Transitional Care Management (TCM)

The 30 days following a hospital discharge represent the highest-risk period in a patient's care journey. Readmission rates during this window are one of the most significant quality and cost challenges facing providers and health systems today. Transitional Care Management is the CMS-reimbursable program designed specifically for this period — and BloomCare executes it with the clinical urgency it demands. Our virtual RN teams initiate contact within the required timeframes, coordinate follow-up care, reconcile medications, and keep patients connected to their providers during the transition period when gaps in care are most likely to result in readmission.

What's Included

• Contact initiation within 2 business days of discharge per CMS requirements
• Medication reconciliation and patient education during transition period
• Coordination with discharging facility, specialists, and primary care providers
• Face-to-face visit coordination within CMS-required timeframes
• Full documentation of all transitional care activities in Bloom360™
• Readmission risk assessment and escalation protocols
• Reporting on TCM completion rates, readmission outcomes, and revenue generated

Why Choose BloomCare for TCM

• CMS timeframe requirements are met consistently — BloomCare manages the entire process
• Medication reconciliation and care coordination reduce readmission risk at the most critical point
• Full documentation and compliance management built into every discharge transition
• TCM integrates directly with CCM for patients requiring ongoing chronic care management
• Providers receive reimbursement for high-value care that was previously uncompensated

Program Details

TCM is billed under CMS codes CPT 99495 and 99496, differentiated by the complexity of medical decision-making and the timing of the required face-to-face visit. BloomCare manages patient identification at discharge, all required outreach and coordination activity, and complete documentation to support billing — giving practices a fully managed transitional care program that reduces readmissions and generates consistent reimbursement.

Schedule a consultation to learn how BloomCare reduces readmissions while generating TCM revenue for your practice.