The 30 days after discharge are the highest-risk window in a patient's care. CareSpace turns TCM into an automatic motion — an interactive contact within two business days, a guided medication reconciliation, and a timely follow-up visit — so transitions are safer and readmissions fall.
Nearly one in five Medicare patients is readmitted within 30 days of discharge, and most of those readmissions are avoidable. Transitional Care Management is CMS's structured answer: reach the patient quickly, reconcile their medications, and get them in front of a clinician before a small drift becomes a crisis.
An interactive contact within 2 business days. A real two-way touchpoint — phone or in-person — to catch problems while they're still small.
Medication reconciliation, done right. Discharge orders are reconciled against the home regimen, with changes and discrepancies surfaced for review.
A follow-up visit within 7 or 14 days. Timed to complexity, so the highest-risk patients are seen first — and the encounter is fully documented.
where the difference between a safe transition and a setback is decided.
meaningfully lower 30-day readmissions across discharged cohorts
interactive contact window, tracked automatically on every discharge
captured per high-complexity discharge that often goes unbilled today
added annual revenue at ~30 qualifying discharges per month
TCM is reimbursed once, per qualifying discharge, when the contact, reconciliation and follow-up elements are met and documented. Two CPT codes apply, set by complexity and how quickly the patient is seen.
Interactive contact within 2 business days, medication reconciliation, and a follow-up visit within 14 calendar days of discharge.
The same interactive contact and reconciliation, with a follow-up visit within 7 calendar days for your highest-risk discharges.
A practice managing roughly 30 qualifying discharges per month — care you're very likely already delivering — captures on the order of $75k+ in new annual TCM revenue. Most of it is left on the table today simply because the elements aren't documented for a clean claim.
2025 CMS national averages — estimates, verify with your MAC
CareSpace ingests the feed, starts the clock, guides the work, and documents every element — so the claim writes itself and nothing slips.
Discharge and ADT feeds flow in automatically. The moment a patient leaves, CareSpace creates a TCM task and starts the 2-business-day contact clock.
Your team works a prioritized queue to log the interactive contact in time — with the window tracked so the requirement is never missed.
Guided medication reconciliation surfaces changes against the home regimen, then schedules the follow-up visit within 7 or 14 days by complexity.
Every element is captured for a clean 99495 or 99496 claim — audit-ready, no spreadsheets, no revenue left behind.
See how CareSpace turns every discharge into a safe transition — and a clean, compliant claim. Pair it with Chronic Care Management for end-to-end coverage, or explore the full solutions suite.