One of the most effective ways to improve patient health outcomes is with the help of a Transitional Care Management (TCM). Aside from improving the results, it can also reduce the cost of care and increase revenue. The problem is, getting started with TCM is a challenge, especially if you don’t have a clear workflow in place. Don’t worry; we will help you with that! 

To create an efficient TCM workflow, here are some of the things you need to consider: 

Have a TCM Patient Coordinator

Choose a dedicated person who has been trained to address TCM needs. The person could be a care manager, a registered nurse, or a licensed vocational nurse. 

Have a Designated Discharge Phone Number or Email Address

When a patient has been or is about to be discharged, an acute or post-acute facility partner must alert the facility through a phone number or email address. The message should be specific to how soon the patient needs to be seen. 

Now, when this has been alerted, the TCM patient coordinator will monitor the messages and access hospital notes and discharge summary for additional details. 

Have the TCM Coordinator Contact the Patient Within 48 Hours

Within 48 hours, have your TCM coordinator contact the patient, family, or caregiver to verify the patient was discharged. Also, have this done to ascertain the plan of care. You can use the EHR template for this. 

The CM coordinator should schedule a face-to-face appointment that will take place within 72 hours, one week, or two weeks, depending on the needs of the patient. 

Track and Follow Up with Your Patients Closely

Your facility or practice must receive daily emails from various payers and acute/post-acute facilities listing patients. 

Have Scheduling Options for TCM Patients

A nurse practitioner or physician assistant can do TCM visits. However, you need to have scheduling options for TCM patients who want to see their primary care physician. 

Coding Requirements

TCM ensures safe and proper handling of patients from one facility to another. CPT codes for TCM need face-to-face visits, medical reconciliation, and management during the 30-day service period. 

Code 99495 has these requirements: 

  • Communication with patient or caregiver within two business days following discharge
  • Medical decision making of at least moderate complexity within the service pipe
  • Face-to-face visit within two weeks of discharge

Code 99496 has these requirements: 

  • Communication with patient or caregiver within two business days of discharge
  • Medical decision making of high complexity within the service period
  • Face-to-face visit within a week following discharge


TCM will help ensure proper patient care, specifically when patients are taken from one facility to another place. When you improve your TCM, you need to improve plenty of things within your practice, such as the communication between the patient or caregivers, primary care practice, and acute/post-acute facility partners. To make your TCM effective, you need to have a detailed protocol that will guide your staff and physicians to identify the needs of your patients that need TCM. 

TCM is the way to go! Medistics Health helps with transitional care management through our remote patient monitoring system. Let us help you today!


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