Transitional Care Management

Transitional Care Management and code(s) 99495/99496 lend a new care opportunity for patients who would aid from medical and/or psychosocial decision making during transitions in care from an inpatient hospital setting to the patient’s community setting. Patients which receive this level of care now have a post-acute healthcare professional assuming care after discharge, effectively picking up where the hospital left off resulting in better outcomes, higher patient satisfaction and and a lowered risk of readmission. However, Medicare payment records for 2014 show only 20% of patients discharged from acute hospitalization subsequently showed TCM visits post hospitalization.

A key component of Medicare’s TCM program is the ability to follow up with the patient right after they are discharged from the hospital. Patients must be communicated with (direct contact, telephone, electronic) 2 business days post discharge and subsequently seen face-to-face 7 or 14 days thereafter depending on the level of medical complexity. This deadline poses a huge challenge for the downstream providers who are responsible for a patients transitional care post hospitalization. A PCP must somehow be notified that their patient was in the hospital and understand why so that they can be flagged as a candidate for TCM and management is started.

However, most EHR systems lack the ability to generate real-time, proactive reports that can be passed to downstream care manager and providers. The majority of the time, providers are not even aware one of their patients was ever in the hospital, let alone receive any sort of notification or information regarding the event.

Axial can help. With our Care Transition software, providers receive real-time alerts of condensed, discharge summaries of their patients hospital event. Providers do not need access to a health system’s EHR or special credentials to receive information.


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