Transitional Care Management

Own the 30 days
after discharge

The riskiest month in a patient's care is the one right after the hospital. HealthViewX catches every discharge, drives the two-business-day contact and the follow-up visit on time, and manages the full 30-day transition — reducing readmissions and capturing the reimbursement you're owed for the work.

Transitional Care Management — Discharge Queue
14 discharges today · 3 contact windows closing soon
40%
Faster post-discharge follow-up
PatientDischargedContact WindowComplexityVisit StatusBilling
Steve Rogers
Today
1 day leftHighVisit in 5d99496 Ready
Maria Jelene
Yesterday
ContactedModerateScheduledIn Progress
Wilbur Harris
2 days ago
ContactedHighCompleted99496 Ready
Brenda Smith
Today
2 days leftModeratePendingIn Progress
−30%
reduction in 30-day readmissions across the panel
✦ AI Call Center
14
discharge outreach calls placed automatically today
40%
+40%
Faster post-discharge follow-up
Proven Outcomes

Transitions that don't bounce back

What organizations achieve when every discharge is followed up on time.

30%
Reduction in 30-Day Readmissions
Structured post-discharge outreach within the required contact window.
40%
Faster Post-Discharge Follow-Up
Automated discharge alerts trigger same-day patient contact.
25%
Reduction in Avoidable Acute Care
Medication reconciliation and early follow-up prevent complications.
24%
Reduction in 30-Day Mortality After Discharge
Timely face-to-face visits for high-complexity discharges.
The Challenge

Discharges slip through the cracks

TCM has the tightest clock in Medicare, and most practices can't run it manually.

A 2-Business-Day Clock

Interactive contact is required within two business days of discharge — miss it and the service can't be billed.

No Discharge Visibility

Practices often don't know a patient was hospitalized until they call or get readmitted.

Medication Risk at Home

Post-discharge medication errors and confusion drive avoidable ED visits and readmissions.

Missed Visits, Missed Revenue

Without tracking the 7- and 14-day windows, visits slip and 99495/99496 goes unbilled.

Schedule Demo
The TCM Journey

Every discharge, managed end to end

HealthViewX runs the full 30-day service period on rails, with every deadline tracked.

01 · IDENTIFY

Catch the discharge

ADT feeds and hospital notifications surface every discharge the moment it happens.

02 · CONTACT
within 2 business days

Reach out within 2 business days

Worklists and AI-powered calls streamline patient outreach at scale.

03 · RECONCILE

Review & reconcile medications

Discharge summary reviewed and medications reconciled before the visit.

04 · VISIT

Face-to-face visit on time

The follow-up visit scheduled and tracked within 7 days (high complexity) or 14 days (moderate).

05 · COORDINATE
30-day timeline

Manage the 30 days

Capture every referral, service, and patient interaction in real time.

06 · BILL & REPORT
99496

Claim-ready documentation

99495/99496 assigned automatically based on complexity and timing.

Reimbursement

Medicare TCM reimbursement, built in

TCM pays a premium for owning the transition. HealthViewX tracks contact timing, visit windows, and complexity, and assigns the right code automatically.

ServiceRequirementFrequencyReimbursement
CPT 99495
TCM, moderate complexity
Moderate MDM
Contact in 2 business days, face-to-face visit within 14 daysOnce per 30-day period~$205
CPT 99496
TCM, high complexity
High MDM
Contact in 2 business days, face-to-face visit within 7 daysOnce per 30-day period~$278
Interoperability

Works with your existing systems

HealthViewX, HealthBridge, connects seamlessly with your EMR/EHR, PHM, and third-party systems for a true all-in-one, value-based care experience.

Epic
Allscripts
NextGen
eClinicalWorks
MEDITECH
Centricity
AdvancedMD
CareCloud
Practice Fusion
Cerner
✓ Bi-directional Sync
✓ Real-time Updates
✓ Patient Demographics
✓ Clinical Data
✓ Orders & Results
✓ Scheduling
Built for Enterprise Healthcare
HIPAA
GDPR
AICPA SOC
EscrowTech Secured
ONC-Certified Health IT
Drummond Certified
Trusted by Leading Healthcare Organizations
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