TCM is a short-term intervention, CCM is ongoing. 
• Reimbursement structure: For TCM, reimbursement is tied to transitional care services and depends on whether the patient qualifies as moderate or high complexity. Chronic Care Management is billed according to the length of the care encounter.
• Patient population: TCM and CCM target different patient populations. Transitional care focuses on patients who have been discharged from an acute care center or other qualifying healthcare facility. CCM is designed to support patients with two or more chronic conditions. 
• Primary goal: TCM is focused squarely on supporting patients during the critical 30 days post-discharge to prevent readmission. While minimizing acute care incidents is within the scope of CCM, the program’s core aim is to improve overall health for patients with two or more chronic illnesses. 

Because TCM and CCM have different focuses, it is acceptable to have patients participate in TCM, as needed, while they are enrolled in a CCM program. 

TCM vs. APCM

TCM and APCM have an overlapping goal to support Medicare beneficiaries as they transition from one care setting to another. Both programs aim to prevent readmissions with post-discharge follow-up and ongoing support for 30 days. Patient education and provider involvement are key characteristics of both TCM and APCM, and each program also has protocols in place to escalate urgent issues to the appropriate care team as needed. 

While both TCM and APCM offer discharge management, TCM is more narrowly focused on care transitions, while APCM includes such support as one part of a broader goal to improve patient health. 

TCM is a standalone service specifically focused on managing transitions in care from an acute care setting to a community setting to prevent readmissions and improve outcomes. 

APCM offers a more comprehensive care strategy framework. It positions providers who serve as the focal point of patient care to support better quality, coordinate care across providers, and promote patient engagement. Discharge management from any care setting is a required APCM element. 

Key differences

Although there are several similarities between TCM and APCM, they differ in several key ways.

• Billing frequency: Primary care providers can bill TCM codes 99495 (moderate complexity) or 99496 (high complexity) once per patient per month, if the patient has not been readmitted to the hospital. APCM G-codes can be billed every month, even if discharge management services were not needed that month. 
• Reimbursement rates: On average, one-time reimbursement is $201 for TCM code 99495 (moderate complexity) and $273 for 99496 (high complexity). Annual reimbursement for APCM averages $180 for Level One patients, $600 for Level Two patients, and $1,1320 for Level 3 patients. 
• Post-discharge follow-up: Both TCM and APCM call for initial patient contact within 48 hours of discharge; however, each program follows unique follow-up protocols. TCM requires an in-person visit within seven days of discharge for high complexity patients or within 14 days for moderate complexity patients. For APCM, patient follow-up must occur within 7 days of discharge from any healthcare facility, but can include direct contact, phone, or electronic communication. Care managers encourage in-person appointments after a discharge, but they are not an APCM billing requirement. 
• Risk stratification: TCM distinguishes patients as either moderate or high complexity. APCM applies to any Medicare beneficiary, but it stratifies patients into three risk levels. Level One patients are those with one or fewer chronic conditions. Level Two patients must have two or more chronic conditions. Level Three patients must have two or more chronic conditions and be Qualified Medicare Beneficiaries (QMB).  
• Redundancy: Both TCM and APCM provide transitional care support. Because the programs overlap, you can’t bill both TCM and APCM for the same patient in the same month. 

Because you cannot bill for APCM and TCM for the same patient in the same month, providers must choose between the two programs.

If you already have a Chronic Care Management or Principal Care Management program and have no intention of changing to Advanced Primary Care Management, it makes the most sense to bill TCM. While this program has demanding requirements, it ensures patients have a source of discharge support.

However, if you’re a primary care provider and the central point of care for your patients, you could offer a more unified, comprehensive program by offering Advanced Primary Care Management. APCM allows you to integrate discharge support with ongoing preventative care, and is available to all Medicare patients. 

Billing for TCM and APCM 

Billing workflow and requirements are different for TCM versus APCM. The table below illustrates the key distinctions in how each is billed. 

Billing Requirement	Transitional Care Management (TCM)	Advanced Primary Care Management (APCM)
Frequency	Episodic; billed once per hospital discharge	Monthly billing, even if no discharge management in that month
Patient follow-up	In-person visit required within 7 days for moderate complexity patients or 14 days for high complexity patients	Follow-up within 7 days via any communication method (text, phone, digital)
Timing	Billing must occur within 30 days of discharge	Bills align with calendar month
Reimbursement structure	Category-dependent; rates hinge on whether a patient qualifies as moderate or high complexity based on the medical decision-making required in their follow-up visit	Risk-based; reimbursement linked to patient risk level (Level One, Two, Three)

Because you cannot bill for APCM and TCM, it’s important to understand the differences in services between the two. If you’re a primary care provider offering APCM, you can simply bill APCM for every enrolled patient, every month, whether or not they require discharge management that month. 

However, if you’re continuing to use CCM as your preventative care program, you must carefully track when to bill TCM. TCM can only be billed for the first 30 days after a hospital discharge, if there is no readmission. TCM and CCM cannot be provided at the same time. To bill for CCM in the same month as TCM, all 20 minutes of care for CCM must occur after TCM is completed. 

Do you need TCM, CCM, or APCM programs?

Determining whether you should offer TCM, CCM, or APCM all depends on your patient population, existing billing structure, and what goals you want to target. Implementing TCM and CCM together or APCM alone affords the greatest scope of services for the broadest patient population. Here are a few important things to consider when navigating your options: 

• Existing transitional care services: If your practice is already offering APCM, adding TCM services would be redundant, since the entire scope of TCM is included within APCM. Billing TCM and APCM in the same month for the same patient is not an option. 
• Patient population: Practices with a large population of patients suffering from chronic illness are best served by the framework and structure of CCM, which is specifically designed for those with more than two chronic conditions. APCM, however, includes a broader patient population and more services. Offering APCM and CCM to different patients at the same practice is allowed, though it can be more complex. 
• Practice care model: TCM and CCM are well-suited to practices operating in a fee-for-service model. APCM’s emphasis on quality might be a better cultural fit for practices trying to realign their services with value-based care metrics while still receiving FFS payments. Although CCM can be part of value-based care, APCM moves further in that direction. 
• Reimbursement projections: Analyzing your patient population and projecting annualized rates of reimbursement for each program can offer some clarity when it comes to choosing a course of action. TCM and CCM sometimes reimburse more for patients who require frequent support after leaving the hospital, but APCM often reimburses more overall, depending on the risk level of the patients you serve. 
• Intended outcome: For the discharge management element of TCM and APCM, the goal is ultimately to reduce patients’ risk of readmission and promote preventive care. Each accomplishes this goal in a unique way and with other auxiliary services and goals. Carefully consider how you want to improve your service to determine which program or programs make sense for your practice. 

Recognize that whether you choose TCM and CCM or APCM, patient consent is a requirement of any of these programs, including moving a patient from one program to another. ChartSpan, for example, has a dedicated care manager who handles the process of switching patients from one program to another whenever applicable. 

How TCM, CCM, or APCM support patients

TCM, CCM, and APCM each have a distinct role in supporting whole-patient health. Though the programs share overlapping goals, each is geared toward a specific patient population and designed for a unique purpose. 

For patients leaving the hospital, TCM or APCM discharge management serves as a bridge to preventive care, closing gaps in care and preventing readmission. APCM also empowers more effective primary care by acting as a care coordination hub across providers. For patients requiring ongoing care , both CCM and APCM offer critical support between appointments that keeps patients on track toward their health goals and enables them to achieve better outcomes. 

By integrating these programs strategically, your practice can offer more comprehensive, patient-centered care. Although a single patient can only be enrolled in one care management program at a time, offering CCM with TCM as needed or offering a comprehensive APCM program helps you adapt to patients’ evolving healthcare needs. This approach improves whole-patient health and streamlines care coordination. 

Simplify care coordination with ChartSpan’s fully-managed solutions

Transitional Care Management is essential for supporting non-APCM patients immediately after discharge, but ongoing care often requires a more sustained approach. That’s where partnering with a fully-managed service provider like ChartSpan makes a difference.

ChartSpan offers comprehensive CCM and APCM solutions that seamlessly support your care management. By taking on tasks like staffing your 24/7 care line, crafting personalized care plans, sending medication reminders, and conducting monthly touchpoints, ChartSpan acts as an extension of your practice—helping to maintain continuity of care after the transitional care period ends.

Working with ChartSpan ensures that your patients receive consistent, high-quality follow-up, reducing the risk of readmission and promoting long-term health outcomes. Talk with an expert today to learn how our fully-managed CCM and APCM programs can support your discharge management strategy.

→ Learn more about ChartSpan’s Chronic Care Management Program 

→ Learn more about ChartSpan’s Advanced Primary Care Management Program

You might also like: 

• Chronic Care Management CPT Codes & Billing Guide
• Value-Based Care Programs – Which Ones Deliver Results?