Transitional Care Management (TCM) 

OnCare360
OnCare360

What is Transitional Care Management? 

Transitional Care Management (TCM) ensures continuity of care as patients transition from acute care settings (e.g., hospital) to their homes or other care settings. 

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?

  1. Physicians

  2. Nurse practitioners

  3. Physician assistants

Potential Benefits:

  1. Reduced readmissions. 

  2. Enhanced recovery and patient satisfaction.

  3. Improved medication adherence through timely reconciliation. 

OnCare360
OnCare360
OnCare360
OnCare360
OnCare360

How OnCare360 Can Help:

  1. Discharge tracking tools to monitor transitions and follow-ups.

  2. Automated reminders for scheduling post-discharge appointments.

  3. Medication reconciliation support through integrated workflows.

  4. Communication logs for documentation of interactions.

  5. Analytics and reporting dashboards to measure TCM program outcomes.

© 2025 OnCare360 Inc. All rights reserved.

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© 2025 OnCare360 Inc. All rights reserved.

Have questions?

Are you ready to explore the future of healthcare with OnCare360?

Contact us for more information or request a free consultation today.

© 2025 OnCare360 Inc. All rights reserved.

Have questions?

Are you ready to explore the future of healthcare with OnCare360?

Contact us for more information or request a free consultation today.

© 2025 OnCare360 Inc. All rights reserved.

Have questions?

Are you ready to explore the future of healthcare with OnCare360?

Contact us for more information or request a free consultation today.