What Is TCM and Why It Matters for Obesity

TCM is a Medicare program designed to support patients as they transition from inpatient or skilled nursing facilities back into their communities. It includes:

• Interactive patient or caregiver contact within 2 business days of discharge

• Face-to-face visit within:

  • 14 days for moderate complexity (CPT 99495)

  • 7 days for high complexity (CPT 99496)

• Non-face-to-face coordination, including medication reconciliation, patient education, and arranging follow-ups

For obese patients with multiple chronic conditions, these requirements provide safety during a vulnerable time when complications and readmissions are most likely.

Benefits of TCM in Obesity Care

• Reduced Readmissions: Close follow-up after hospitalization for complications such as heart failure, diabetes crises, or infections.

• Medication Safety: Ensures proper use of antihypertensives, diabetes medications, or anticoagulants often prescribed in this population.

• Care Coordination: Aligns primary care, endocrinology, cardiology, nutrition, and behavioral health.

• Patient Confidence: Provides reassurance and ongoing contact, improving adherence to recovery plans.

• Support for Comorbidities: Addresses the interplay of obesity with hypertension, CKD, diabetes, and other chronic conditions.

Which Patients Benefit Most

TCM for obesity is especially valuable for:

• Patients hospitalized for obesity-related complications (e.g., uncontrolled diabetes, CHF, sleep apnea exacerbations)

• Seniors with multiple chronic conditions requiring complex care plans

• Individuals with polypharmacy, at risk of confusion with new prescriptions

• Patients recovering from bariatric surgery or procedures

• Those with limited health literacy or poor social support networks

What a 30-Day TCM Cycle Looks Like

1. Day 0 – Discharge: Patient discharged after hospitalization for obesity-related complication.

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

3. Day 3–14 – Face-to-Face Visit: In-office or home visit (within 7 days for high-risk patients).

4. Days 1–30 – Ongoing Support: Staff coordinate labs, arrange referrals to specialists, and monitor patient adherence to diet, medication, or physical therapy plans.

5. End of Period – Billing: Submit CPT 99495 or 99496 with documentation of outreach, face-to-face visit, and coordination.

TCM in Action: A Case Example

Ms. R, a 64-year-old with obesity, diabetes, and hypertension, was discharged after hospitalization for congestive heart failure. Within 48 hours, a nurse coordinator contacted her to review medications and confirm follow-up appointments. A clinic visit on day 6 allowed her physician to adjust diuretics and reinforce a low-sodium diet. Over the 30-day period, care coordinators tracked symptoms and helped schedule a nutrition consultation. Ms. R remained stable and avoided readmission.

Implementation Tips

• Use hospital discharge notifications to quickly identify obese patients eligible for TCM.

• Standardize an outreach script to confirm discharge instructions, medications, and warning signs.

• Ensure medication reconciliation is documented thoroughly.

• Train staff on obesity-related complications and red flags to monitor.

• Transition patients into CCM or RPM programs once the TCM period ends for continued support.

Key Takeaway

For patients with obesity, the 30 days after hospital discharge are a critical opportunity to prevent setbacks. TCM offers practices a reimbursable, structured pathway to ensure safe transitions, reduce readmissions, and support long-term health.