Transitional care management and chronic care management are the two service lines primary care practices most consistently deliver without billing. Both pay well. Both have documentation requirements that fail silently – no claim is created, so no denial ever flags the loss.

TCM: 99495 and 99496

The requirements: interactive contact with the patient within two business days of discharge, a face-to-face visit within 14 days (99495, moderate complexity) or 7 days (99496, high complexity), and medication reconciliation by the visit date. Most practices already perform this sequence. The billing failure is operational – nobody tracks discharges against the calendar, so the visit gets billed as an ordinary E/M at a fraction of the TCM rate.

CCM: 99490 and 99439

Twenty minutes per calendar month of non-face-to-face clinical staff time for patients with two or more chronic conditions expected to last 12 months, under a documented care plan, with patient consent. The add-on 99439 covers each additional 20 minutes. The work – refills, coordination calls, care plan maintenance – already happens in every primary care office. The claim only exists if time is logged against the patient.

Building the Workflow

TCM needs a discharge feed – from the hospital, an HIE, or even payer admission-discharge-transfer notifications – reconciled daily against the schedule. CCM needs a time-tracking habit inside the EHR and a monthly claim run. Both are process builds measured in weeks, and both convert existing labor into revenue rather than adding work.

The Honest Test

TCM claims over the last twelve months versus known discharges. CCM enrollment versus the count of patients with two or more chronic conditions on the active panel. Practices are routinely delivering these services on five to ten times more patients than they bill.

Revenant Care runs billing operations for physician groups. Every report specification in this guide is available via our contact page – usable with or without us.