Transitional Care Management (TCM) services are designed to assist healthcare providers and their staff in coordinating care for patients after certain types of hospital discharges. Effective TCM helps to ensure that patients receive the appropriate follow-up care to prevent complications or readmission, particularly for patients with complex needs.
In ChronicCareIQ, the TCM Dashboard allows users to track and log critical post-discharge actions, including phone calls and appointments, necessary for billing under CPT codes 99495 (Moderate Complexity) and 99496 (High Complexity).
Moderate Complexity (CPT 99495)
This CPT code applies when:
The patient has moderate complexity medical decision-making.
Contact (e.g., phone call) is made within 2 business days after discharge.
An in-person visit is completed within 14 days.
High Complexity (CPT 99496)
This code is used for high complexity cases, which require:
More complex medical decision-making.
A phone call within 2 business days post-discharge.
A follow-up in-person visit within 7 days.
How the TCM Dashboard Works
Patient Enrollment & Discharge Tracking
The TCM Dashboard is designed to track patients who have recently been discharged from the hospital. Once a discharge date is recorded, the patient will appear on the TCM dashboard for monitoring. Both enrolled and unclaimed patients are supported.
To add a discharge date, navigate to the patient chart and select the Discharge Date field at the top:
In the window that opens, fill in the date of the hospital discharge:
Once the discharge date is entered, navigate to Dashboard > Transitional Care to see the patient populated on the TCM Dashboard:
With the patient now being tracked by the TCM dashboard, you will see new fields appear on the patient chart for tracking the follow up call and appointment:
Once all required actions are taken for TCM the dashboard will display a green checkmark by the patient and the billing code will appear on your Monthly Billing Summary.
Best Practices for Using the TCM Dashboard
Timeliness is key: Ensure all phone calls and appointments are logged promptly to meet billing requirements.
Automated Reminders: Make use of the system’s automated alerts for upcoming deadlines.
Documentation: Keep detailed records of interactions to support your claims for CPT reimbursement.