Transitional Care Management Guidelines 2025

Best practices for navigating transitional care management

Transitional care management (TCM) involves coordinated services to help patients safely transition from one healthcare setting to another, such as from a hospital to home. The goal is to reduce hospital readmissions, improve health outcomes, and ensure a smooth recovery process. TCM services are reimbursed by Medicare and other insurers if certain conditions, such as timely follow-up and care planning, are met. Understanding TCM guidelines helps to ensure high-quality, patient-centered care that supports both clinical success and financial sustainability.

Transitional care management documentation requirements

Proper documentation is foundational for effective TCM compliance and billing. According to the Centers for Medicare & Medicaid Services (CMS), the following must be recorded:

1. Initial patient contact
   • Document the timing and method of the initial post-discharge communication, including the date, time and scope of discussion
2. Face-to-face visit details
   • Record the date, time and key insights from the face-to-face visit
   • Ensure that any medical decision-making, risk assessments and care adjustments are explained thoroughly
3. Medication review
   • Provide a comprehensive account of medication reconciliation efforts, listing adjustments made to prescriptions and patient education on medication use
4. Care coordination activities
   • Document any coordination with specialists, community resources or other services required to support the patient’s transition
   • This ensures transparency and validates the complexity of the services provided
5. Discharge information
   • Include a summary of the patient’s hospital discharge, highlighting diagnosed conditions, treatment progression and reasons for follow-up care.

By meeting these documentation requirements, you not only validate the services provided but also ensure reimbursements under Medicare and other payer contracts.

How to maintain accuracy in billing

Currently, billing guidelines remain consistent with prior years, though CMS continues to stress the importance of accurate submissions:

• Use CPT codes 99495 (moderate complexity) and 99496 (high complexity) based on the complexity of the medical decision-making and corresponding timelines for face-to-face visits
• Pair the TCM CPT codes with appropriate ICD-10 codes reflecting the primary reasons for discharge
• Ensure documentation aligns with CMS standards to mitigate risks of claim denials

Health care organizations are advised to review their workflows regularly to maintain compliance with the most current billing regulations

A step further: Emerging trends in TCM

Beyond these specific requirements, several emerging trends are shaping the future of TCM delivery:

1. Holistic care integration
   • TCM services are becoming more integrated with behavioral health, addressing complex patients’ needs more comprehensively during the vulnerable discharge period
2. Patient-centered technology
   • Patient-facing technologies like care apps are being deployed to support home care readiness
   • These apps collect patient feedback, offer condition-specific education and track symptoms post discharge
3. Focus on access
   • Guidelines emphasize improving access to TCM for underserved populations, including expanded payer initiatives to support services in rural and low-income communities

Actionable insights for your organization

To adapt to these updates effectively, primary care teams should take the following steps:

• Invest in technology: Upgrade to electronic health records and telehealth platforms that include TCM-specific templates and capabilities to maintain compliance and documentation easier while enhancing patient engagement
• Stay educated on payer policies: Regularly review payer-specific TCM guidelines and participate in webinars or training sessions hosted by CMS or professional associations
• Optimize internal workflows: Create standardized processes for initiating communication within two business days and ensuring face-to-face appointments meet the required timelines
• Focus on outcomes: Monitor quality metrics like readmission rates and patient satisfaction to demonstrate the value of your TCM services in contracts with payers

By keeping pace with TCM requirements, health care teams can not only stay compliant but also position themselves at the forefront of high-quality, patient-centered care, ensuring smooth transitions, reducing readmissions and improving overall health outcomes.

Stay on top of transitional care management with Aledade

Our team of experts is here to help you navigate regulations, streamline your workflows and optimize care delivery. Aledade can help. Contact us today for a consultation and discover how we can help your organization thrive.