What Is TCM and Why It Matters for CHF

TCM is a Medicare service designed to ensure safe, supported transitions from inpatient or skilled nursing back into the community. Reimbursed under CPT codes:

• 99495 – Moderate complexity decision making, with a face-to-face visit within 14 days of discharge

• 99496 – High complexity decision making, with a face-to-face visit within 7 days of discharge

Key requirements include:

• Interactive contact with patient/caregiver within 2 business days of discharge

• Medication reconciliation and review of discharge instructions

• Non-face-to-face support such as coordinating referrals, ordering labs, or educating patients

For CHF patients, this structure is essential to prevent fluid overload, medication errors, and avoidable rehospitalizations.

Benefits of TCM in CHF Care

• Reduced Readmissions: Provides oversight during the high-risk 30-day post-discharge period.

• Medication Optimization: Ensures diuretics, beta-blockers, ACE inhibitors, or ARNI therapies are reconciled and dosed correctly.

• Symptom Monitoring: Identifies weight gain, edema, or shortness of breath before they escalate.

• Integrated Care: Coordinates communication among hospitalists, cardiologists, and primary care providers.

• Patient & Caregiver Support: Reinforces education and builds confidence in self-management.

Which Patients Benefit Most

TCM for CHF is particularly valuable for:

• Patients discharged after acute decompensated heart failure

• Seniors with CHF and comorbidities such as diabetes or CKD

• Patients with frequent hospitalizations or ED visits for fluid overload

• Individuals with limited health literacy or social support

• Patients recently started on or adjusted to new heart failure medications

What a 30-Day TCM Cycle Looks Like

1. Day 0 – Discharge: Patient leaves hospital after CHF exacerbation.

2. Day 1–2 – Initial Contact: RN or care coordinator calls within 48 hours to confirm medications, symptoms, and follow-up.

3. Day 3–14 – Face-to-Face Visit: In-person visit with physician/NP (within 7 days for high-risk patients).

4. Days 1–30 – Ongoing Care Coordination: Regular follow-up on weight, symptoms, and adherence; communication with cardiology.

5. End of Period – Billing: Submit CPT 99495 or 99496 with documentation of contact, visit, and care management.

TCM in Action: A Case Example

Mrs. P, a 74-year-old with CHF and CKD, was discharged after her third hospitalization in four months. Within 48 hours, a nurse coordinator contacted her to review medications and daily weight monitoring. A face-to-face office visit occurred on day 6, during which her physician adjusted her diuretic regimen. Over the next four weeks, the care team tracked her symptoms, coordinated a nephrology referral, and prevented another hospitalization.

Implementation Tips

• Create hospital discharge alerts in your EMR to flag eligible CHF patients.

• Use a standardized outreach checklist for the 2-day contact.

• Train staff on CHF red flags (e.g., 2–3 lbs weight gain overnight, increased shortness of breath).

• Document thoroughly: date/time of initial contact, face-to-face visit, and care coordination.

• Pair TCM with CCM or RPM for long-term chronic care support.

Key Takeaway

For CHF patients, the first 30 days post-discharge are critical. TCM offers practices a structured, reimbursable way to close care gaps, support patients and caregivers, and reduce costly readmissions. When combined with CCM or RPM, TCM forms the foundation of a comprehensive heart failure management strategy.