Transitional Care Management (TCM)
What is Transitional Care Management?
Eligibility Requirements:
• Patients discharged from an inpatient hospital, observation, or skilled nursing facility.
• The service must be initiated within 48 hours post-discharge.
Moderate complexity
CPT Code: 99495
Face- to-face visit within 14 days.
Once per discharge period
Communication logs, follow-up visit summaries, and medication reconciliation.
High complexity
CPT Code: 99495
Face- to-face visit within 7 days.
Once per discharge period
Record communication attempts, face-to- face visit details, and medication adjustments.
Who can provide the service?
Physicians
Nurse practitioners
Physician assistants
Potential Benefits:
Reduced readmissions.
Enhanced recovery and patient satisfaction.
Improved medication adherence through timely reconciliation.
How OnCare360 Can Help:
Discharge tracking tools to monitor transitions and follow-ups.
Automated reminders for scheduling post-discharge appointments.
Medication reconciliation support through integrated workflows.
Communication logs for documentation of interactions.
Analytics and reporting dashboards to measure TCM program outcomes.
