Care Continuum with Transition Care Management Software

The TCM process includes:

1. Interactive Contact: Within 2 business days of discharge, a healthcare provider must make contact with the patient or their caregiver to discuss their care.
2. Face-to-Face Visit: A follow-up visit must occur within 7 or 14 days of discharge, depending on the patient's complexity.
3. Medication Reconciliation and Management: Review and reconcile medications as part of the care transition.
4. Coordination of Services: Ensure the patient can access necessary healthcare resources such as specialists, home health, or social services.

1. CPT Code 99495: Includes communication with the patient or caregiver within 2 business days, medical decision-making of at least moderate complexity, and a face-to-face visit within 14 calendar days of discharge.
2. CPT Code 99496: Includes communication with the patient or caregiver within 2 business days, medical decision-making of high complexity, and a face-to-face visit within 7 calendar days of discharge.

By ensuring timely follow-up and coordinated care, Transitional care management software reduces hospital readmissions, improves medication adherence, and ensures patients receive the right care at the right time. Automated reminders and tracking tools also enhance communication between care teams and patients, leading to more proactive interventions.

Yes, most TCM software platforms are designed to integrate seamlessly with existing EHR systems. This integration ensures that patient data is automatically pulled from the EHR into the TCM workflow, streamlining documentation and reducing administrative burden.

Below are some benefits of using TCM software solutions:

1. Increased Efficiency: Automated workflows reduce manual tasks and paperwork.
2. Improved Compliance: Ensure adherence to TCM regulations for timely follow-up and documentation.
3. Revenue Generation: Accurate billing using TCM CPT codes (99495 and 99496) enhances revenue opportunities.
4. Better Care Coordination: Care coordination for hospital transitions facilitates communication between providers and specialists involved in the patient’s care.

Medicare and other payers reimburse providers for TCM services or Post-hospital discharge care using CPT codes 99495 and 99496. These codes allow for compensation for the time spent coordinating care, conducting follow-up visits, and managing the transition from hospital to home. Practices that successfully implement TCM can see an increase in revenue through proper documentation and coding.

TCM services can be provided by a variety of healthcare professionals, including:

1. Physicians (MD/DO)
2. Nurse Practitioners (NP)
3. Physician Assistants (PA)
4. Clinical Nurse Specialists (CNS)

These providers must deliver the face-to-face visit, but non-face-to-face services (e.g., coordination, patient contact) can be done by clinical staff under supervision.

To get started:

1. Contact our team for a demo: We’ll provide a walkthrough of how the software works and how it can be customized for your practice.
2. Training and Onboarding: We offer comprehensive training to your staff on how to use the software efficiently.
3. Implementation: Once set up, the software will be integrated with your existing systems, and we’ll support you throughout the transition.