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Transitional Care Management with Medication Reconciliation PostDischarge Complete to meet quality care standards and promote better health outcomes. UnitedHealthcare encourages you to help address
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Step 1: Begin by collecting all the necessary patient information, including their medical history, current medications, and recent discharge summary.
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Step 2: Familiarize yourself with the specific requirements and guidelines for transitional care management (TCM) set by the Centers for Medicare and Medicaid Services (CMS).
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Step 3: Ensure that the patient meets the criteria for TCM, which generally includes having a moderate or high complexity medical decision-making during the 30 days following discharge.
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Step 4: Schedule an initial TCM visit within 7-14 days of the patient's discharge from a hospital, skilled nursing facility, or other qualifying inpatient facility.
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Step 5: During the TCM visit, thoroughly assess the patient's condition, address any immediate health concerns, and develop a comprehensive care plan that includes medication reconciliation, coordinating follow-up appointments, and identifying any necessary community resources.
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Step 6: Provide necessary TCM services, such as non-face-to-face communication with the patient and/or caregiver within 2 business days of discharge, subsequent care coordination, and transition management.
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Step 7: Document all TCM services provided accurately, including the time spent on each activity, to ensure proper billing and reimbursement.
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Step 8: Follow up with the patient regularly, provide ongoing care coordination, and ensure smooth transitions between healthcare settings.
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Step 9: Maintain thorough and up-to-date documentation of all TCM services provided, including progress notes, communication logs, and any referrals made.
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Step 10: Continuously stay informed about any updates or changes to TCM guidelines to ensure compliance.

Who needs transitional care management with?

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Transitional care management is typically provided to patients who have been discharged from a hospital or other inpatient facility and require additional support during their transition back to the community or a lower level of care.
02
Patients who have complex medical needs, multiple chronic conditions, or are at high risk for readmission may especially benefit from transitional care management.
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Additionally, individuals who have recently undergone a surgical procedure, experienced a significant change in their health condition, or require close monitoring and coordination of care may also be candidates for transitional care management.
04
It is important to assess each patient's individual needs and eligibility for TCM based on the specific criteria set by CMS or other relevant healthcare organizations.
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Transitional care management involves the coordination and management of care for patients as they move from one healthcare setting to another.
Healthcare providers are required to file transitional care management services with the appropriate coding and billing information.
Transitional care management can be filled out by documenting the necessary patient information, services provided, and follow-up plans.
The purpose of transitional care management is to ensure smooth transitions for patients between healthcare settings and reduce the risk of complications.
Information such as the patient's medical history, current medications, treatment plan, and any follow-up appointments must be reported on transitional care management forms.
Penalties for late filing of transitional care management services may vary depending on the specific regulations and guidelines set by healthcare authorities.
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