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Transitional Care Management

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TCM Software Designed by Clinicians, for Clinicians

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Transitional Care Management (TCM)


ThoroughCare Features:

  • Patient dashboard to identify qualified TCM candidates and their care transition status
  • Support for defining discharge complexity (low, medium, high)
  • Forms for documenting the following (with workflow supported by the American College of Physicians):
    • post-discharge review and patient communication notes, including  observations, findings and recommendations
    • review of diagnostic tests
    • medication review and reconciliation
    • referrals and other care coordination needs




  • Formal tracking of physician review and approval of care transition activities
  • Time management/Scheduling features, assisting users in managing patient outreach (initial contact) and office visit requirements
  • Printable summaries that outline the patient care transition activities
  • Reporting capabilities supporting the review and administration of all 99495 and 99496 claims
  • Tech Support via email and phone


What is Transitional Care Management?

Through the Transitional Care Management (TCM) program, Medicare reimburses healthcare providers for two CPT codes - 99495 and 99496 - that are used to report physician or qualifying non-physician practitioner care management services for a patient following a discharge from a hospital, SNF, or CMHC stay, outpatient observation, or partial hospitalization. The TCM operation intends to assist patients with the transition from the hospital to a community-based setting over a 30-day timeframe from the date of discharge, while reducing the number of unnecessary readmissions that are associated with the discharge diagnosis.

Reimbursement for a successful 30-day transition can range (based on national rates) from $167 (moderate medical decision complexity) to $237 (high medical decision complexity). Please check with your Medicare Administrative Contractor for more information on reimbursement rates within your locality.

Who provides 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:

  • Certified Nurse Specialists (CNSs)
  • Certified Nurse Assistants (CNAs)
  • Nurse Practitioners (NPs)
  • Physician Assistants (PAs)

While non face-to-face services can be provided by any of the listed healthcare professionals, the face-to-face service must be provided by the physician.

Transitional Care Management Components

The following are the three key components of TCM services to be provided during the 30 days beginning on the date of patient discharge:


1. 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



2. 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. 

Recommended services are as follows:





Services Performed by Physicians/NPs:
  • Retrieval and review of patient discharge summaries or other discharge information
  • Review of pending diagnostic tests/treatments, including those that are recommended but not yet performed
  • 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 Clinical Staff
  • 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



3. 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.  Timeframes are as follows:

  • Moderate Medical Decision Complexity: face-to-face visit within 14 days of discharge
  • High Medical Decision Complexity: face-to-face visit within 7 days of discharge

“ThoroughCare is by far the most user friendly software application that captures all ingredients of Chronic Care Management. We see this as a great value for our enrolled patients. ThoroughCare has made this seemingly complicated task very easy for patients and providers alike.”

Eugene Sangmuah, MD
Matthews Internal Medicine, Matthews NC

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Hospital Discharge and Readmission Facts

  • Unplanned 30-day readmissions can result in financial penalties for your practice, which may negatively affect Medicare payments!

  • Over 35 million hospital discharges occur annually within the US

  • Approximately 20% of all discharged Medicare-eligible patients are readmitted to the hospital within 30 days of discharge.
  • The estimated cost of unplanned hospital readmissions ranges between $15M and $20M annually.
  • Factors affecting readmission, many of which are avoidable, include inadequate post-discharge support, insufficient follow-up, failed handoffs, adverse drug events and other medication related issues, and therapeutic errors.
  • Continuity of care between the inpatient and outpatient settings, including the prioritization of discharge processes and the optimization of care transition procedures, has demonstrated success in the prevention of unnecessary hospital readmissions.

Learn more about the TCM Program

These documents outline specific details about the program. 

View TCM Guidelines from CMS

View TCM FAQ From Medicare 








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