Reach the patient
Support the timely discharge-contact workflow.
Transitional Care Management · TCMA supported return home. Less chasing for your team.
MySeema helps your team reach patients after discharge, coordinate follow-up and keep the next steps moving. You provide the clinical visit and decisions; we carry the agreed coordination around them.
Patients get personal follow-through
A coordination team you don’t have to recruit
Revenue potential from eligible services
More support, without a new coordination department
We take the follow-through off your team’s list.
Coordinate the follow-up
Help with appointments and records, and route medication questions to your clinicians.
Close the handoff
Document the completed work and route unresolved concerns.
MySeema carries the coordination.Your clinicians retain clinical decisions, oversight and the required clinical services. Your organization bills eligible services.
See a patient’s path through the service
- A patient returns home with several next steps.
- MySeema helps coordinate the follow-up visit and requested records.
- The treating team receives a clear handoff during the transition.
Illustrative workflow, not an actual patient record or an outcome claim.
Anwar KaziCEO, IntraCare
ACO partnership experience · IntraCare
“Partnering with MySeema allows us to expand critical programs like remote monitoring and care navigation in a way that supports both patient health and our broader population health strategy.”
From MySeema’s broader care-management partnership.
Read about the partnership →TCM codes, at a glance.
30-day transition
Moderate complexity
- 99495
- Clinical visit within 14 days
At least moderate-complexity medical decision-making during the service period.
Estimate this base service →30-day transition
High complexity
- 99496
- Clinical visit within 7 days
High-complexity medical decision-making during the service period.
Estimate this base service →One qualifying transition uses one TCM code. Required contact is within two business days of discharge. Medication reconciliation, visit timing, medical decision-making and other requirements must be met.
See the revenue opportunity.
Choose a service and patient count. Adjust the assumptions if needed.
Requirements for the selected estimate
Codes modeled: None selected
One-off services and add-on codes are excluded unless they appear in the selected scenario.
The details, when you need them.
Which patients fit TCM?
- A patient is returning to a community setting after discharge from a qualifying inpatient or partial-hospital setting.
- The patient needs moderate- or high-complexity medical decision-making during the transition period.
- Medication reconciliation, follow-up appointments, referrals, education, or community support require coordinated action.
What must be in place before launch?
- Reliable, timely discharge notification and transfer of discharge information
- Named billing practitioner and clinical owner for the 30-day period
- Workflow for timely contact, visit scheduling, and medication reconciliation
- Documented roles for non-face-to-face coordination and clinical escalation
- Contingency plan for unsuccessful contact and non-qualifying discharges
Conditional on timely discharge information and clinical follow-up
Billing details, patient costs and service boundaries
- One claim by one practitioner per patient for the 30-day transition episode.
- Contact patient/caregiver within two business days; CMS permits documented timely unsuccessful attempts if remaining requirements are met.
- 99495 requires moderate-or-higher medical decision making and a visit within 14 calendar days; 99496 requires high complexity and a visit within 7 days.
- Reconcile/manage medication no later than the required visit; that visit is included in the episode payment.
- Do not bill both episode codes; avoid overlapping episodes and same-practitioner postoperative global periods.
Patient cost sharing and protections depend on coverage and the service. Explain them before consent. Do not use this illustration to charge a Qualified Medicare Beneficiary protected amounts. RHC/FQHC payment rules and Medicare Advantage contracts differ from the national PFS benchmark.
Sources and review notes
Reviewed October 6, 2026. Estimates use the October 2026 CMS rate release.
Put a care team around your patients.
We’ll show you the coordination MySeema can take on, how it fits your practice and what the financial model could look like.