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Ambulatory providers: achieving TCM success

As hospitals and health systems increasingly rely on ambulatory care providers to support patient care outside the four walls of a hospital, ambulatory providers must work to ensure a patient’s successful transition and recovery when moving from one care setting to another – such as from the hospital to the home. To improve pa­tient transitions back into the community, reduce avoidable emergency department (ED) visits and hospital readmissions, and minimize gaps in care, many ambulatory providers – including physician offices, outpatient departments, ambulatory surgical centers, specialty clinics or centers (for example, dialysis or infusion), and urgent care clinics – are conducting transitional care management (TCM) services.

Transitional care management

Transitional care management, an initiative from CMS, is a set of services conducted during the patient tran­sition to the community following discharge from an acute, LTACH, SNF, or IRF setting of care.

TCM services are offered within a 30-day period beginning on the date of a patient’s discharge from inpatient care. The three TCM components include interactive contact, and certain non-face-to-face and face-to-face services.

  • An interactive contact with the patient or caregiver must be made – or attempted – within 48 hours of patient discharge via telephone, email, or in-person communication to discuss and schedule follow-up services, and review diagnosis at discharge and inpatient services.
  • Within either seven or 14 days of discharge (depending on patient complexity), face-to-face services are required. Medication reconciliation is required for patients on or before the date of the face-to-face visit as part of TCM.
  • Non-face-to-face services refer to a provider’s activity to assess and inform the patient, other providers, caregivers, and involved community services regarding the patient’s health and care coordination or educational needs.[1]

Billing for TCM services

In 2013, CMS began offering payment to ambulatory care practices for TCM services. The first provider to make interactive contact is the only one that can bill for the services. If two or more unsuccessful attempts are made to reach the patient within two days post-discharge, and all other TCM criteria are met, the service may still be reported – and billed. If contact with the patient is not made within this required timeframe, the provider cannot bill for TCM services.

Achieving success in TCM with CarePort

Ambulatory providers can leverage CarePort to help conduct TCM services to improve transitions, reduce readmissions, optimize outcomes, and drive revenue.

Allegheny Health Network

Handling more than 80,000 discharges and observations per year, Allegheny Health Network (AHN) lacked visibility into all transitions of care – including discharges from non-AHN acute and post-acute providers – and faced challenges in identifying and contacting patients that qualified for post-discharge interactive contact and subsequent face-to-face services. As part of AHN/Physician Partners of Western Pennsylvania’s Practice Transformation initiative, AHN leveraged CarePort Connect to receive real-time notifications of patient discharges and improve the speed to conducting TCM services. Through this partnership, AHN achieved a 49% year-over-year increase in TCM encounters – and also increased seven-day follow-up visits post-discharge, optimized their TCM revenue stream, and improved medication reconciliation completion post-patient discharge.


New York-based independent practice association CAIPA lacked visibility into patient events at acute care hospitals across the state. Leveraging CarePort Connect, CAIPA can monitor patient admissions and discharges via real-time notifications and alerts to conduct TCM services for patients within 48 hours post-discharge and schedule follow-up office visits seven to 14 days post-discharge. Supporting CAIPA’s TCM initiatives, CarePort helps streamline pa­tient transitions back into the community and minimize gaps in care – ultimately reducing costs from unnecessary emergency department visits and hospital readmissions.

To learn more about how CarePort can help your organization succeed in TCM services, visit our website or send us an email.


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