Healthcare Glossary→Care Coordination
Clinical Measures

Care Coordination

Care coordination is the deliberate organisation of patient care activities and information-sharing among all participants involved in a patient's care to achieve safer and more effective care across settings and providers.

What is Care Coordination?

Care coordination encompasses the planning, communication, and management activities that connect healthcare services, providers, and settings for a patient across the continuum of care. Effective care coordination reduces redundancy, prevents care gaps, ensures medication reconciliation, and facilitates smooth transitions between care settings — particularly between hospital and post-acute settings where care failures most commonly occur.

Transitional Care Management (TCM)

Transitional Care Management (TCM) is a Medicare-reimbursed service for patients discharged from an inpatient setting (hospital, skilled nursing facility, inpatient rehabilitation, or long-term care) to community living. TCM requires:

  • Interactive contact attempt within 2 business days of discharge (phone or face-to-face)
  • Face-to-face visit within either 7 or 14 days of discharge
  • Medication reconciliation
  • Patient/caregiver education
  • Coordination with community resources as needed

TCM CPT Codes and Reimbursement

  • CPT 99495: TCM with moderate medical decision making; face-to-face visit within 14 days of discharge. ~$178 Medicare reimbursement.
  • CPT 99496: TCM with high medical decision making; face-to-face visit within 7 days of discharge. ~$267 Medicare reimbursement.

TCM services have demonstrated significant reductions in 30-day readmission rates — studies show 20–40% reduction in readmissions for patients receiving structured TCM compared to those without post-discharge follow-up. Given the HRRP penalty risk (up to 3% of Medicare payments), TCM is one of the highest-ROI clinical programmes available to hospitals and their affiliated primary care practices.

PCMH Care Coordination Requirements

NCQA PCMH recognition requires documented care coordination processes including: tracking referrals and specialty care, coordinating care for patients seen in the ED or hospitalised, systematically following up after hospital discharge, and managing patients on care plans. Analytics demonstrating care coordination activities — TCM completion rates, referral tracking, post-discharge follow-up within 7 days — are essential for PCMH data submission.