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Transitional Care Management

ChronicCare serves hospitals by offering transitional care management (TCM) services to their discharged patients. We help high-risk patients stay out of the hospital, reduce likelihood for readmission, and coordinate patient transitional care services.


Our approach to transitional care management is meant to improve the patient's care post-acute discharge and ensure the patient is transitioned back into the ambulatory setting.


Approximately 1 in 5 Medicare beneficiaries in the US are readmitted in the hospital within 30 days of discharge.


An efficient TCM program is estimated to prevent up to 76% of the readmission rates and in-turn uplift patient outcomes.


Transitional Care Management

Transitional Care Management (TCM) usually focuses on the post-discharge period (30 days) when patients transition from a hospital or other healthcare facility to their home or another setting. It aims to support patients during this critical period to reduce the likelihood of readmissions and complications, and improve overall health outcomes.

Why choose Chronic Care's Transitional Care Management?

Our HIPAA-compliant cloud-based software application is designed specifically for managing patients in care transitions. It automates your entire care transition workflow - from enrolling the patient and creating the electronic care plan to reconciling medications, scheduling and documenting phone calls, and generating reports needed for billing purposes.


Key Features

Ease of Use

Allowing ease of use and incorporation into existing workflow

Interactive Contact

Initiating an interactive contact with the patient within the first two days of discharge

Discharge Summary

Reviewing the discharge summary and discharge instructions with the patient or caregiver

Easy Care Transfer

Coordinating care with other health care professionals who may assume or resume care 

Education Transfer

Providing seamless knowledge transfer to the patient or caregiver

Care Coordination

Determining any needs that exist by coordinating care with community organizations for the patient

Medication Reconciliation

Providing medication reconciliation to newly discharged patients

Follow-up Care

Scheduling and reminding the patient of required physician follow-ups or additional services

CPT Codes for Transitional Care Management

CPT Code 99495

It includes:

  • Communication within 2 days of discharge

  • At least moderate medical decision making

  • Face-to-face visit, within 14 calendar days of discharge

Reimbursement: $205.4

CPT Code 99496

It includes:

  • Communication within 2 days of discharge

  • At least complex medical decision making

  • Face-to-face visit within 7 calendar days of discharge

Reimbursement: $278.2

" - Payments vary with subject to specific locations - Please refer to

Frequently Asked Questions

+ Interactive Contact An interactive contact must be made (or attempted) within 2 business days following the patient's discharge to a community setting. Contact can be performed via telephone, email, or in-person communications, and can be performed by the practice's clinical staff.

+ Office Visit The physician responsible for the care transition operation must provide one face-to-face visit with the patient, within a timeframe based on the medical decision complexity determined for the discharge.

+ Provision of Non-Face-to-Face Services Several non-face-to-face services are to be performed by a combination of clinical staff members in support of the continuity of care operation.

+ Who Can Provide TCM Services? TCM services are furnished by a combination of healthcare professionals, including physicians (of any specialty), and other accredited clinical staff under the general supervision of a physician including: - Physicians (any specialty) - Physician Assistants - Nurse Practitioners - Certified Nurse Assistants - Clinical Nurse Specialists CNMs, CNSs, NPs, and PAs may furnish non-face-to-face TCM services "incident to" the services of a physician and other CNMs, CNSs, NPs, and PAs.

+ Services Performed by Physicians/NPs Retrieval and review of patient discharge summaries or other discharge information Interact with healthcare professionals and/or care team members who will take responsibility for supporting care of the patient's problems Provide education to necessary care team members Establish referrals and arrange for community resources (as needed) Support scheduling activities for required follow-ups with necessary providers/services

+ Services Performed by Non-Physicians / NPs Identify and communicate with necessary agencies, health resources and community services Educate necessary care team members in areas including self-management, independent living and ADL's Assess/Support treatment regimen adherence, including medication management Assist patients and/or non-clinical care team members in accessing care services

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