Transitions of Care

Transitions of Care is a software application designed to help independent primary care practices document and bill Transitional Care Management services under Medicare CPT codes 99495 and 99496. The platform guides practices through the required steps during the 30-day post-discharge window, including initial patient contact within two business days and follow-up visits within 7 or 14 days. It organizes the documentation elements required to meet audit requirements for reimbursement.

The service is specifically designed for independent primary care practices that need to manage the 30-day post-discharge window for Medicare patients. It addresses the challenge of preventing readmissions by ensuring every step is documented correctly to qualify for reimbursement. The app watches every deadline and assembles the record so the practice can focus on seeing the patient.

The platform is offered to practices nationwide, covering patients across America. It is free to register with no contract or IT project required, making it accessible for practices of various sizes. The service runs on PanelMD and maintains HIPAA BAA and SOC 2 Type II compliance.

The app provides interactive contact capabilities that reach the patient in the practice's voice with every touch timestamped. It also schedules both the 7-day and 14-day windows so the right code is earned, not guessed. At the end, it creates an audit-ready record mapped line by line to the code billed.

The service claims that about one in five Medicare patients is readmitted within a month, and Medicare pays $20–40K a year to prevent this. The app helps practices collect this revenue by clearing the documentation bar that most never meet. The billable window is described as a clock that runs itself from day 0 discharge to day 30 billing.

The platform confirms whether a patient actually stayed home by pulling from the hospital and the health plan for thirty days. It tells the practice what happened once a patient leaves the hospital, which is information their own doctor usually never finds out. This feature helps verify that the patient remained in the community during the critical window.

The website states that missing one element in the documentation process means the whole episode pays nothing. The app ensures every step is present to avoid this risk. The documentation bar is cited as the reason most practices never collect the full reimbursement amount.

The process involves an initial contact within two business days, a face-to-face visit within 7 or 14 days depending on complexity, and 30 days of care oversight. The final step is an audit-proof record where every element is mapped to the code. The entire workflow is designed to run itself without needing a care-management department.

The platform is described as the first tool that helps a doctor catch patients slipping during the thirty days after discharge and document it properly so it counts. A primary care doctor on the platform provided this feedback. The system is positioned as essential for stopping the path from recovering to readmitted.

The site profile notes that the service addresses the documentation challenges of preventing Medicare readmissions. It simplifies the process of registering practices and managing the required documentation for reimbursement. The site is a software tool designed to manage TCM billing for CPT codes 99495 and 99496.

The website claims that the thirty days after discharge are when patients slip, and this tool helps catch them. It is positioned as different from other solutions by actually helping to document properly so the work counts. The app clears the documentation bar that causes most practices to miss out on revenue.

A first-time customer should know that the app watches every deadline and assembles the record automatically. The practice just sees the patient, while the software handles the clock and the file. The discharge arrives on the worklist with the clock already running, requiring no manual setup.

The platform offers a free registration process that takes under 10 minutes. There is no contract or IT project required to begin using the service. The site profile confirms it is a software tool designed to manage TCM billing for CPT codes 99495 and 99496.

The official website of Transitions of Care is care-transition.com.

On Trustburn, Transitions of Care has a rating of 3.3 out of 5 based on 4 reviews.