Post-Discharge and Transition of Care Management (TCM)

Purpose

These visits ensure safe continuity after discharge by:

• Assessing current risk and stability
• Reconciling medications
• Reviewing the discharge recommendations

• Coordinating ongoing care

• Better patient outcomes: Early engagement reduces risk after discharge, including suicide and medication-related errors.
• Accurate reimbursement: Reflects the true intensity of care provided beyond the visit
• Sustainable operations: Supports the significant time spent on coordination, communication, and follow-up

Framing Post-discharge and Transition of Care

We are not a transitional program. We are ongoing outpatient psychiatry. However, we provide transition services when patients are discharged from higher levels of care (HLOC).

All recently discharged patients should be scheduled as:

Post-Discharge (40 mins)

These visits should:

• Confirm stability for outpatient level of care
• Reconcile meds
• Screen for relapse/suicidality, safety concerns
• Set clear boundaries for when a higher level of care is needed

Important Distinction

• Transition of Care (TOC) = the clinical work we perform
• TCM (99495/99496) = billing codes used only when strict criteria are met

Not all discharge visits qualify for TCM billing

How We Capture TCM (Workflow Overview)

All patients being discharged from HLOC are treated as potential TCM candidates until ruled out.

Step 1: Identify Discharge (at scheduling)

Document:

• Discharge date
• Facility name
• Facility type

Step 2: Request Discharge Records

Initiate request for:

• Discharge summary (true discharge summary may not be ready for 30-days) which should include: 
  • Medication list
  • Summary of care including any labs
  • Do not delay outreach or visit while waiting for records
  • Proceed with available information if records are pending

Complete 2-Business Day Contact

Conduct Post-discharge Visit

Billing Review (final determination)

Appointment Type

All patients are scheduled as:

Post-Discharge  (40 min)

• Appointment type does not determine billing
• TCM eligibility is determined by workflow + documentation

Post-Discharge Questionnaire (Automatic)

When a Post-Discharge visit is scheduled, a brief questionnaire (Post-Discharge) is automatically sent to the patient through the portal.

Purpose

• Capture key discharge details (facility, date of admission and discharge)
• Identify potential safety concerns early
• Prepare for more efficient outreach

• The questionnaire does not replace required contact
• TCM still requires interactive communication within 2 business days of the patient’s discharge

Why discharge information may be confirmed multiple times

Discharge details should be collected during scheduling, through the questionnaire, and again during outreach. This is intentional.

Each step serves a different purpose:

• Scheduling: Initial capture to ensure timely follow-up
• Questionnaire: Allows patient or caregiver to confirm or clarify details
• Outreach: Final clinical verification used for care decisions and billing.

Discharge information is frequently incomplete or inaccurate on first report. Confirming details ensures safe care, accurate documentation, and appropriate billing.

Billing: Transitional Care Management (TCM)

Transitional Care Management (TCM) services are used to bill for the coordination, communication, and medical decision making involved when a patient transitions from a facility (e.g., hospital, residential, SNF) to outpatient care.

These codes are not just for the visit—they capture the entire post-discharge management period (30 days).

MDM Level Selection (Practical Guidance)

• 99495 (Moderate):
  • Worsening psychiatric symptoms without immediate safety risk
  • Medication adjustments
  • Routine post-discharge stabilization
• 99496 (High):
  • Recent suicidality or safety concerns
  • Severe symptom exacerbation
  • High-risk medication management (e.g., lithium, antipsychotics with instability)
  • Significant coordination with facility, family, or other providers

Deciding between Post-Discharge and Transition of Care

Discharge Facility Types: TOC Eligible vs. Non-Eligible

What Is Included in TCM (Do Not Bill Separately)

The TCM code includes:

• Review of discharge records
• Communication with patient/caregiver
• Care coordination (family, pharmacies, facilities)
• Medication reconciliation
• Ordering/referring services