What is Transitional Care Management? What Insurance covers TCM?

If you are new to care management, you must be wondering what is transitional care management. Transitional care management (TCM) is a healthcare discipline that focuses on providing care and support to patients during a transition in their healthcare journey. The goal of TCM is to ensure that patients receive the right care, at the right time, and in the right place.

TCM services are typically provided by a team of healthcare professionals, including nurses, social workers, and pharmacists. The team works with the patient and their family to develop a plan of care that meets the patient’s needs and preferences. The team also provides education and support to the patient and their family to help them manage their health and well-being.

If you or a loved one is transitioning from one stage of health care to another, transitional care management services can help to ensure that you receive the care and support you need.

For example, when a patient is discharged from the hospital, TCM can help coordinate their care with their primary care providers and other specialists to ensure a smooth transition and avoid any gaps in care.

The goal of TCM is to prevent hospital readmissions and improve patient outcomes. TCM services are provided by a team of healthcare professionals, including nurses, social workers, and pharmacists.

If you are a Medicare patient, you may be eligible for TCM services. Keep reading to learn more about this important benefit!

What is Transitional Care Management – 3 Important Modules

Transitional Care Management modules

Transitional care management represents a comprehensive and coordinated approach to care that includes all members of the care team, from the primary care physician to the patient’s family.

It is a critical service for patients who are at risk for readmission or who need help managing their complex medical and social needs.

TCM services must be provided by a qualified provider and must include all of the following components:

1. A Thorough Assessment of the Patient’s Needs

As per Medicare requirements, the beneficiary should be contacted via email, telephone, or text within 2 business days once the discharge has been made.

The hospital staff should ensure that the patient’s needs are met after discharge addressing their health status.

2. Development of a Care Plan that is Tailored to the Patient’s Individual Needs

Medicare instructs the provision of services the individual needs and they could be non-face-to-face communication. This includes reviewing the history and timeline of the care that indicates extra care, educating patients about their health, making referrals, scheduling appointments, and activities, etc.

3. Regular Communication and Coordination between the Care Team and the Patient (and/or the Patient’s Caregiver)

Medicare also requires making face-to-face visits when needed and managing visits if the patient cannot make it to the clinic. There are two CPT codes that Medicare suggests for billing. These include;

  • 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)

Transitional care management is a vital service for patients who are transitioning between care settings. It can help to ensure that patients receive the care they need to avoid readmission and manage their complex medical and social needs.

Benefits of Transitional Care Management

Transitional care management is a type of care that helps people who are moving from one care setting to another. This type of care is important because it helps to ensure that people receive the care they need during this transition period.

There are many benefits to transitional care management, including improved patient outcomes, reduced readmission rates, and lower overall costs. Transitional care management can also help to improve communication between care providers and patients and make sure that everyone is on the same page about the care plan.

If you or someone you know is transitioning between care settings, be sure to ask about transitional care management. It can make a big difference in the quality of care received during this important time.

For healthcare providers, TCM can help to improve care coordination and communication, and it can also lead to cost savings. A recent study found that TCM led to a 12% reduction in readmissions and a 9% reduction in overall costs for Medicare patients.

If you are a healthcare provider, transitional care management may be a good option to consider

Steps to Qualify for Transitional Care

If you or a loved one is discharged from the hospital but still needs extra care before returning home, you may be wondering if you qualify for transitional care. Transitional care is designed to provide extra support during the transition from hospital to home, and it can be a vital resource for patients who still need help with daily activities like eating, bathing, and dressing.

To qualify for transitional care, you must meet certain criteria. First, you must be medically stable and ready to be discharged from the hospital. Second, you must be able to return home but still need help with activities of daily living. And third, you must have a care plan in place that includes transitional care services.

If you meet all of these criteria, then you may be eligible for transitional care. For more information, you can speak with your doctor or case manager, or insurance provider for the continuation of the services.

What Insurance Covers TCM?

If you are a Medicare member, they will cover the cost that you need for TCM. For this, patients need to confirm that the practitioner they are trying to approach, they are approved through Medicare. The coverage for TCM is discussed in part B of Medicare, by which the patient’s costs are designated as;

  • Coinsurance – Through Medicare, patients are responsible to pay 20% of the total cost of the coverage that Medicare approved.
  • Part B deductible – The amount that the patient has to pay before the coverage of Medicare Part B jumps in. According to the year 2021, the deductible for Part B Medicare was $203.
  • Part B monthly premium – The amount that is paid monthly for Part B coverage. As of 2021, the standard part B premium is $148.50.

In other cases, if the patient acquires Medicare Part C, the Medicare plan should cover the same percentage as Part B or Part A. Taking this advantage into the account, Medicare is one of the suitable options for transitional care management coverage. Medicare plans can also provide some exceptional benefits, which include transportation to appointments, meal deliveries, etc. If a patient has Part C Medicare coverage, the coverage may vary. Plus, before they make an appointment, they must consider verifying if the provider is Medicare in-network provider.

When you can Bill Transitional Care Management Services?

The Centers for Medicare and Medicaid Services (CMS) has established certain guidelines for how often TCM services can be billed. Specifically, CMS states that TCM services can be billed once per beneficiary, per discharge, within a 30-day period.

In most cases, Transitional Care Management (TCM) can be billed once per patient, per episode of care. An episode of care is defined as the period of time between the date of a patient’s discharge from a facility and the date that the patient’s care is transferred to another provider.

There are some exceptions to this rule. If a patient is readmitted to a facility within 30 days of their previous discharge, TCM can be billed again. In addition, TCM can be billed multiple times for patients with chronic care needs who are discharged and then re-engaged with care within a short period of time.

If you have any questions about when TCM can be billed, please contact your Medicare Administrative Contractor.

Transitional Care Hospital Roles

A transitional care hospital is a short-term, acute care hospital that provides care for patients who are transitioning from one level of care to another. Transitional care hospitals are designed to meet the needs of patients who require intense medical care and monitoring, but who are not well enough to be discharged from the hospital.

Transitional care hospitals offer a variety of services and amenities that are designed to help patients transition to the next level of care. These hospitals typically have private rooms, on-site laboratory and imaging services, and a staff of experienced medical professionals. Transitional care hospitals usually have a shorter length of stay than traditional hospitals, and they often offer a lower cost of care.

These hospitals are often located within larger hospitals or medical centers, and they typically have a staff of nurses and other medical professionals who are specifically trained in providing this type of care.

Transitional care hospitals are often used for patients who are recovering from surgery or an illness, or for patients who are dealing with a chronic condition that requires close monitoring. These hospitals can also be used for patients who are transitioning from one type of care to another, such as from an inpatient setting to an outpatient setting.

If you are in need of short-term, intensive care, a transitional care hospital may be the right option. These hospitals can provide the care and support you need.


Transitional care management (TCM) is a Medicare-covered service that can be provided to Medicare beneficiaries who are discharged from a hospital or skilled nursing facility (SNF). TCM services are designed to help patients transition from one care setting to another and can be provided by a variety of healthcare professionals.

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