Transitional
Care Management

Medsien’s TCM solution helps practices streamline the discharge process without incremental administrative work.

Rapid, algorithmic identification of eligible patients
Seamless implementation and deep EHR integration
Automated billing, claim tracking, and detailed financial reporting
Transitional Care Management
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Reach more people

in need—fast

Transitional care is often critical and always time-sensitive. With Medsien’s TCM solution, you can identify more eligible patients and obtain discharge reports faster with the most advanced technology.

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Manage all the moving parts of care management

Tacking the day-to-day of TCM programs can be an unwieldy process. Medsien’s bidirectional EHR integration simplifies the entire workflow and automates the most time-consuming tasks at each stage, from discharge to home transition.

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Spend more time providing quality care

Tracking and logging all the crucial details of TCM programs takes away from more valuable services, like transitioning patients properly. Let Medsien’s automated platform crunch the numbers and handle claims while you focus your efforts where it counts.

Designed to fit your workflow

Medsien can help you simplify your TCM program by automating time-consuming elements of the program. This is possible through our deep integration with your EHR.

Obtain discharge reports

Medsien algorithms can identify patients that are discharged from hospitals in your area where you are the primary care provider.

1
Schedule appointment

Our staff will then contact your patients to schedule an appointment for them within 7 or 14 days of their discharge.

2
Automated billing and reporting

After the patient visit, our software keeps tracks of your claims to provide detailed financial reports.

3

Connect seamlessly 
with our comprehensive 
EHR ecosystem

With ever-growing number of technology integrations,
you can get up and running with Medsien in a matter of days.

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I recommend partnering with Medsien to improve your clinic’s patient experience without adding work for your office.
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Medsien client at a multispecialty care clinic

Schedule a demo

Contact us to see Medsien in action and learn how your organization can reimagine remote care management.

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Frequently asked questions

Everything you need to know about transitional care management.

What is transitional care management?
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Transitional care management (TCM) is intended to reduce potentially preventable readmissions following discharge from an inpatient encounter. TCM requires initial contact with the patient within two business days after discharge and a face-to-face visit within a specified period of time.

How long is transitional care?
Plus

Transitional care involves a 30-day period that begins on a patient’s inpatient discharge date and continues for the next 29 days. TCM services begin the day of discharge from an inpatient or partial hospitalization setting.

What are examples of transitional care management?
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Examples of transitional care management include taking responsibility for a patient’s care, supporting that patient’s transition to a community setting, such as a home or nursing facility, and making moderate or high-complexity decisions regarding their medical issues.

What are the benefits of transitional care management?
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Transitional care management benefits patients after discharge from an inpatient encounter by providing continuous care without service gaps. TCM also benefits practices by reducing the chance of readmission or rehospitalization.

What are the components of transitional care management?
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You must provide at least three components of transitional care management during the 30-day period: interactive contact within 2 business days, 1 face-to-face visit, and medically reasonable and necessary non-face-to-face services, like patient education and medication management.

What are the goals of transitional care management?
Plus

The goals of transitional care management are to effectively provide continuous care during the 30-day TCM period and transition a patient back to their home, domiciliary, nursing facility, or assisted living facility.

What are the requirements for transitional care management?
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Transitional care management is evaluated by the type of medical decision-making involved. Patients who receive TCM must require either moderate or high complexity, which is defined by multiple, extensive diagnoses and significant complications, morbidity and mortality risk.

Is transitional care management only for Medicare patients?
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Transitional care management services are defined by the Centers for Medicare & Medicaid Services (CMS). Thus, reimbursement for these services is only available to patients who meet CMS eligibility and providers who meet CMS requirements.

Does Medicare pay for TCM?
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Yes, as long as a patient is eligible for transitional care management, Medicare does reimburse TCM services. CPT codes through a TCM program include communication with the patient or caregiver within 2 business days of discharge, face-to-face visits, and medical decision-making of moderate complexity (99495) and high complexity (99496).

How do you implement transitional care management?
Plus

Medsien’s TCM solution makes it easy to implement a transitional care management program in as fast as just a few days. Reach out to our team of TCM experts today to get started.

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Blog and resources

The latest news, technologies, and resources from our team.

2024 Checklist to power up your practice. It’s time to reimagine remote care management
2024 Checklist to power up your practice. It’s time to reimagine remote care management
New year, time for a new approach It’s time to plan for 2024. Are you ready to introduce seamless, scalable remote care management and monitoring into your practice?
CMS 2024 Updates and Changes for Remote Care Services
CMS 2024 Updates and Changes for Remote Care Services
CMS continues to advance the ability of RPM and RTM services to drive revenue and improve the patient care experience. The 2024 Final Rule addresses billing scenarios and requests for clarifications on the appropriate use of these remote monitoring codes, and clarifies CMS’ position on how it interprets certain requirements for these services.
A little less lonely: How remote care management improves the lives of seniors
A little less lonely: How remote care management improves the lives of seniors
Loneliness is a serious epidemic and major public health problem impacting individuals and communities in the United States and around the globe.
Why the benefits of remote care management implementation outweigh the risks
Why the benefits of remote care management implementation outweigh the risks
Robust remote care management programs help practices provide the highest quality of care resulting in better outcomes and reduced costs.
Re-imagine remote care management: Your roadmap to best-in-class remote care
Re-imagine remote care management: Your roadmap to best-in-class remote care
Medsien’s remote patient monitoring (RPM) programs combine an intelligent software platform with scalable staffing augmentation to create seamless, scalable programs with effortless implementation.
Overview of CPT codes for Medsien related products
Overview of CPT codes for Medsien related products
Medsien offers software and solutions for a suite of services – including CCM, PCM, RPM, RTM, TCM and AWVs. Accurate coding is essential for proper reimbursement.
World class Remote Care Management during a recession? Here’s how.
World class Remote Care Management during a recession? Here’s how.
Recessions can impact a facility or provider’s bottom-line, patient care and health outcomes.
The Medsien Care Partner
The Medsien Care Partner
Medical Assistants (MAs) are an essential part of successful care management. At Medsien the two things that make our remote care programs so successful are our unique proprietary software and our staffing model.
How Medsien makes remote care programs easy to implement
How Medsien makes remote care programs easy to implement
You are busy, and do not have the staff or time to implement a care management program. Your practice can’t invest the money for care management right now.
Why should we hire someone else to do this?
Why should we hire someone else to do this?
The challenges of successful in-house Chronic Care Management (CCM) and Remote Patient Monitoring (RPM) programs
Transitional Care Management (TCM) Overview & Benefits
Transitional Care Management (TCM) Overview & Benefits
Transitional Care Management is a program designed to support and track Medicare patients in the 30 days following discharge from a hospital or treatment facility.