Two programs, two jobs
Advanced Primary Care Management (APCM) is a monthly bundle for ongoing primary care. Transitional Care Management (TCM) is a 30-day episode that starts when a patient is discharged from an inpatient or certain facility settings to the community. Most APCM practices will see both: steady monthly management, broken up by discharges.
| Question | APCM | TCM |
|---|---|---|
| Codes | G0556, G0557, G0558 | 99495, 99496 |
| Period | Calendar month, ongoing | 30 days beginning on the discharge date |
| Trigger | Consent and, when applicable, an initiating visit | A qualifying discharge to the community setting |
| Face-to-face visit | Not required each month | Required within 7 or 14 days, depending on the code |
| Level driver | Chronic-condition count and QMB status | Medical decision-making complexity and visit timing |
What TCM requires
Interactive contact
Contact with the patient or caregiver, by phone, electronically, or in person, within two business days of discharge. Document the attempts.
Face-to-face visit
99496 requires high-complexity medical decision-making and a visit within 7 days. 99495 requires at least moderate complexity and a visit within 14 days.
Non-face-to-face services
Reviewing discharge information, following up on pending tests, medication reconciliation, referrals, and patient and caregiver education.
One biller per episode
Only one practitioner may report TCM for a patient during the 30-day period. Confirm current CMS and payer rules before billing.
The overlap month
CMS identifies several care-management services as duplicative of APCM when the same practitioner reports them for the same patient in the same period, and TCM is among the services practices need to check. Do not add the APCM and TCM headline rates together for a discharge month. Pick the pathway deliberately and document why.
- Check the current CMS list of services that cannot be billed alongside APCM
- Compare the APCM month you would give up with the TCM episode you would bill
- Confirm the face-to-face visit can happen inside the TCM window
- Record the decision, the reviewer, and the supporting evidence for the month
Our APCM codes and reimbursement guide covers the rest of the billing stack, and the revenue calculator nets the overlap out of its estimate instead of double counting.
A discharge workflow for APCM practices
- Catch the discharge. Watch ADT feeds, hospital portals, or payer notifications so the two-business-day clock does not start without you.
- Make contact. Reach the patient or caregiver, triage new symptoms, and schedule the follow-up visit.
- Reconcile. Review discharge records, reconcile medications, and update the care plan.
- Choose the pathway. A qualified reviewer decides between TCM and APCM for the period, based on current rules and what was furnished.