Skip to main content

«  View All Posts

Transitional Care Management

Transitional Care Management: 3 Benefits of Care Coordination Software

August 10th, 2021 | 5 min. read



Content Team

Print/Save as PDF

How do you realize the maximum potential of a Transitional Care Management (TCM) program? 

Medicare requires specific benchmarks to be met for your practice to seek reimbursement. 

If you miss any of them, you’re looking at a financial loss. Medicare may deny your claim. 

As we’ll cover below, these benchmarks are the exact means to deliver service to your patients. 

But how do you keep track of everything? How do you ensure efficiency and effectiveness? 

Utilizing care coordination software is one way.

At ThoroughCare, we’ve helped healthcare organizations derive the most value from care management and wellness programs.

In this article, we’ll cover the benefits of care coordination software to streamline the TCM process

With this information, you’ll have a better understanding of why such technology is crucial for TCM management. 

New call-to-action

What is Transitional Care Management (TCM)? 

Medicare created TCM to provide patients with continuous health services in the first 30 days after a hospital discharge

The goal is to ensure the patient avoids readmission

The patient’s discharge must be from one of the following settings:

  • Inpatient acute care hospital
  • Inpatient psychiatric hospital
  • Long-term care hospital
  • Nursing home
  • Inpatient rehabilitation center
  • Hospital outpatient observation/partial hospitalization

Primary care doctors and specialists, as well as non-qualifying medical practitioners, may offer TCM services. 

These services consist of three segments. 

They are interactive contact, non-face-to-face services, and office visit

All are mandatory within a specific timeframe, as required by Medicare to fulfill TCM. Unless they are determined to not be medically necessary.

Interactive Contact

This is simple, initial outreach to the patient or their caregiver. It is required to be performed within two business days following the patient’s hospital discharge

Contact may be made by telephone, email, or face-to-face.

It may be made by the provider or clinical staff. The conversation will touch upon the patient’s general well-being, as well as the next steps in the TCM process. 

Non-Face-to-Face Services

Non-Face-to-Face services may be performed by either the physician or clinical staff

Services vary depending on who is providing them. 

For the physician, services include: 

  • 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 team members
  • Establish referrals and arrange for community resources (as needed)
  • Support scheduling activities for required follow-ups with necessary providers/services

For clinical staff, services include:

  • Identify and communicate with necessary agencies, health resources, and community services
  • Educate necessary care team members in areas including self-management, independent living, and ADLs
  • Assess/support treatment regimen adherence, including medication management
  • Assist patients and/or non-clinical care team members in accessing care services

Office Visit 

An in-person office visit is a final step. It should occur within either seven or 14 days of the patient’s hospital discharge

This time frame depends on the complexity of medical decision-making inherent to caring for the patient.

Medical decision-making refers to establishing a diagnosis and/or selecting a care management option, which is determined by the following factors:

  • How many possible diagnoses and/or the amount of care management options need to be considered
  • The breadth and/or complexity of medical records, diagnostic tests, and/or other information that needs to be acquired and analyzed
  • The risk of significant complications, morbidity, and/or mortality as well as comorbidities associated with the patient’s problem(s), the diagnostic procedure(s), and/or the possible management options

Medicare utilizes two different CPT codes to distinguish between office visit types. These are separated and labeled as involving either moderate or high complexity decision-making.  

  • CPT Code 99495 – Transitional care management services with moderate medical decision complexity (face-to-face visit within 14 days of discharge)
  • CPT Code 99496 – Transitional care management services with high medical decision complexity (face-to-face visit within 7 days of discharge)

Please note: Office visits are part of the overall TCM service. They should not be reported separately.

How Care Coordination Software Can Streamline the Process for Transitional Care Management

To deliver the three service segments covered above, you’ll want a system in place to track and manage TCM.

A practical resource, such as care coordination software, will keep key details from being lost or overlooked. For you and your staff, this will promote a more efficient process. 

Below, we cover three of the benefits this software solution can provide to aid with TCM management.

1. Time Management / Scheduling

As covered above, TCM revolves around a 30-day timeframe. Two of its three service segments require action by predetermined deadlines

Care coordination software will help meet these requirements. 

Simple features, such as built-in scheduling and time management tools, will assist clinical staff with patient outreach and office visits.  

It’s crucial to consider the timing when providing TCM services to patients, and software will keep your practice on time.

2. Documentation

Care coordination software is a great way to create a paper trail of patient data and services. 

This can help you hedge against a possible audit by Medicare, as well as provide exceptional medical care.

Such software will vary in what exactly it can document, but some common examples are:

  • Notes on previous medical care and/or office visits
  • Medication records
  • Summaries of patient care transition activities, such as what TCM services were provided
  • Details that pertain to the patient’s hospital discharge, such as diagnoses and type of hospital care provided

As well, care coordination software can create patient chart summaries, circumventing such a need from your Electronic Health Record (EHR)

This attention to documentation will ensure your practice’s TCM program is effective. 

3. Guided Workflow

Lastly, care coordination software can streamline your practice’s overall TCM process by providing a go-to workflow to follow. 

These steps can include:

  • Post-discharge review and patient communication
  • Review of diagnostic tests
  • Medication review and reconciliation
  • Referrals and other care coordination needs

As the provider, your input in the overall TCM process may be limited to the office visit, but for your staff, a guided process will go a long way toward consistent, quality care service. 

New call-to-action