New regulatory action from CMS is proving that adopting value-based care models should be — and will be — easier in the future. The 2021 Final Physician Fee Schedule ruling stated that FQHCs and RHCs can now concurrently bill Transitional Care Management (TCM) and Chronic Care Management (CCM) in the same month. Specifically, CMS finalized the allowance of the new CCM HCPCS code G2058* — additional 20 minutes per calendar month of clinical staff time — to be billed concurrently with TCM when reasonable and necessary. This is a prime opportunity to engage the most high-risk patients and lead them into better health as the new year starts. Here’s how to combine the two services to maximize their transformative effects. 

*HCPCS Code G0511: Rural Health Clinic or Federally Qualified Health Center (RHC or FQHC) only, general care management, 20 minutes or more of clinical staff time for chronic care management services or behavioral health integration services directed by an rhc or fqhc practitioner (physician, np, pa, or cnm), per calendar month

What Does TCM Cover?

TCM is a care management service designed for patients who have been recently discharged from the hospital. The involved nature of the service aims to decrease the risk of readmission or complications by staying closely connected with the patient and providing them with ample resources. 


First in order to be reimbursed, a TCM program must have all three of the following elements: 

  1. Interaction with the patient within two days of discharge (that is, if able to reach the patient) 
  2. Patient assistance by way of non face-to-face services, which include reviews of tests and procedures, the procurement of educational materials, referrals to community services and assistance with scheduling appointments
  3. A face-to-face visit that occurs within 14 days (for patients faced with moderate medical decision making) or seven days (for patients facing highly complex medical decision making).¹


For moderate cases, clinicians would bill CPT code 49495¹

For severe cases, clinicians would bill CPT code 49496¹


What Does CCM Cover?

While TCM introduces value-based care in the short-term, CCM’s purpose is to integrate long-term, routine VBC. It is designed for patients with two or more chronic conditions. 


Have Patients With Only One Chronic Condition? See PCM


General criteria for a CCM program include: 


  1. A total of 20 minutes of care management service time per month
  2. The care must be furnished by a qualified healthcare professional
  3. The patient must have at least two chronic conditions, which are expected to last a year or more, or until the death of the patient and pose risk of functional decline
  4. A comprehensive care plan must be designed to address the unique needs of the patient, which must be continuously monitored and revised

For non-complex CCM services, physicians should bill CPT code 99490, which assumes 15 minutes of work by the billing practitioner.²


Merging the Two

Now that CCM and TCM can be billed concurrently, and you know the requirements of each, you can now begin to harness the power of both by combining them. You can do so in multiple ways. 


1. A clinician could use a TCM program to launch a CCM program for patients who have undergone a recent surgery. During the TCM face-to-face visit, the patient can be enrolled in CCM services as well, for care that follows the patient’s whole health journey and not just a part of it.

2. Make the transition: Finish the required TCM services related to the patient’s surgery, then keep the momentum going by developing a comprehensive care plan tailored to the patient’s needs/conditions. Form the basis of your care team here. 

3. Seek help if needed, managing complex patients can be time-consuming. Finding a partner can help reduce stress and allow your patients to receive all the attentive care that is required– and needed. A partner like Certintell can help your clinic with billing, time tracking, patient education and outreach, as well as patient eligibility checks.

Solve Physician Burnout with Remote Health Coaches


4. Fully integrate CCM into the patient’s care routine and set them up with the resources they need to be successful in the long-haul. This can include introducing team members such as a health coach who can work on behavior change. Adapt and modify care plans and inform team members accordingly. It’s important to remember that the patient is a team member here too and an active participant in their care, rather than just someone the care is being done unto. Seek their input and feedback about their treatment plans.

5. In the event another surgery arises for the patient, TCM can be billed again to get them back on track. If a strong CCM foundation is already backing the patient, it will be easier to fall back into the groove of delivering quality-assured care. 


Let’s Get Started: Certintell has specialized processes in place to support your community health organization’s TCM + Workflows. As a Virtual Medical Practice we can support your organization’s high-risk patients and strengthen your internal workflows as a partner focused on improving health outcomes for your patients.


Schedule a demo with us to see CCM and TCM in action



¹ Thalken, Mary Kay. “CCM and TCM Codes: Providers Leave More Than Money on the Table.” Health IT Answers, 6 Dec. 2019,

² “Chronic Care Management Services.” Center for Medicaid and Medicare Services, July 2019,


UPDATED: January 18, 2021