Best Practices: Transition of Care (TOC) Visits | February 2021 | Clinical Corner

Best Practices: Transition of Care (TOC) Visits


  1. Utilize MPP Transition of Care documentation or notifications from your local hospitalist group to initiate need for TOC appointment.

  2. Establish open access scheduling with appointments for TOC visits each week.

  3. Review and sign the Care Manager’s notes (from the required initial patient contact within 48 hours of discharge) enabling you to bill the Transitional Care Management (TCM) codes and generate higher revenue.
    1.  99495- TOC visit within 14 days = 2.11 wrvu’s, Medicare reimbursement $187
    2.  99496- TOC visit within 7 days = 3.05 wrvu’s, Medicare reimbursement $247
    3.  Non-TCM codes:
      1.  99213 = 0.97 wrvu’s, Medicare reimbursement $76
      2.  99214 = 1.5 wrvu’s, Medicare reimbursement $110
      3.  99215 = 2.11 wrvu’s, Medicare reimbursement $148

  4.  Refer your patients with chronic medical conditions for enrollment into MPP chronic care management program or McLaren’s Palliative Care program.

  5. Perform medication reconciliation with patient and/or care giver to ensure patient is taking the correct medications at the correct dosages.

  6. Instruct patients to bring pill bottles and discharge medication lists to the appointment.

  7. Coordinate follow-up appointments with specialists, as appropriate.
    1.  Often the patient does not know the specific specialist physician that saw them in the hospital.

  8.  Sign Homecare orders as soon as possible to prevent delay in start of care.