Transitional
Care Management

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

Eligibility report

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Rapid, algorithmic identification of eligible patients

Seamless implementation and deep EHR integration

Automated billing, claim tracking, and detailed financial reporting

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.

Manage all the moving parts of care management

Tracking 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.

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.

Schedule appointment

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

Automated billing and reporting

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

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.

I recommend partnering with Medsien to improve your clinic’s patient experience without adding work for your office.

Medsien client at a multispecialty care clinic

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Frequently asked questions

Everything you need to know about transitional care management.

What is transitional care management?

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?

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?

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?

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?

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?

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?

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?

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?

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). Refer to CMS.org for the latest CPT code updates.

How do you implement transitional care management?

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.