Transitional Care Management

Transitional Care Management (TCM) services address the hand-off period between the inpatient and community setting. Please use these resources as learning materials about TCM services, as well as the requirements and implementation process for your practice.

Photo of hospital coworkers

What Are TCM Services?

Services rendered to new and established patients that have a moderate or high medical decision making during their transition from an inpatient hospital setting to a community setting.

Inpatient Hospital Settings:

  • Inpatient Acute Care Hospital
  • Inpatient Psychiatric Hospital
  • Long Term Care Hospital
  • Skilled Nursing Facility
  • Inpatient Rehabilitation Facility
  • Hospital outpatient observation or partial hospitalization
  • Partial hospitalization at a Community Mental Health Center

Community Settings:

  • His or her home
  • His or her domiciliary
  • A rest home
  • Assisted living

Why provide TCM to your patients?

Transitional care management (TCM) is intended to reduce potentially preventable readmissions and medical errors during the 30 days following discharge from the acute care setting. The TCM codes recognize the additional work required to provide support to patients after discharge.

Implementing TCM

Implementing TCM requires cooperation between the acute care setting and outpatient provider to review and redesign processes and workflows. Leadership and medical staff in the practice and acute care setting should champion the change. Nursing staff should be involved in designing the process. Working with coding and billing staff prior to implementation is important for developing complete documentation and systems to bill for the service.