Service · TCM
Transitional Care Management
Closing the gap between discharge and the next office visit.
Overview
What TCM looks like in practice
The days immediately following a hospital, skilled nursing, or rehab discharge carry the highest risk of readmission. Spire's Transitional Care Management program closes that gap with structured, time-sensitive follow-up.
We reach out within two business days of discharge, review medications and discharge instructions, help schedule the required follow-up visit, and stay in contact through the full transitional period.
The result is a documented, CMS-compliant transitional care process that catches problems while they're still small — and a smoother handoff back into your practice's care.
How it works
Discharge notification
Spire is notified of the patient's discharge as soon as your practice is.
Contact within 2 days
We reach the patient by phone within two business days, as required for TCM billing.
Medication & instruction review
Discharge medications and instructions are reviewed for accuracy and understanding.
Schedule the follow-up visit
We help coordinate the required face-to-face visit within the CMS timeframe.
Document & bill
The full 30-day transitional period is documented against TCM CPT codes.
Who it's for
- Patients discharged from an inpatient hospital stay, SNF, or rehab facility
- Practices wanting a reliable, documented post-discharge follow-up process
- Patients at elevated risk of readmission due to complex medication regimens or comorbidities
Key benefits
- Patient contact within two business days of discharge, as CMS requires
- Medication reconciliation and discharge instruction review
- Help scheduling the required face-to-face follow-up visit
- Full documentation aligned to TCM's 30-day billing window
Billing & compliance
Documentation is structured around TCM's required two-day contact window and 30-day service period, so the claim reflects exactly what CMS requires.