Transitional Care Management (TCM) Workflow Checklist

Providing high-quality, continuous care after a patient leaves the hospital is one of the most important steps we can take in improving health outcomes and reducing hospital readmissions. That’s where Transitional Care Management (TCM) steps in. TCM involves a series of carefully planned and timed steps that help patients recover successfully after they’ve been discharged. By following a consistent, well-organized checklist, healthcare providers can ensure they meet compliance requirements and deliver excellent patient care.

This detailed Transitional Care Management (TCM) workflow checklist covers each critical task based on Centers for Medicare & Medicaid Services (CMS) requirements and leading healthcare sources like the Patient Quality Alliance, CMS TCM Fact Sheet, and the AAPC. Let’s dive into the full process, from the moment a patient leaves the hospital through the 30-day follow-up window.

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Understanding Transitional Care Management (TCM)

Transitional Care Management is a Medicare-approved process that helps patients move safely from hospitals or skilled nursing facilities back to their home, assisted living, or community setting. It's designed to ensure that patients understand their care plan, take medications properly, attend follow-up appointments, and don’t end up back in the hospital.

To qualify for reimbursement under TCM guidelines, providers must complete certain critical steps within specific timeframes. These include contacting the patient quickly, completing a face-to-face visit within a certain number of days, reconciling medicines, providing proper documentation, and reviewing red flags. It all begins the moment a patient is discharged.

Two CPT (Current Procedural Terminology) codes are commonly used to bill TCM services:

• 99495: For moderate complexity cases—requires contact within 2 business days and a face-to-face visit within 14 days.
• 99496: For high complexity cases—requires contact within 2 business days and a face-to-face visit within 7 days.

Let’s break down everything that needs to happen—from discharge day to the end of the 30-day TCM period.

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Critical Timelines for TCM Success

Task	Timeframe	Key Notes
Interactive Contact	Within 2 business days of discharge	Must be direct communication (phone, electronic, or face-to-face) with patient or caregiver, per CMS. Document all attempts.
Face-to-Face Visit	Within 7 (99496) or 14 (99495) days	The in-person (or telehealth) visit must match complexity level and timing standards.
Medication Reconciliation	On or before the face-to-face visit	Reconcile all current medications, including any changes made during the hospital stay.
Ongoing Follow-up Support	Throughout 30-day post-discharge	Includes follow-up calls, symptom monitoring, care coordination, and final documentation.

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Step-by-Step: TCM Checklist Timeline and Tasks

Let’s look at each step of the TCM process in detail.

1. Post-Discharge (Day 0)

As soon as the patient is discharged from a hospital, the TCM clock starts ticking.

Tasks:

• Confirm receipt of a discharge alert from the facility.
• Verify the patient’s community setting where they’ll reside after discharge (e.g., home, assisted living).
• Identify high-risk patients who may need more attention based on factors like multiple chronic conditions or previous hospitalizations.

Why It Matters:

This first step ensures no one falls through the cracks. Knowing where the patient went and who’s supporting them influences how care is planned.

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2. Initial Interactive Contact – Within 48 Hours

Effective communication must happen quickly—within two business days—to meet CMS requirements and to address urgent issues early.

Tasks:

• Make at least one attempt for contact on Day 1.
• If the first attempt fails, try again on Day 2. (CMS requires two documented attempts before this step is considered complete.)
• Contact can be by phone, video, electronic communication, or in-person—whichever works best for the patient.

Discussion Topics May Include:

• Review hospitalization and discharge summary.
• Discuss any new or changed medications.
• Ask about symptoms (shortness of breath, confusion, pain) that could signal complications.
• Clarify red flags to watch for and when to call the provider.

Documentation Must Include:

• Date and time of attempts.
• Names of people involved in the conversation.
• Patient condition and any immediate concerns.
• Barriers to care such as transportation, hearing issues, or limited English proficiency.

Resources:

This contact is a great chance to provide tools like medication lists, symptom trackers, and emergency contact cards.

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3. Face-to-Face Visit (Day 7 or Day 14)

This is one of the most important parts of the TCM process and determines whether it qualifies for CPT code 99495 or 99496 billing.

Tasks:

• Schedule the in-person or telehealth visit early to meet the deadline: within 7 days for high-complexity (99496) or within 14 days for moderate-complexity (99495).
• Include a full clinical assessment:
  • Check vital signs and perform a physical exam.
  • Screens for depression, fall risk, medication adherence, and the patient’s understanding of their care plan.

Care Tasks Often Covered:

• Medication reconciliation, reviewed for accuracy and duplication.
• Evaluate new prescriptions or medications changed during the hospital stay.
• Discuss lifestyle changes (diet, activity) or new medical equipment (walker, oxygen).
• Schedule referrals to specialists or tests (labs, imaging).
• Create or update a care plan.

Remember:

Don’t bill separately for the office visit if you’re billing TCM—it’s included.

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4. Ongoing Care – Day 10 to Day 30

TCM isn’t a “one-and-done” type of service. It’s a process that continues throughout the month following discharge, helping the patient avoid setbacks and gain independence.

Follow-Up Attempts:

• Day 10 Call: Reconnect with the patient to answer remaining questions about the face-to-face visit, new meds, symptoms, or follow-up plans.
• Day 26 Call: Confirm improvement or address any issues. Adjust care plans as needed and begin preparing for ongoing care or Chronic Care Management (CCM) if appropriate.

Documentation Essentials:

• Record any updates to the care plan or medication list.
• Note any ongoing problems or patient concerns.
• Include complexity of medical decision-making to support billing.
• Use EHR alerts and templates to stay on schedule and track outcomes.

Helpful Templates & Tools

Medication Reconciliation Template Should Include:

Medication	Before Hospital	At Discharge	Current (Reconciled)
Example Med	Yes	No	No
New Med	No	Yes	Yes

Red Flags Checklist:

Patients should be instructed to call right away if they notice:

• Uncontrolled pain
• Confusion, disorientation
• Trouble breathing
• Swelling in legs
• Fever or chills
• Missed medication doses

By providing clear red flag guidance, patients and caregivers can prevent hospital readmissions.

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Documentation for TCM Billing Compliance

Proper documentation is key to getting reimbursed and providing proof of quality care. According to AAPC's TCM Guidelines, documentation must prove:

• The timing and nature of the first contact.
• The complexity of medical decision-making (moderate or high).
• That a face-to-face visit occurred within the required timeframe.

Use standardized templates in your EHR to track each section. Maintain strong internal audits of completed checklists, contact logs, and progress notes.

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Best Practices for a Smooth TCM Workflow

1. Use EHR alerts for time-sensitive tasks: contact deadlines, visit dates, and follow-up calls.
2. Train staff on TCM timeframes and billing compliance.
3. Assign responsibilities—make sure someone "owns" each step.
4. Offer telehealth options when in-person visits are not convenient.
5. Coordinate with caregivers, home health, or specialists for better outcomes.

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Frequently Asked Questions (FAQ)

Q1: How soon should I contact the patient after they’re discharged?
You must attempt patient contact within two business days of discharge. Two documented attempts are needed if the first fails.

Q2: Can the TCM face-to-face visit be done via telehealth?
Yes! According to CMS, the face-to-face visit may be conducted via telehealth if necessary, assuming all other requirements are met.

Q3: Do I have to conduct follow-up calls after the in-person visit?
While not specifically required by CMS, ongoing follow-up helps identify red flags and supports good care—and it's a best practice for reducing readmissions.

Q4: What conditions qualify for TCM billing?
Eligible patients must have medical and/or psychosocial problems that require moderate or high-complexity decision-making during the 30-day post-discharge period.

**Q5: Can I bill