What Is Transitional Care Management & How It Works?

By Sudeep Bath | May 27, 2024

When a patient is admitted in the hospital to treat or manage a condition, he/she has an easy access to the medications and licensed healthcare providers. Once the condition (or conditions) is under control, the patient may be discharged from the hospital, either to their home or to an assisted living facility.

Unfortunately, the interval between discharge from the hospital and the resumption of routine care in the patient’s community setting can be challenging for both the patient and their caregivers. This is where transitional care management (TCM) comes in.

Table of Contents

Introduction to Transitional Care Management

The Centers for Medicare and Medicaid Services (CMS) introduced transitional care management (TCM) services in 2013 with the goal of improving care coordination, reducing hospital readmissions, and lowering healthcare expenditures. These services include communication with patients, in-person visits, and medication reconciliation.

Adoption and development of TCM services could help bridge the gap to a value-based care paradigm, boosting patient outcomes, and reducing overall healthcare costs.

What Is the Purpose of Transitional Care Management?

No matter, which chronic illness a patient is suffering from, any interruption in care when the patient is transitioning from inpatient to in-home care raises the risk of recurrence and readmission. Transitional care management ensures that care continues during the transition time and significantly minimizes the chance of readmission by taking responsibility for the patient’s health and promotes a healthy transition.

Transitional care management is intended to last 30 days, beginning on the date the beneficiary is discharged from the hospital and continuing for the following 29 days. These services can be provided by qualified healthcare professionals, including physicians, non-physician practitioners (NPPs) like certified nurse midwives (CNMs), clinical nurse specialists (CNSs), nurse practitioners (NPs), and physician assistants.

How TCM Works For Patients & Providers?

During the transition from an inpatient hospital to the patient’s community environment, TCM treatment falls into three categories:

Interactive contact
Out-patient services
In-person visits

Interactive contact can be established via email, phone, or in person, with the first contact occurring within two business days of the patient’s discharge from the hospital. This initial contact is designed to discuss the patient’s status and transitional needs, and it may be conducted by the TCM provider or clinical staff.

If the physician or other competent professional is not directly involved in the first discussion, the interaction must be documented and communicated with the provider so that the patient’s status and any medical concerns can be addressed.

During the 30-day TCM period, the following non-face-to-face activities are provided:

Collecting and reviewing discharge information, including continuity of care records or a discharge summary.
Connecting and communicating with healthcare providers to maintain continuity of care.
Identify a patient’s primary needs to ensure appropriate health care services are provided.
Assess the need for additional treatments, diagnostic testing, or follow-up on previous appointments’ results.
Assistance in organizing necessary visits with healthcare providers. Patients who attend appointments upon release and receive proper care are less likely to be readmitted.
Providing instruction and assistance for treatment regimen adherence. This may be beneficial to the patient, their family, guardian, and/or caregiver.
Offering education on self-management, everyday tasks, and independent living in relation to the patient’s illness may also be offered.
Medication management and prescription assistance.

Components Of Transitional Care Management

Transitional care management focuses on effectively managing care transitions and aims to ensure that patients’ experience continuity of care, receive appropriate follow-up, and avoid complications or unnecessary hospital readmissions. The critical components of TCM include:

Care Coordination: Effective TCM requires a well-coordinated healthcare team that includes physicians, nurses, case managers, pharmacists, and other medical professionals who collaborate to enable a smooth transition between care settings and facilitate communication.
Medication Management: Taking the right medications and on time is crucial during care transition. TCM emphasizes the significance of medication reconciliation, patient education, and follow-up monitoring to improve drug management and reduce the risk of problems.
Comprehensive Assessment: A complete evaluation of the patient’s medical, functional, and psychological needs is required for successful TCM. This assists in identifying potential barriers to a seamless transition and creation of a personalized care plan.
Patient Education: TCM emphasizes providing patients and their caregivers with the knowledge they need to effectively manage their health. Patients can actively participate in their care and prevent adverse events by receiving education on drug adherence, self-care strategies, warning signals, and access to appropriate services.

How Often Can Transitional Care Management Be Billed?

TCM services are documented using two TCM CPT codes, i.e. 99495, and 99496. The key difference between these codes is the level of medical decision-making complexity and the duration of the post-discharge visit.

Code 99495 is for patients who require moderate complexity decision-making and have appointments planned within 14 calendar days after discharge.

Code 99496 is for patients who require high-complexity decision-making and must be visited within seven calendar days of discharge. The visit must be with a physician or an NPP, but it can be conducted via an audio and video medium.

TCM Billing Guidelines

In general, the TCM must meet three specific requirements during the 30-day period: direct contact with the patient within two business days of discharge, a face-to-face visit within seven or 14 days of discharge (depending on the codes), and medical decision-making of moderate to high complexity.

Only one clinician may bill for TCM services within the 30-day period following each patient’s release; additional time spent on TCM treatments may be invoiced for discharge as long as they do not overlap with the 30-day period.

Because transitional care management is a temporary arrangement, billing should include just one, non-recurring fee. After 30 days of release, the healthcare provider must submit the bill.

Reduce Readmissions & Maximize Reimbursements With HealthArc

HealthArc is a pioneer in remote monitoring systems and bridges the patient-provider communication gap with a unified digital health platform. Our transitional care management platform is designed to provide the right care and convenience to patients transitioning from hospital to in-home settings. From billing TCM CPT Codes to reducing rehospitalizations, rely on HealthArc to boost your clinical revenue and reimbursements.

Frequently Asked Questions (FAQs)

1. What is Transitional Care Management (TCM)?

Transitional Care Management (TCM) is a set of services provided to patients transitioning from a hospital or facility back to their community setting, such as home or assisted living. It ensures proper follow-up, medication review, and communication between healthcare providers to prevent readmissions and complications within 30 days of discharge.

2. Why is TCM important for patients, providers, and payers?

TCM reduces avoidable hospital readmissions, improves care continuity, and enhances patient satisfaction. For providers, it increases engagement and reimbursement opportunities under CMS guidelines. For payers, it supports cost-effective care by preventing post-discharge complications and improving patient outcomes.

3. Who is eligible to receive TCM services?

TCM services apply to patients discharged from inpatient hospitals, skilled nursing facilities, or rehabilitation centers who are returning to community settings. The patient must require medical decision-making of at least moderate complexity and receive a follow-up visit within 7 or 14 days, depending on condition severity.

4. What settings qualify for TCM after discharge?

Qualifying settings include acute care hospitals, psychiatric hospitals, long-term care facilities, rehabilitation centers, and partial hospitalization programs. TCM begins the day the patient transitions back to the community, whether to their home, group home, or assisted living environment.

5. What are the key components of TCM?

Interactive contact with the patient or caregiver within two business days of discharge
Non-face-to-face services, such as medication reconciliation and follow-up coordination
Face-to-face visit within 7 or 14 days, depending on medical complexity

6. What is the 30-day TCM service period, and when does it begin?

The 30-day service period begins on the patient’s discharge date and includes the following 29 days. During this time, providers must perform follow-up activities, monitor progress, and document all care coordination actions to meet CMS requirements.

7. What are the CPT billing codes for TCM?

CPT 99495: Moderate complexity, face-to-face visit within 14 days
CPT 99496: High complexity, face-to-face visit within 7 days

Proper documentation of medical decision-making, patient contact, and service timelines is required.

8. How does the complexity of medical decision-making affect TCM coding?

Complexity determines which CPT code to bill. Moderate complexity (99495) covers most post-discharge cases, while high complexity (99496) applies when patients have multiple comorbidities or high readmission risk requiring closer supervision and faster follow-up.

9. Who can provide and bill TCM services?

Physicians, nurse practitioners, physician assistants, clinical nurse specialists, and certified nurse midwives can deliver and bill for TCM, provided state laws permit and documentation meets CMS standards.

10. What documentation is required for TCM billing and compliance?

Documentation must include the date of discharge, patient/caregiver contact date, face-to-face visit date, medication reconciliation, care coordination details, and evidence of moderate- or high-complexity decision-making.

11. Can TCM services be combined with other care management programs?

Yes, TCM can complement Chronic Care Management (CCM) or Remote Patient Monitoring (RPM), but overlapping timeframes cannot be billed simultaneously for the same patient. Practices often sequence services—TCM for 30 days post-discharge, then CCM for long-term management.

12. Does TCM apply only to Medicare patients?

No. While TCM originated as a Medicare program, several private insurers and state Medicaid programs now reimburse for similar post-discharge care management services, expanding access beyond the Medicare population.

13. What are common challenges in implementing a TCM program?

Typical challenges include missed follow-up calls, lack of discharge information, poor communication across settings, and inadequate documentation. Using digital platforms like HealthArc’s TCM software streamlines workflows, automates reminders, and ensures compliance.

14. How does TCM reduce hospital readmissions?

TCM minimizes readmissions by promoting early follow-up, medication reconciliation, and care coordination. Studies show structured TCM interventions can cut 30-day readmission rates by up to 20%, especially for heart failure, COPD, and diabetes patients.

15. What constitutes the face-to-face visit, and what are the timelines?

The visit must happen in person or over the phone within 7 days (high complexity) or 14 days (moderate complexity) of discharge. It involves physical assessment, medication review, and planning for ongoing care.

16. How soon must the patient be contacted after discharge?

A patient or caregiver must be contacted within two business days after discharge by phone, electronic message, or direct communication. Timely outreach is essential for TCM eligibility and patient safety.

17. What non-face-to-face services are included under TCM?

Medication reconciliation
Appointment scheduling
Patient education
Community service coordination
Lab and diagnostic review
Communication with specialists or home care teams

18. What happens if a patient is readmitted during the TCM period?

If a patient is readmitted within 30 days, the TCM episode ends, and a new episode may begin upon the next qualifying discharge. Providers should document the event and update billing accordingly.

19. Are telehealth visits allowed for TCM?

Yes. CMS permits telehealth for the required face-to-face visit if state laws allow and the technology meets HIPAA compliance. Tele-TCM has been particularly beneficial in rural and post-pandemic care delivery.

20. How can practices identify eligible patients and implement TCM effectively?

Best practices include integrating hospital discharge alerts, automating patient contact reminders, using care coordination software, and training staff on documentation rules. Digital solutions like HealthArc’s TCM module streamline workflows and improve outcomes.

Book a free demo or call us today at +201 885 5571 to set up a consultation with our experts.

Tags: #tcm, #transitionalcaremanagement