Samantha SizemoreThe Centers for Medicare & Medicaid Services (CMS) introduced transitional care management (TCM) in 2013 to help reduce readmission rates for patients with complex physical or psychosocial needs, presenting a strong financial opportunity for physicians who help Medicare patients transition from a hospital to a community environment. The incentives are high: CMS estimates primary care physicians could increase collections by up to 4 percent by offering TCM services, while internists could see a 6 percent boost in collections. Further, physician practices that excel in TCM could qualify for performance incentives under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

For many physician practices, however, meeting the billing requirements for TCM isn’t easy, and many miss out on opportunities to collect TCM revenue. For example, CMS requires practices to contact qualifying patients within two business days of discharge. If a practice is unaware that one of its patients was hospitalized, that makes TCM compliance extraordinarily difficult.

Holston Medical Group’s Five Tips for Success

Holston Medical Group (HMG), a regional medical group that serves 200,000 patients in northeast Tennessee and southwest Virginia, averages an 86 percent success rate in billing TCM services, with only a 3 percent denial rate. The organization attributes its success to five best practices in its efforts to efficiently incorporate TCM billing into provider workflows. 

Establish an electronic admission/discharge/transfer (ADT) feed with the hospitals in the area. This feed alerts the healthcare organization’s physicians when Medicare patients are discharged from the hospital to their homes or to assisted living centers, thereby ensuring the team is able to call patients within 48 hours of discharge, per TCM requirements. At HMG, ADT feeds and discharge summaries are incorporated into a community health information exchange so staff can view the data easily and act upon the information readily.

HMG has dedicated two full time employees and one part-time employee to support its 88 physicians in meeting TCM requirements and follow up with patients who have been seen in the emergency department. HMG’s physician practice staff monitors ADT feeds and follows up with patients and caregivers to schedule post-discharge appointments. Practices that do not have the resources for a dedicated staff member to review ADT feeds or that have a low number of TCM discharges can enlist the help of front-desk staff.

Develop a template in the electronic health record (EHR) for documenting the initial call to the patient. To meet TCM requirements, a practice must show that it attempted to contact the patient three times within 48 hours of discharge. Documentation of a good-faith effort to contact the patient—even if unsuccessful—is critical. A template in the EHR can help document the date of discharge, time and date of each follow-up call, and a summary of the conversation or message left for the patient and/or caregiver. 

Prioritize time daily for post-discharge visits. TCM requires that patients receive face-to-face follow-ups within seven or 14 days (including weekends) depending on whether the patients’ conditions are of moderate or high medical complexity, respectively.

One best practice is to set aside time in the morning and the afternoon for post-discharge follow-up visits to increase convenience for patients and their caregivers and to improve support staff efficiency. If openings with the patient’s primary care physician are booked, another physician in the practice should see the patient.

Engage patients and caregivers in TCM protocols during the first office visit. In their first visit, patients should be educated about TCM processes and how these processes can help manage their condition and avoid readmission. Addressing the patient’s concerns and providing the right education will help support compliance, improving outcomes. 

Create a template for nurses and physicians to use in following and documenting TCM protocols. The organization should build alerts into the EHR to notify the care team when a TCM patient is seen and develop a checklist, accessible from the EHR, that makes it easy for physicians and nurses to make sure key components for care are addressed. The checklist could include the discharge summary, making referrals for appropriate community services and providing education around patient self-care.

Managing the Complexities of TCM Billing

Meeting the requirements for TCM billing isn’t always easy, but with the right tools and staff support, it is manageable. Practices that address TCM’s challenges improve health outcomes for a provider organization’s patients while protecting the organization’s financial health.


Samantha Sizemore is COO, Holston Medical Group, Kingsport, Tenn.  

Publication Date: Tuesday, January 01, 2019