Transitional Care Management (TCM)

Transitional Care Management (TCM)

The Centers for Medicare and Medicaid Services (CMS) have created several targeted programs that use primary care providers as a gateway to address the population health disparities associated with chronic diseases. Private practice providers can increase their business’ profitability, while improving patient outcomes, if they can effectively incorporate chronic care management (CCM) into their workflow. CCM is a comprehensive, holistic patient care program that requires providers to proactively engage in their patient’s care beyond the traditional office visit. For CCM to be done effectively, providers will need electronic medical record (EMR) and enterprise solutions that:

  • Track information regarding the annual wellness visit (AWV) and initial preventative physical examination (IPPE)
  • Provide comprehensive data tracking, querying options, and reporting capabilities
  • Provide 24/7 accessibility management services through enhanced remote communication capabilities
  • Provide support for continuity of care management
  • Provide support for the coordination of care
  • Provide the ability to create comprehensive patient-centered care plans
  • Provide the ability to track maintain patient consent forms
  • Provide the ability to manage transition care

Through the implementation of initiatives such as the Comprehensive Primary Care initiative (CPC), the Medicare Access CHIP Reauthorization Act (MACRA), the Quality Payment Plan (QPP), and CCM, CMS has worked with providers to improve the continuity and coordination of care in an effort to bring down costs.

One key aspect of improving the continuity and coordination of care in alignment with CCM standards is a provider’s ability to provide patients with remote consultations. Medicare classifies remote consultations as telehealth services.

Additional telehealth procedural codes were added in 2014 to support the CCM initiative that became effective in 2015. The expansion of telehealth provisions included coverage for remote CCM within the framework of the CCM standard CPT code 99490. The CCM initiative allows physicians to bill for a minimum of 20 minutes of remote interaction each month with patients and other providers in an effort to improve continuity and coordination. To qualify for reimbursement, physicians must appropriately document each interaction.

Transitional care management (TCM) under Medicare

Another key aspect of improving continuity and coordination is to addressing issues associated with transitional care. Transitional care management (TCM) under Medicare involves the transition of a patient to:

  • Community settings following specific types of discharges
  • Another healthcare professional post-discharge without a gap
  • Another healthcare professional who takes responsibility for the patient’s care
  • A setting that can handle more complex decision making, if the patient has a medical and/or psychological health problem that requires it
Timeframe and Duration

TCM begins the day the patient is discharged from an inpatient hospital and lasts for a total of 30 days. Additional discharge points include: long-term care hospitals, skilled nursing facilities, inpatient rehabilitation facilities, hospital outpatient observation or partial hospitalization, and partial hospitalization at a community mental health center. Within the 30-day period, the assigned provider must provide the three TCM components of care: interactive contact, certain remotes services, and a face-to-face visit. All three components must be offered in some form for providers to receive reimbursement. Although the CCM CPT code (99490) cannot be used during the 30-day period, specific TCM codes are available:

  • Interactive Contact: no assigned code; provider must initiate contact within 2 days of patient being discharged
  • Telehealth, remote contact: CPT Code Series 99495 and 99496
  • Face-to-Face:
    • CPT Code 99495: TCM decisions with moderate medical complexity; face-to-face visit within 14 days of discharge
    • CPT Code 99496: TCM decisions with high medical complexity; face-to-face visit within 7 days of discharge

Physicians serving as primary care managers can use TCM benefits to provide patients with continuity and support. After the 30-day period, these physicians can continue receiving CCM reimbursement based on the 20-minute minimum per month standard for remote interactions as a routine part of the patient’s care.



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Remote Consultations and Transitional Care Management Solutions

Medicare’s CCM initiative provides reimbursement to providers for a minimum of 20 minutes of remote contact each month. The remote contact is classified as a form of telemedicine. CCM also requires that patients have 24/7 access to their healthcare team. Integrated, turnkey solutions can provide doctors with the tools they need to effectively manage remote consultations.

Similarly, for patients who are being discharged from the hospital, private practice providers can continue to serve as the patient’s primary medical doctor through the implementation of TCM. TCM cannot be used in conjunction with CCM, but it provides patients with 30 days of benefits beginning the day that the patient is discharged. To qualify for TCM benefits, the provider must have documented proof of meeting Medicare’s threefold requirements: interactive contact (telephone initiation), remote contact, and a face-to-face visit. TCM software must effectively integrate the necessary tools that allow providers to ensure the proper continuity and coordination of care. The CCM remote consultation requirement aligns with the TCM remote contact requirement; therefore, turnkey solution options will have similar functions. Remote consultation and TCM solutions should provide:

  • Patient Accessibility and Schedule Management
  • Encrypted Communication Accessibility:
    • text messaging
    • email
    • instant chat
    • telephone
    • video
  • Provider Documentation Capabilities
  • Patient Tracking, Dashboard Reports, and Data Analysis
  • Medication Management
  • Ability to Review Images (X-Rays and Labs)
  • Ability to Make and Track Referrals
  • Ability to Receive Information from Mobile Apps Used by Patients
  • Ability to Exchange Information
  • Reimbursement Capabilities and Patient Payment Management

In addition to the ability to meet CCM and TCM standards, providers with remote consulting capabilities have an opportunity to increase revenue through the introduction of telemedicine into their practice.



1. Oculus has the flexibility to seamlessly integrate with the practice and provider’s existing workflow.
2. During the initial onboarding period, we identify various touch points within the workflow
3. Oculus is also able to automatically convert a patient’s EMR file to an electronic Care Plan for wellness, preventive, and Chronic Care Management.
4. 1:1 Patient and Medical Staff relationship
5. Patented experiential rewards program