Catch the discharge
We monitor ADT feeds, portals and faxes so no discharge goes unnoticed.
Transitions & preventionTCM
The weeks after a hospital or facility stay are when patients are most likely to slip. TCM pays for contacting patients quickly, reconciling medications and seeing them soon after they get home. We watch discharge feeds, make the two-day contact and book the follow-up visit on time.
Who qualifies
Eligibility is confirmed against your own population before a pilot group is approached.
- 01
Discharge from an inpatient, observation, skilled nursing or similar facility to the community
- 02
Interactive contact within two business days of discharge
- 03
A face-to-face visit within 7 or 14 days, depending on complexity
- 04
Medication reconciliation no later than the face-to-face visit
What your patients experience
- A call within two business days of getting home
- Help understanding new medications
- A follow-up visit booked before they leave the phone
- Fewer surprises in the first month home
How we run it
Your clinicians keep every clinical decision. We run the operations around them.
Call within two days
Coordinators reach the patient or caregiver and record the interactive contact.
Book the visit
Follow-up appointments are scheduled inside the required window.
Prepare the clinician
Discharge summaries and medication lists are gathered before the visit.
Hand off to ongoing care
Eligible patients are offered CCM, PCM or RPM once the transition period ends.
Stays with your clinicians
Medication reconciliation, the face-to-face visit and medical decision-making remain with the practitioner.
What your practice receives
- Discharge-notification monitoring
- Two-day contact logs
- Visit timing tracked to the 7/14-day window
- Medication-reconciliation prompts
Billing reference
Listed as published for calendar year 2026 under the Medicare Physician Fee Schedule. Requirements, documentation rules and payer policies change — confirm current CMS and payer guidance with your billing team. Carevory does not guarantee reimbursement. TCM billing codes
| Code | What it covers |
|---|---|
| 99495 | Moderate complexity — face-to-face visit within 14 days of discharge |
| 99496 | High complexity — face-to-face visit within 7 days of discharge |
Carevory does not guarantee reimbursement. Confirm current CMS and payer guidance with your billing team before you bill.
Often combined with
The same minutes are never counted toward two programs — time is logged against one at a time.
FAQ
What practices ask before launching TCM.
Through the sources you already have — ADT notifications, hospital portals, health-information exchanges or faxes — and we confirm feasibility during discovery.
Attempts are documented according to CMS guidance and your protocol, and we keep trying until contact is made.
Your clinicians, or qualified clinical staff working under your supervision and protocols where contracted. Carevory runs the operations around them: eligibility, enrollment, outreach, scheduling, queues, documentation and reporting.
No. Payer rules, documentation and clinical decisions determine payment. We help you meet program requirements and give you clean records for billing review.
Start with one workflow
Tell us about your patient population, systems and staffing. We'll scope a pilot group, the workflow and the reporting you'd see each month.
Business inquiries only. Please don't include patient information.