TCM Software to Track Every Discharge and Bill 99495/99496 Confidently
Real-time discharge tracking, automated 2-day contact workflows, and complete TCM billing — all in one platform.
Measurable Outcomes for Transitional Care Management Programs
The 30 days after hospital discharge is when patients are most vulnerable to readmission — and when TCM generates its highest clinical and financial return. Most practices miss over half of their billable TCM opportunities simply because they don't have a system to track discharges in real time.
Revenue Per Episode
$165–$234
Medicare Reimbursement Per TCM Episode (99495: ~$165 / 99496: ~$234)
30-Day Readmissions
−32%
Average Reduction in 30-Day Readmissions with Active TCM Follow-Up
Missed Opportunities
54%
Of Billable TCM Episodes Are Missed by Practices Without Discharge Tracking
Medication Errors
−41%
Reduction in Post-Discharge Medication Errors with Structured Reconciliation Workflows
Features
A Comprehensive Feature Pack for Your Transitional Care Management Platform
From real-time hospital ADT discharge feeds and automated 2-business-day contact workflows to structured medication reconciliation, face-to-face visit scheduling, and 99495/99496 claim generation — Vervelo manages every TCM deadline automatically.
Transitional Care Management
Real-Time Discharge Notification Tracking
ADT feeds from hospitals and SNFs alert coordinators to every discharge in real time — with countdown timers for 2-day and 7/14-day deadlines built into the worklist.
Transitional Care Management
2-Business-Day Interactive Contact Workflow
Automated outreach triggers immediately on discharge. Coordinators document interactive contact with CMS-required detail. Escalation rules catch non-responders before the deadline.
Transitional Care Management
Structured Medication Reconciliation
Discharge med list vs. home med comparison flags discrepancies and high-risk medications. Structured teach-back documentation ensures patient education is captured.
Transitional Care Management
Automated 99495/99496 Billing
Auto-selects 99495 or 99496 based on complexity. Tracks face-to-face visit requirements. Produces complete audit-ready documentation packages for every claim.
Why Vervelo for Transitional Care Management
Built for primary care practices that need to catch every discharge, meet every CMS deadline, and bill every TCM episode with confidence.
HIPAA Compliant
All discharge data, contact records, medication reconciliation logs, and billing documentation are encrypted and stored with role-based access controls.
Real-Time ADT Feeds
Live hospital and SNF discharge notifications mean no discharge goes unnoticed — and no TCM billing window silently closes before you know a patient was hospitalized.
EHR Compatible
Bi-directional EHR integration keeps discharge notes, medication lists, and visit documentation in sync with your existing system — no duplicate charting.
Deadline Automation
From the 2-day contact window to the 7-day or 14-day face-to-face requirement, Vervelo tracks every TCM deadline automatically and alerts staff before windows close.
Primary Aims of Vervelo Transitional Care Management
TCM is CMS's highest-reimbursed care management code — and the most time-constrained. Every TCM capability in Vervelo is designed around these core outcomes.
Reduce 30-Day Readmissions
Structured post-discharge follow-up, medication reconciliation, and early warning identification are the evidence-based interventions that prevent the avoidable readmissions that trigger CMS penalties.
Capture Every Billable TCM Episode
Real-time discharge tracking and automated deadline management ensure that no 99495 or 99496 billing opportunity is missed — converting a chaotic reactive process into a systematic revenue stream.
Eliminate Medication Errors at Discharge
The transition home is the highest-risk moment for medication errors. Structured discharge-to-home medication reconciliation with clinical review closes the most dangerous gap in transitional care.
Meet All CMS TCM Requirements
2-day interactive contact, face-to-face visit within the complexity window, medication reconciliation, and comprehensive care management — Vervelo tracks and documents every CMS-required element.
Identify New VBC Program Opportunities
A hospitalization often signals a patient whose chronic conditions are not well-controlled. Vervelo automatically flags newly eligible CCM, RPM, or BHI patients identified through TCM — converting a crisis into a long-term enrollment.
Reduce CMS Readmission Penalties
Under the Hospital Readmissions Reduction Program, practices and hospitals share accountability for readmission rates. Systematic TCM directly reduces the events that trigger shared savings penalties.
120+ Healthcare Organizations Trust Vervelo
Across TCM, CCM, RPM, BHI, AWV, PCM, and APCM programs
Transitional Care Management in Practice
Real results from practices using Vervelo's TCM platform.
CarePlus Telehealth
Reduced 30-day readmissions by 34% across 800 high-risk Medicare patients using Vervelo's discharge tracking and structured follow-up workflows.
Grandview Hospital Medical Group
Increased TCM billing from 12% to 89% of eligible discharge episodes — adding $41,000/month in 99495/99496 revenue previously left on the table.
HealthBridge Primary Care
Identified and resolved medication discrepancies in 63% of post-discharge reconciliations — including 14 high-risk anticoagulant errors caught before harm occurred.
Built to Meet Healthcare's Highest Compliance Standards
Ready to Capture Every TCM Billing Opportunity?
Talk to a Vervelo TCM specialist. We'll analyze how many discharge episodes your practice is currently missing and show you exactly what the TCM revenue opportunity looks like for your patient panel.
TCM revenue opportunity analysis based on your discharge volume
Projected 99495/99496 billing uplift and readmission cost savings
ADT feed setup and EHR integration assessment
Get a Free TCM Revenue Assessment
Frequently Asked Questions
Common questions about Transitional Care Management and Vervelo's TCM platform.