Transitional Care Management Documentation Template

A documentation form for Transitional Care Management (TCM) that captures the required interactive contact, face-to-face visit timing, and billing support details for CPT 99495 and 99496.

Patient and Discharge Details

• Patient Identifier
  Enter the internal medical record number or other approved patient identifier. Do not enter SSN.
• Date of Discharge
  Select the date the patient was discharged from the qualifying facility.
• Discharge Setting
• Other Discharge Setting

Interactive Contact Within 2 Business Days

• Was interactive contact completed?
• Date of Interactive Contact
• Interactive Contact Method
• Completed within 2 business days of discharge?

Face-to-Face Visit Timing

• Was the face-to-face visit completed?
• Date of Face-to-Face Visit
• TCM Billing Code
  Select the code being supported by this documentation.
• Visit occurred within the required window?

Clinical Follow-Up and Documentation

• Medication reconciliation completed?
• Care plan updated?
• Follow-up Notes
  Document any relevant follow-up actions, barriers, or exceptions. Avoid unnecessary PII.
• Documentation complete and ready for billing review?
  Confirm that the record is complete and supports the selected TCM code.

Attestation

• Attestation
  I attest that this documentation accurately reflects the transitional care management services provided and supports the selected billing code.
• Documented By
  Enter the name or approved identifier of the staff member completing this form.
• Documentation Date