Transitional Care Management Software  For Closing The Post-Discharge Gap

ChronicCareIQ helps high-volume Medicare practices coordinate post-discharge follow-up, medication reconciliation, patient outreach, documentation, and reimbursement in one workflow, so care teams can support patients during the highest-risk transition period.

4.8

800+ unsolicited patient reviews

What is Transitional Care Management?

Transitional Care Management reimburses practices for managing a patient’s transition from an inpatient or qualifying facility setting back to the community. It includes timely patient communication, medication reconciliation, care coordination, and a required face-to-face follow-up visit.

Patients discharged from a qualifying setting, such as an inpatient hospital, skilled nursing facility, inpatient rehabilitation facility, or similar care setting, who require coordinated follow-up after discharge, including patients at risk for complications, medication issues, readmission, or gaps in care.

TCM reimbursement depends on medical decision-making complexity and how quickly the face-to-face follow-up visit occurs. Moderate-complexity TCM is billed with 99495, and high-complexity TCM is billed with 99496. See the full breakdown below.

The Post-Discharge Window Is Short, Risky, And Easy To Miss

Patients are often most vulnerable right after discharge, creating urgent work. Outreach, medication reconciliation, appointment scheduling, care coordination, patient education, documentation, and follow-up tracking, must occur within 7 days for high-complexity transitions or 14 days for moderate-complexity transitions.

When that work is spread across calls, EHR notes, task lists, and manual reminders, patients can fall through the cracks and valuable care can go undocumented.

How ChronicCareIQ Simplifies TCM

ChronicCareIQ helps practices operationalize TCM around timely outreach, post-discharge follow-up, medication reconciliation, documentation, and reimbursement.

Identify & Enroll Recently Discharged Patients

Surface patients who need post-discharge follow-up and support TCM enrollment within the workflows your practice already uses.

Coordinate Follow-Up Before The Window Closes

Care teams can monitor TCM patients through ChronicCareIQ’s color-coded RiskIQ dashboard that quickly identifies patients drifting off plan or requiring follow-up.

Capture & Document TCM Activity

ChronicCareIQ captures qualifying TCM activity and organizes audit-defensible documentation as your team follows up.

Leverages the EHR, phone systems, and connected devices your practice already uses.

Why Care Management Programs Fail As They Grow

See why disconnected outreach, manual documentation, and missed follow-up windows make care-management programs harder to scale as patient volume grows.

How Much Do TCM
CPT Codes Reimburse?

CPT Code

What it covers

Time / requirement

Est. monthly reimbursement*

99495

Transitional Care Management — moderate complexity

Communication within 2 business days of discharge; face-to-face visit within 14 calendar days; moderate medical decision-making

~$220.11

99496

Transitional Care Management — high complexity

Communication within 2 business days of discharge; face-to-face visit within 7 calendar days; high medical decision-making

~$298.60

*Estimated 2026 national non-facility Medicare reimbursement. Actual reimbursement varies by geography, payer, site of service, patient eligibility, documentation, medical decision-making complexity, discharge setting, timing, and billing circumstances. This content is educational and is not billing, coding, or legal advice.

See Your Reimbursement Potential

Enter your NPI and we'll estimate the recurring monthly revenue your practice could generate from CPM and other programs — based on your real patient population.

Designed for scalable monitoring between visits

$146/hour in reimbursable chronic care revenue

Advanced Medical Care used ChronicCareIQ to support care-management workflows across 2,100 patients with primarily cardiac conditions, helping the practice document and capture reimbursable activity tied to complex condition management.

“You need to make sure your vendor-partner understands all the nuances of chronic care management. ChronicCareIQ is just leaps and bounds above the rest.”

Dina Lemkova-Seryy, MS, Nurse Practitioner

TCM Helps Patients Transition Safely Back to care

Every specialty faces unique post-discharge challenges. Explore how TCM helps your team coordinate follow-up care, reduce gaps in treatment, and support better patient outcomes.

Cardiology

Identify meaningful cardiac changes sooner through connected-device readings, symptom tracking, and condition-specific monitoring protocols.

Pulmonology

Track respiratory health between visits through oxygen saturation trends, symptom reporting, inhaler adherence, and treatment response.

Primary Care

Monitor chronic conditions between visits through symptom reporting, blood pressure, glucose, weight, mood, and medication adherence trends.

Nephrology

Monitor kidney health through blood pressure trends, fluid and weight tracking, symptom reporting, and medication adherence.

Neurology

Track neurologic symptoms, mobility changes, medication adherence, and functional status through structured assessments and monitoring.

Gastroenterology

Support ongoing behavioral health care through mood screening, medication adherence monitoring, risk assessment, and condition-specific protocols.

Behavioral Health

Support ongoing behavioral health care through mood screening, medication adherence monitoring, risk assessment, and condition-specific protocols.

Multi-Specialty

Manage multiple chronic conditions from one platform with symptom tracking, medication adherence monitoring, and specialty-specific care protocols.

When Patients Engage, Care Programs Scale

4.8 stars. 800+ patient reviews. Every rating below is unsolicited.
No incentives. No campaigns.

4.8

4.8

ChronicCareIQ has helped tremendously in keeping in touch with our patients on a constant and recurrent basis. It has also helped us improve our quality scores, decrease our emergency room utilization, and also decrease hospitalizations.

Dr. Salma SaigerInternist, Salma Mazhar MD PA Primary Care Clinic

Doctors are not going to be able to live without ChronicCareIQ. The convenience and regular contact with patients is the big key going forward.

Dr. Gary P. JonesThoracic Surgeon, Louisiana Cardiovascular & Thoracic Institute

As a healthcare provider committed to delivering the highest quality of care, ChronicCareIQ has become an indispensable ally in our mission. The platform's impact on patient outcomes, from reducing hospital admissions to enhancing communication and achieving financial success, has exceeded our expectations.

Dr. Jim Carmical MDPrimary Care Physician, Woodside Medical

I’ve really been pleased with our patient retention rate with ChronicCareIQ. Patients are very thankful for it and want to continue using it.

Dr. Brian FlowersCardiologist, Birmingham Heart Clinic

At Chesapeake & Washington Heart Care, we've seen remarkable improvements with ChronicCareIQ. It has greatly enhanced the efficiency of our phone interactions and the promptness in updating patient care. This has been vital in providing timely and effective healthcare services to our patients.

Gina Baxter Chief Operating Officer, Chesapeake and Washington Heart Care

With ChronicCareIQ, we are better in touch with our patients, and patients feel better knowing that they have daily or regular contact with our office. We have also seen a significant decrease in office call volume.

Dr. James WestInternist, Perimeter North Internal Medicine

ChronicCareIQ has helped tremendously in keeping in touch with our patients on a constant and recurrent basis. It has also helped us improve our quality scores, decrease our emergency room utilization, and also decrease hospitalizations.

Dr. Salma Saiger Internist, Salma Mazhar MD PA Primary Care Clinic

FAQ

How is TCM different from CCM?

TCM supports patients during the transition from a qualifying facility discharge back to the community. CCM supports non-face-to-face care management for patients with two or more chronic conditions expected to last at least 12 months. Many patients may need both transition support and longer-term care management, but billing depends on patient eligibility, payer rules, timing, documentation, and avoiding duplicate or incompatible billing.

Which practices are a strong fit for TCM?

TCM is often relevant for primary care, multispecialty, cardiology, pulmonology, nephrology, and other practices that manage Medicare patients after hospital, skilled nursing, or other qualifying facility discharges.

What activities are commonly part of TCM?

TCM workflows often include patient outreach after discharge, medication reconciliation, follow-up scheduling, symptom review, care-plan updates, coordination with other providers, patient education, and documentation of qualifying care-management activity.

What does the post-discharge timing requirement mean?

TCM generally requires timely communication after discharge and a face-to-face follow-up visit within the required timeframe. Practices should confirm current CMS and payer requirements before billing. ChronicCareIQ helps organize outreach, follow-up, and documentation so teams can manage the transition window more consistently.

Can TCM be used with CCM, RPM, PCM, APCM, or BHI/CoCM?

Many practices manage TCM alongside other care-management programs, but billing depends on patient eligibility, payer rules, timing, documentation, and avoiding duplicate or incompatible billing. ChronicCareIQ helps organize program activity so practices can evaluate the right care-management path for each patient.

Who manages TCM work: providers or clinical staff?

TCM often involves both providers and clinical staff. Care teams may support outreach, medication reconciliation, follow-up coordination, documentation, and patient education, while providers complete the required visit and medical decision-making requirements.

How does ChronicCareIQ help prevent missed follow-up after discharge?

ChronicCareIQ helps practices organize post-discharge outreach, follow-up tasks, patient communication, medication reconciliation, documentation, and reimbursement activity in one connected workflow, reducing reliance on disconnected notes, manual reminders, and spreadsheets.

Does TCM require manual time tracking?

TCM is not billed the same way as monthly time-based care-management programs, but practices still need clear documentation supporting eligibility, outreach, follow-up, medical decision-making, and billing requirements. ChronicCareIQ helps keep that documentation connected.

How does ChronicCareIQ keep TCM documentation audit-defensible?

ChronicCareIQ helps organize qualifying patient communication, care coordination, follow-up activity, medication reconciliation, and program documentation into clearer records that support internal review and payer audit readiness.

Build a modern,  Scalable TCM program