For nearly two decades, Better Health Group has been a leader in value-based care and operating top-rated primary care clinics. Our network of owned and independent clinics leverage our model to improve care for both Medicare Advantage (MA) and Traditional Medicare patients. Now, the Centers for Medicare & Medicaid Services (CMS) has ranked Better Health Group in the top 5% of Medicare Shared Savings Program (MSSP), Accountable Care Organizations (ACOs) for performance year 2023.
At a time when independent clinics face mounting challenges, our providers are exceeding CMS quality goals and maximizing shared savings revenue, in every state in which we operate—Florida, Alabama, Georgia, Texas, Oklahoma, and Tennessee.
What Is Transitional Care Management?
Transitional Care Management (TCM) is a Medicare-covered service designed to support patients during the 30 days immediately following discharge from a hospital, skilled nursing facility, or other inpatient setting. CMS created TCM billing codes in 2013 specifically to reduce preventable readmissions and close the coordination gap between the inpatient and outpatient setting.
TCM isn't a single visit. It's a structured, three-part service: an interactive contact with the patient within two business days of discharge, a face-to-face visit within either 7 or 14 days (depending on medical complexity), and non-face-to-face care coordination, including medication reconciliation, throughout the 30-day window.
Why TCM Matters So Much for Readmission Rates
The discharge period is one of the highest-risk windows in a patient's care. Roughly one in five Medicare beneficiaries is readmitted within 30 days of discharge, and a substantial share of those readmissions are considered preventable. A peer-reviewed study published in the American Journal of Medical Quality found that patients who received the full complement of TCM services had 86.6% lower odds of a 30-day readmission compared to patients who received none.
That's not a marginal improvement. It's one of the more consistently effective, low-cost interventions in post-acute care, which is exactly why value-based arrangements pay close attention to it.
Who Can Provide TCM Services?
TCM can be furnished by physicians of any specialty, as well as nurse practitioners, physician assistants, and clinical nurse specialists. Much of the non-face-to-face coordination work, like the initial two-day contact, can be performed by clinical staff under general supervision, which makes TCM more scalable for a busy primary care practice than it might initially appear.
Why This Matters in a Value-Based Contract
Readmissions are expensive, both for the health system and for any ACO or MSO holding risk for total cost of care. A practice that reliably identifies discharged patients, makes contact within 48 hours, and gets them seen within the required window is directly reducing the kind of avoidable utilization that value-based contracts are built to prevent. It also happens to be one of the more straightforward ways an independent practice can differentiate itself when negotiating with hospital partners and payers.
FAQ
- How long does the TCM service period last? 30 days, beginning the day of discharge.
- What's the difference between the two TCM billing codes? CPT 99495 requires moderate-complexity decision-making and a face-to-face visit within 14 days; CPT 99496 requires high-complexity decision-making and a face-to-face visit within 7 days.
- Can TCM be provided via telehealth? Yes, the required face-to-face visit can be furnished via telehealth if it meets CMS's telehealth billing requirements.
What Is Transitional Care Management?
Transitional Care Management (TCM) is a Medicare-covered service designed to support patients during the 30 days immediately following discharge from a hospital, skilled nursing facility, or other inpatient setting. CMS created TCM billing codes in 2013 specifically to reduce preventable readmissions and close the coordination gap between the inpatient and outpatient setting.
TCM isn't a single visit. It's a structured, three-part service: an interactive contact with the patient within two business days of discharge, a face-to-face visit within either 7 or 14 days (depending on medical complexity), and non-face-to-face care coordination, including medication reconciliation, throughout the 30-day window.
Why TCM Matters So Much for Readmission Rates
The discharge period is one of the highest-risk windows in a patient's care. Roughly one in five Medicare beneficiaries is readmitted within 30 days of discharge, and a substantial share of those readmissions are considered preventable. A peer-reviewed study published in the American Journal of Medical Quality found that patients who received the full complement of TCM services had 86.6% lower odds of a 30-day readmission compared to patients who received none.
That's not a marginal improvement. It's one of the more consistently effective, low-cost interventions in post-acute care, which is exactly why value-based arrangements pay close attention to it.
Who Can Provide TCM Services?
TCM can be furnished by physicians of any specialty, as well as nurse practitioners, physician assistants, and clinical nurse specialists. Much of the non-face-to-face coordination work, like the initial two-day contact, can be performed by clinical staff under general supervision, which makes TCM more scalable for a busy primary care practice than it might initially appear.
Why This Matters in a Value-Based Contract
Readmissions are expensive, both for the health system and for any ACO or MSO holding risk for total cost of care. A practice that reliably identifies discharged patients, makes contact within 48 hours, and gets them seen within the required window is directly reducing the kind of avoidable utilization that value-based contracts are built to prevent. It also happens to be one of the more straightforward ways an independent practice can differentiate itself when negotiating with hospital partners and payers.
FAQ
- How long does the TCM service period last? 30 days, beginning the day of discharge.
- What's the difference between the two TCM billing codes? CPT 99495 requires moderate-complexity decision-making and a face-to-face visit within 14 days; CPT 99496 requires high-complexity decision-making and a face-to-face visit within 7 days.
- Can TCM be provided via telehealth? Yes, the required face-to-face visit can be furnished via telehealth if it meets CMS's telehealth billing requirements.
What Is Transitional Care Management?
Transitional Care Management (TCM) is a Medicare-covered service designed to support patients during the 30 days immediately following discharge from a hospital, skilled nursing facility, or other inpatient setting. CMS created TCM billing codes in 2013 specifically to reduce preventable readmissions and close the coordination gap between the inpatient and outpatient setting.
TCM isn't a single visit. It's a structured, three-part service: an interactive contact with the patient within two business days of discharge, a face-to-face visit within either 7 or 14 days (depending on medical complexity), and non-face-to-face care coordination, including medication reconciliation, throughout the 30-day window.
Why TCM Matters So Much for Readmission Rates
The discharge period is one of the highest-risk windows in a patient's care. Roughly one in five Medicare beneficiaries is readmitted within 30 days of discharge, and a substantial share of those readmissions are considered preventable. A peer-reviewed study published in the American Journal of Medical Quality found that patients who received the full complement of TCM services had 86.6% lower odds of a 30-day readmission compared to patients who received none.
That's not a marginal improvement. It's one of the more consistently effective, low-cost interventions in post-acute care, which is exactly why value-based arrangements pay close attention to it.
Who Can Provide TCM Services?
TCM can be furnished by physicians of any specialty, as well as nurse practitioners, physician assistants, and clinical nurse specialists. Much of the non-face-to-face coordination work, like the initial two-day contact, can be performed by clinical staff under general supervision, which makes TCM more scalable for a busy primary care practice than it might initially appear.
Why This Matters in a Value-Based Contract
Readmissions are expensive, both for the health system and for any ACO or MSO holding risk for total cost of care. A practice that reliably identifies discharged patients, makes contact within 48 hours, and gets them seen within the required window is directly reducing the kind of avoidable utilization that value-based contracts are built to prevent. It also happens to be one of the more straightforward ways an independent practice can differentiate itself when negotiating with hospital partners and payers.
FAQ
- How long does the TCM service period last? 30 days, beginning the day of discharge.
- What's the difference between the two TCM billing codes? CPT 99495 requires moderate-complexity decision-making and a face-to-face visit within 14 days; CPT 99496 requires high-complexity decision-making and a face-to-face visit within 7 days.
- Can TCM be provided via telehealth? Yes, the required face-to-face visit can be furnished via telehealth if it meets CMS's telehealth billing requirements.