Transitional care management: make the follow-up count

The work after discharge often happens between appointments: clarifying medications, reviewing hospital records, and helping a patient reach the next service. Transitional care management recognizes an organized period of care around that transition.

Understand the basic timing

CMS describes a 30-day TCM service period for eligible transitions from specified facilities to a community setting. Interactive contact with the patient or caregiver is generally required within two business days after discharge.

For CPT 99495, the required visit occurs within 14 calendar days with at least moderate medical decision making. For CPT 99496, it occurs within seven calendar days with high medical decision making. Medication reconciliation and management must occur by the visit date.

The service includes more than an appointment

TCM includes appropriate work outside the visit. CMS also limits reporting to one practitioner during the service period, and the required visit is not billed separately. These are selected requirements; the complete CMS booklet addresses eligible settings, unsuccessful contact attempts, and other billing conditions.

Build a dependable workflow

A practical team approach is to identify discharges promptly, assign the initial contact, and reserve follow-up capacity. Track the discharge date, contact attempts, completed visit, medication review, and clinical decision making in one place.

During the first conversation, ask about barriers to the plan as well as symptoms. A timely billing workflow is most valuable when it also identifies a patient who needs help before the scheduled visit.