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Transitional Care Management

By automatically receiving real-time discharge notifications, your practice can reach out to patients to ensure a smooth transition between care settings and eliminate gaps in care.

Eliminate gaps in care with automatic discharge notifications

When patients are discharged or transition between care settings, let the system automatically inform you and keep tabs on them for the first 30 to 180 days to prevent re-admissions, avoid complications, and automatically track the activities necessary for proper and secure reimbursements.

With ChronicCareIQ, you receive real-time discharge notifications that allow your staff to proactively reach patients and other care providers in a timely manner to avoid gaps in care and stay connected with you.

Plus, your practice gets reimbursed for all of the extra time and effort your staff spends on helping to coordinate the transition of your medically complex and patients at risk of complications.

Top Benefits of TCM

  • Strengthen patient relationships as they transition between care settings
  • Proactively alert care management staff when enrolled patients change care settings
  • Ensure patients get the help they need during care transitions

“Our participation in value-based payment models continues to grow as a percentage of our revenue. ChronicCareIQ helps us ensure we hit all of the quality measures that are important to both our reimbursement rates and our patients.”

Primary Care Physician, Hospital-Owned Physician Group

How It Works

How ChronicCareIQ Simplifies TCM

With ChronicCareIQ, your staff is notified through an automatic alert whenever an enrolled patient transitions to a different care setting.

They are able to proactively reach out to the patient, caregivers, and care providers via smartphone app, text, email, desktop or tablet to exchange information, documentation, and other insights that ensure a seamless transition.

Integrated with your EHR and phone systems, ChronicCareIQ automatically captures the data and timestamps needed to bill accurately and properly for the TCM reimbursement.

Transitional Care Management CPT Billing Codes (as of CMS FY2022 Fee Schedule)

CPT 99495 – $209 (Increased 2022)
Transitional care management services with moderate medical decision complexity (face-to-face visit within 14 days of discharge)

CPT 99496 – $281 (Increased 2022)
Transitional care management services with high medical decision complexity (face-to-face visit within 7 days of discharge)

Hear What Our Customers are Saying