Every health care provider knows how critical the first 30 days are after a patient has been discharged from in-patient care in a hospital or other medical facility. This is especially so if the patient suffered from a complex medical issue. Unless the patient has been provided with proper transition and high quality of care during this crucial time, there is a high probability of the patient getting readmitted. 

Transitional Care Management (TCM) plays a big role in the full recovery of patients, whether they suffered from complications due to hypertension, diabetes, or others. But what really is TCM? Medistics Health provides you with the basic information on this important topic:

Transitional Care Management Defined

The Centers for Medicare and Medicaid Services or CMS initiated the Transitional Care management or TCM that aims to provide patients with the proper transition of care for the crucial 30 days after getting discharged from inpatient facilities, whether that’s an acute care hospital, a nursing home, a long-term care facility, a psychiatric facility, or a rehabilitation center. 

It is created so medical practitioners, including specialists and primary care physicians, nurses, nurse-midwives, and other authorized non-physician practitioners can provide the necessary care to patients needing them after confinement. This can significantly lessen the instances of readmission during this critical period by as much as 86%.

How TCM Works 

The TCM service starts on the day the patient is discharged and continues for 30 days. During this period these three components or services should be provided:

  • Interactive contact must be made in the next two days following the discharge of the patient. The contact may be made in-person or via phone and/or email. It may be done by the practice’s staff.
  • Non-face-to-face services should be given by clinical staff members unless it’s determined that it is not medically necessary. The billing provider may provide instructions to their clinical staff to educate patients about self-management or to help them access health resources.
  • A face-to-face visit may also be performed as directed by the CPT code. For CPT code 99495, a face-to-face visit must be performed within 2 weeks of discharge for patients with moderate medical complexity. For CPT code 99496, the visit should be done within a week of discharge for patients with high medical complexity.

Why You Should Provide TCM to Patients

As mentioned above, the main reason is to reduce readmissions which are preventable that may be caused by improper care or medical errors during the first month following a patient’s discharge.

While TCM mainly focuses on the quality of care given to patients it also offers benefits to providers as it reduces the rate of readmissions and improves patient outcomes. Also, CMS penalizes hospitals with excessive readmission rates. Reducing readmissions means reduced costs for the provider, the patients, and Medicare. Also, as lower readmission rates are an indicator of the quality of services given, providing TCM can greatly help the practice, too. 


Combining the benefits for the patients and your practice, it’s easy to make a decision to implement TCM. The focus is on providing optimal care for your patients but the provider reimbursement, as well as the reduced healthcare costs, are a nice bonus. What can make the implementation of this program easier is software that is specifically designed for managing it and devices that allow you to monitor your patient’s test results at home. 

Medistics Health can provide you with a remote patient monitoring system that can help you track your patients’ blood pressure, glucose, weight, and more. Contact us today to find out how our devices can help you with TCM!

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