What Is TCM and Why It Matters for CKD

TCM is a Medicare service designed to ensure continuity of care immediately after discharge from a hospital, skilled nursing facility, or observation stay.

It involves two 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

To bill TCM, providers must:

• Make interactive patient/caregiver contact within 2 business days of discharge

• Conduct medication reconciliation

• Provide ongoing non-face-to-face services, such as coordinating labs, referrals, and patient education

For CKD patients, these requirements align directly with the need to monitor labs, manage fluid balance, and adjust therapies after hospitalization.

Benefits of TCM in CKD Care

• Medication Safety: Ensures patients take renal-adjusted doses correctly and avoid harmful drug interactions.

• Lab Coordination: Supports timely ordering and review of labs such as creatinine, electrolytes, and eGFR.

• Reduced Readmissions: Early detection of worsening kidney function prevents avoidable hospitalization.

• Specialist Alignment: Connects nephrology, cardiology, and primary care for a cohesive plan.

• Patient Confidence: Provides reassurance and guidance during a high-risk period.

Which Patients Benefit Most

TCM is especially impactful for:

• Patients recently discharged after AKI (acute kidney injury) or CKD exacerbation

• CKD patients with comorbidities like heart failure, diabetes, or hypertension

• Seniors with polypharmacy who are at risk of medication errors

• Patients awaiting or newly initiated on dialysis

• Those with limited literacy, transportation, or support systems

What a 30-Day TCM Cycle Looks Like

1. Day 0 – Discharge: CKD patient discharged after hospitalization for fluid overload.

2. Day 1–2 – Initial Contact: Care coordinator calls within 48 hours to review discharge instructions and medications.

3. Day 3–14 – Face-to-Face Visit: Provider sees patient in clinic or at home; high-risk patients within 7 days.

4. Days 1–30 – Ongoing Support: Staff coordinate labs, adjust meds, and ensure nephrology follow-up.

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

TCM in Action: A Case Example

Mr. D, a 69-year-old with stage 4 CKD and diabetes, was discharged after hospitalization for acute kidney injury. Within 48 hours, a nurse coordinator contacted him to review medications and confirm lab orders. A clinic visit took place on day 6, during which his provider adjusted his diuretics and arranged nephrology follow-up. Over the next month, the team monitored his labs and prevented another admission.

Implementation Tips

• Build a discharge tracking workflow to capture CKD patients at hospital release.

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

• Train staff on CKD-specific red flags (e.g., swelling, weight gain, electrolyte imbalance).

• Ensure lab orders are in place before the face-to-face visit.

• Pair TCM with CCM or RPM for sustained monitoring beyond 30 days.

Key Takeaway

For CKD patients, the 30 days after discharge are a fragile time. TCM ensures structured outreach, timely follow-up, and coordinated care—reducing readmissions and improving outcomes. Practices that use TCM effectively can better support patients with kidney disease while also capturing Medicare reimbursement.