You’ve likely heard from your colleagues, or maybe even seen for yourself first-hand, how some patients who aren’t receiving sufficient levels of follow-up care services often end up relapsing and need readmitted into the hospital. If you treat most of your patients in your office, you may not be familiar with longer-term types of healthcare and how to effectively manage these types of patients.

But transitional care management, or TCM, involving managing patient transitions from one level of care to the next, is an essential part of healthcare outcomes improvement. This is what gave rise to the concept of transitional care management (TCM) and the Centers for Medicare and Medicaid Services (CMS) initiative behind it.

Here we explain:

  • What TCM Is
  • Provider Requirements
  • Patient Qualifications
  • Billing Requirements
  • Tools for Transitional Care Management
  • And more.

What is Transition Care Management (TCM) ?

Transition care management (TCM) definition: In it’s basic form, TCM involves addressing the hand-off time between the patient’s stay in the hospital or other inpatient facility and community setting. After the patient’s stay, they might be dealing with a new diagnosis, a medical crisis or a change in medicine therapy. Family doctors often manage the transitional care of their patients. 

TCM services involve the transitional care from one of these types of hospital settings:

  • Inpatient rehabilitation facility
  • Inpatient acute care hospital
  • Long-term care hospital
  • Inpatient psychiatric hospital
  • Skilled nursing facility
  • Partial hospitalization within a community mental health facility
  • Partial hospitalization or hospital outpatient observation

It includes services provided to patients who have a medical and/or psychosocial problem that requires medical decision making of moderate or high complexity.

TCM Provider Requirements

With TCM, there are transition care management provider requirements. Only specific categories of healthcare professionals qualify to furnish and bill for TCM services. They are:

  • Doctors of any specialty
  • Clinical nurse specialists
  • Certified nurse midwives
  • Physicians’ assistants
  • Nurse practitioners

Providers who aren’t physicians need to be legally allowed and qualified to provide services in states that offer TCM.

Patient engagement is critical after their discharge from a nursing facility, hospital or another qualifying facility. This is the reason TCM provisions require healthcare professionals to make their first contact within 48 hours of the patient’s discharge.

You’ll have to also make your face-to-face visit with your patient within one or two weeks after they’ve been discharged, depending on how complex the case is. 

Keep in mind, in order for you to qualify for TCM reimbursements, you need to use a properly certified EHR application or electronic health records. If you don’t have these it prevents you from being able to benefit from TCM and the substantial additional revenue you can obtain from it.

TCM Patient Qualification

There are also specific transition care management patient qualification terms. To become involved in TCM, there are some requirements you must meet on the patient’s behalf. Patients need to be discharged from a service setting that qualifies such as:

  • Inpatient acute care hospitals
  • Skilled nursing facilities
  • Long-term hospital
  • Partial hospitalization
  • Inpatient psychiatric hospital
  • Hospital outpatient observation
  • And any of the others mentioned above

Billing for Transition Care Management 

The new Physician Fee Schedule includes TCM codes allowing the reimbursement of non-face-to-face care services provided to patients transitioning to their community from an acute care setting.

You’ll use two new codes to pay for those services you provided that until now weren’t reimbursed.

  1. CPT Code 99495: This code covers patient or caregiver communication within two business days following discharge. You can do this in person, by phone or by email. It involves at least moderate complexity medical decision-making and face-to-face visit within two weeks of discharge. The place where the visit occurs isn’t specified. The work RVU is 2.11.
  2. CPT Code 99496: This code covers patient or caregiver communication within two business days following discharge. You can do this in person, by phone or by email. It involves high complexity medical decision making and a face-to-face visit within seven days of discharge. The place where the visit occurs isn’t specified. The work RVU is 3.05.

You should submit your billing statement on the 30th post-discharge period. 

Tools for Transition Care Management 

Some recommended tools for Transition Care Management are:

1. Establish a hospital discharge process. This should be proceduralized and followed consistently.

2. Identify patients in hospitals that could benefit from TCM. If a hospitalist cares for them, encourage them to let you know before they’re discharged.

3. Use a handheld charge capture software. This can help with identifying discharged patients ,but also to create automatic appointments or wait lists in your practice management system through interfaces.

4. Use a call center or other patient service center. If feasible, this can to help handle and schedule these appointment requests.

5. Use a patient portal tool to communicate with your patients in a timely manner. This portal also allows electronic updates of medication reconciliations and histories in patient charts.

6. Utilize American Academy of Family Physicians (AAFP) FAQ’s on Transitional Care Management. You can find these questions and answers here.

7. Utilize AAFP Transitional Care Management 30-Day Worksheet. You can find this worksheet here.

8. Use of Steth IO Health as a tool. Make TCM efficient and effective with Steh IO. With Steth IO Health, you can:

  • Communicate with ancillary healthcare services
  • Communicate with your patients or their caregivers within 48 hours of their discharge
  • Review discharge and medication information
  • Increase treatment adherence and provide clinical assessment
  • Documentation for appropriate reimbursement
  • Interact with other clinicians

Steth IO also makes follow-up clinical trials more cost-effective.  Its effective documentation and remote examination make for a more efficient and effective follow-up visit. The digital health technology is convenient to patients and therefore improves enrollment and participation in clinical trials. You can recruit patients remotely and monitor them with electronic data capture such as medicine treatment adherence. Patients can provide digital consent.

Some key takeaways:

  • TCM is a CMS initiative to improve the delivery of healthcare while lowering costs.
  • CMS designed TCM to keep patients healthier and prevent unnecessary relapses and readmissions.
  • You must make one face-to-face visit with the patient in an approved format within 30 days of the patient’s discharge from a clinic or hospital.
  • You must conduct a minimum of one non-face-to-face visit during this 30-day period with the patient.
  • Better follow-up care through TCM should help reduce complications and other unpleasant outcomes and control CMS healthcare costs.
  • There are tools, including Steth IO Health, to help you with the management and billing of patients needing TCM.

Because the healthcare industry continually changes, it’s often difficult to keep up with all the things you need to do with initiatives like TCM. Therefore, any resources and tools, like Steth IO Health, can help make a big difference.

Learn More About Steth IO Health

Steth IO commits to enhancing patient satisfaction and outcomes by building technology. We make patient communication and clinical assessment easier with Steth IO Health. TCM becomes much more efficient and effective. Visit our website to learn more.

What is Chronic Care Management?

Six in 10 adults in the United States have a chronic condition, according to the Centers for Disease Control and Prevention (CDC). Four in 10 have two or more. 

Around 80 percent of older adults have at least one chronic condition and 77 percent have a minimum of two, reports the National Council on Aging (NCOA). Four chronic conditions cause around two-thirds of all deaths every year. These are: 

  • Cancer
  • Heart disease
  • Diabetes
  • Stroke

Chronic conditions are long-lasting conditions that you can typically control, but not cure. They last a year or more, and limit activities of daily living and/or require ongoing medical attention. And, while most people have more than one chronic disease, the healthcare system is mainly organized for providing care on a condition-by-condition basis, rather than a multiple-disease umbrella.

Therefore, when patients see multiple specialists, it escalates the opportunity for confusion. A common example is multiple medication use where using one could contraindicate the use of another. This can all lead to fragmented care. Often, the missing link is care coordination. 

This is why chronic care management (CCM) is so important.

Definition of Chronic Care Management 

Basically, CCM encompasses any care healthcare professionals provide to patients with chronic health conditions like:

  • Diabetes
  • Fibromyalgia
  • Lupus
  • Cardiovascular diseases
  • Multiple Sclerosis
  • High Blood Pressure
  • Lung Disease

CCM is designed for helping you and your patients with multiple chronic conditions manage their healthcare. It’s based on their individual needs.

The best part of CCM is you can perform it virtually where you provide non-face-to-face patient care between office visits to ensure you’re providing the best overall quality of care. When your patients visit the hospital or your office, they’re exposed to unnecessary pathogens which can make things worse.

You can perform simple things easily over “Tele-visits” or over the phone such as: 

  • Reviewing lab results
  • Asking and answering questions
  • Reducing your patient load on a daily basis

One very effective telemedicine tool is Steth IO®. Steth IO Health’s distinctive form factor works great for home use which makes it an efficient telemedicine platform. It allows you to perform remote patient examination and monitoring for patients at home. Patient exams can provide you with valuable insight you can use for clinical decision making. It helps improve patient outcomes and satisfaction.

Chronic Care Management Diseases: Cardiovascular Diseases (CHF, Angina, CAD), Asthma, COPD, and Hypertension

Chronic care management diseases Steth IO can help with include:

  • Cardiovascular Disease (keyword) (CHF, Angina, CAD)
  • Asthma
  • Chronic Obstructive Pulmonary Disease (COPD)
  • Hypertension

For instance, common heart issues that you can diagnose with Steth IO are early systolic, diastolic, and holosystolic murmurs, and third and fourth heart sound. Common lung issues that you can diagnose with Steth IO are wheezing and crackles.

Steth IO offers:

1. Real-Time Visualization

The Steth IO device (keyword) enables real-time visualization of the lung and heart sounds while auscultation which helps improve your confidence in diagnosing abnormalities when you compare it to audio auscultation alone. You can record lung or heart sounds on a computer connected through Bluetooth to the Steth IO. You can then visually play these sounds back at a later time.

2. Acoustic Quality

Frequency spectra of the sounds of the heart are concentrated under 400 Hz and could extend up to 800 Hz. Lung sounds peak below 100 Hz generally and could extend up to 2000 Hz. The stethoscope-design is for amplifying these frequency ranges while reducing the amplitude of background noise. To avoid unwanted audio artifacts, the frequency response needs to be smooth across the whole spectrum.

You’ll also find Steth IO provides a smoother frequency response — between 140 and 800 Hz. User-testing found Steth IO doesn’t give off higher-frequency background noise and it has a more “natural timbre”, when compared with traditional stethoscopes, as well as similar acoustic qualities.

3. Usability

Steth IO provides numerous usability functions for making the physical exam experience better. The lung and heart sounds Steth IO collects by default are recorded and digitized. You can then choose to annotate and save them to share the sounds with professionals with just one or two easy clicks.

4. Data Security Controls

The Steth IO device uses various different techniques and tools for ensuring all captured data by the stethoscope is maintained securely. Security features are separated into a couple categories:

  • Those inherent in the Apple iOS
  • Those built into the Steth IO application

Importance of Patient Outcomes and Satisfaction

Patient satisfaction and engagement are key players in overall patient outcomes, always, and particular when managing chronic conditions or multiple chronic diseases. 

Patient Satisfaction

Patient satisfaction is a commonly used and essential indicator to measure the quality in healthcare. It impacts clinical outcomes, medical malpractice claims and patient retention. It affects the efficient, timely and patient-centered delivery of quality healthcare. It is thus a proxy, but an extremely efficient indicator of measuring the success of physicians and hospitals.

Patient Engagement

Patient engagement is gaining recognition as a crucial part of healthcare and a vital element of safe individual-centered services. When you engage your patients, they’re better equipped to make informed decisions about their healthcare options. Additionally, you can better use resources when they’re aligned with your patients’ priorities. 

Steth IO and Patient Engagement and Patient Satisfaction

Those using health services are gaining more interest in more open, responsive and transparent healthcare systems. Patients are expecting doctors to engage them when it comes time to make healthcare decisions, however, they might vary significantly in their involvement preferences.

You’ll find the Steth IO device is a good tool to engage your patients. The visualization function of this device helps to explain the diagnosis. You can play, and replay, lung and heart sounds back to your patients and easily point out any abnormalities.

You can adjust the volume of the device, making it easy to hear murmurs you could miss with a normal stethoscope. Your patients will appreciate being able to see what you’re listening to on the iPhone screen, which includes them in the whole process. When they can hear their own heartbeat playing back to them or when they can see their own heartbeat on the screen, they’ll likely take more interest in the health of their heart.

Learn More About Steth IO Health

Steth IO commits to building technology to enhance patient outcomes and satisfaction. It enables you to provide continuous chronic care efficiently to your patients. Visit our website to learn more about Steth IO and how it can help with your chronic care management objectives. Reach out to us through our contact form, email us at, or purchase Steth IO smartphone stethoscope here

Remote patient monitoring is increasing in momentum as doctors and hospitals look for ways to serve their patients effectively in a quickly aging population with complex chronic healthcare needs. However, up until now, the Centers for Medicare & Medicaid Services (CMS) caused a major hindrance by not making it simple for providers to manage remote monitoring and be reimbursed for it. Fortunately, new CMS rules and reimbursement codes for patient remote health monitoring is quickly changing this. 

Remote Patient Monitoring Reimbursement History and Changes

Beginning in 2019, remote physiological monitoring as taken effect.

In most states, remote patient monitoring reimbursement was an ill-defined situation for healthcare providers, up until recently. Some reimbursement is offered by 20 states, but for all others, CMS categorized remote monitoring into a broad-ranging telehealth category applying only to those in remote or rural areas.

Then, CMS published a two-year study in 2017 on its Chronic Care Management (CCM) program, demonstrating how it:

  • Saved millions of dollars for Medicare
  • Increased patient awareness around managing disease
  • Reduced hospital readmissions

Beginning to recognize how valuable remote monitoring could be for the CCM program, CMS made the decision to make the service more obtainable.

On November 1, 2018, CMS amended the 2019 Medicare Physician Fee Schedule (PFS)for remote patient monitoring reimbursement to include three new CPT codes following reimbursement requirements. 

The new codes became effective on January 1, 2019. These codes include:

  1. CPT Code 99453: “Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial set-up; and patient education on use of equipment.”
  2. CPT Code 99454: “Remote monitoring … device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days.”
  3. CPT Code 99457: “Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified healthcare professional time in a calendar month requiring interactive communication with the patient/caregiver during the month.”

Other applicable reimbursable codes are:

  1. CPT Code 99495:  Covers communication with the patient or caregivers within 48 hours of discharge and prepare the patient for a moderate complexity 14 day face-to-face visit (work RVR 2.11).
  2. CPT Code 99496 -Covers communication with the patient or caregivers within 48 hours of discharge and prepare the patient for a high complexity 7 day face-to-face visit (work RVR 3.05)

Under the new codes, Medicare pays for the initial setup, the device and the continuing management of remote monitoring programs in accordance with adherence to reimbursement requirements. Because remote monitoring and CCM can be billed separately, health care providers may be able to increase revenue without increasing patient numbers.

Advancing Telemedicine and Steth IO Health

Telemedicine should be much more than a simple video call between you and your patients. At present, accessible telemedicine tools don’t provide examination functions. However, Steth IO® Health’s distinctive form factor makes it perfect for home use and an efficient telemedicine platform. It enables remote patient exams and monitoring, providing patients at home with true telemedicine. Patient exams also provide you with valuable information that could affect your clinical decision making and improve your patients’ satisfaction and experience.

About the Steth IO Device

Steth IO builds technology to improve your patients’ outcomes and experience. The Steth IO device is a smartphone stethoscope using the pervasiveness of mobile phones with the power of device learning for more objective lung and heart exams.

As a physician, you can visualize, hear, analyze and share lung and heart sounds for improved diagnosis with many advantages over the traditional stethoscope.

The latest Steth IO application release, which you can download from the App Store, offers an AI capability for analyzing the heart sounds the Steth IO’s smartphone stethoscope captured in real-time.

It contains a few pieces of technology enabling an array of features designed for improving the data you have to diagnose and monitor your patients, including:

  1. Phonocardiogram: Sounds are broken down into separate frequency elements and displayed live on the smartphone screen. The sound’s frequency and amplitude spectrogram is shown across a time scale. You can identify the timing of the sounds with a moving cursor for a better diagnosis.
  2. Listening to Auscultation: The Steth IO application comes with outstanding Sony wireless headphones that come with earbuds with cups that seal the ear canal. These tend to work best. Of course, you can still use your own wireless or wired Bluetooth earbuds or headphones to hear lungs and heart sounds. But, keep in mind, you’re listening to extremely low-frequency sounds.
  3. Digital Filters: The microphone receives recorded sounds in which the digital filters process to improve the naturally low-frequency lung and heart sounds.
  4. Replay for Analysis: You can replay the recorded sounds for analysis for helping with your clinical decision. The screen displays sound loops which you can replay for review and you can change the loop size by zooming the content on the screen in and out.
  5. Ability to Save Files: Like you would a regular stethoscope, you could simply listen to auscultation, come up with a clinical decision and then move forward. However, you can now save the stethoscope exam for future consultation, review or teaching. You save the exams under date of birth and name.

Benefits of Steth IO for Remote Physiological Monitoring 

There are several benefits of Steth IO, including:

1. Helps with Clinical Trial Follow-Up

Clinical trials are becoming increasingly global and complex. It’s both expensive and difficult to follow a large number of participants for obtaining accurate clinical data.

Steth IO’s remote exam and efficient documentation helps with more efficient and cost-effective clinical trial follow-up visits. This digital health technology is convenient for patients, improving enrollment and participation. You can:

  • Recruit patients remotely
  • Provide digital consent
  • Monitor at the source, electronic data capture, including medicine treatment adherence

The Steth IO stethoscope can offer a secure, all-in-one, integrated tool and you can easily customize the platform to deploy forms that are specific to each clinical trial.

2. Assists with Chronic Care Management (CCM)

Steth IO makes chronic care almost effortless. CCM improves patient satisfaction and outcomes. Steth IO enables you to provide continuous chronic care efficiently to your patients. CCM coordination is considered outside normal office visits and applies to patients with a couple or more chronic care disorders at risk of decompensation, exacerbations, functional decline or death. 

Steth IO helps with the management of:

  • Asthma
  • Cardiovascular diseases (i.e. Angina, CHF, CAD)
  • Hypertension
  • Chronic Obstructive Pulmonary Disease (COPD)

3. Assists with Transition Care Management (TCM)

TCM allows you to:

  • Communicate with ancillary healthcare services
  • Communicate with patients within 48 hours of discharge
  • Review discharge information and medications
  • Increase treatment adherence and provide clinical assessment
  • Documentation for appropriate reimbursement
  • Interact with other healthcare providers

4. Helps With Reimbursements

Under the new rules and codes, Medicare will pay for the device, the initial setup and the ongoing remote monitoring program management. Instead of you having to be responsible for the management of these programs, the new rules and codes allow nursing assistants, RNs and other clinical staff to pick up the slack. Also, since remote monitoring and CCM can be billed separately, you can increase your revenue without having to increase your patient workload.

This is good news for doctors, hospitals and home health centers. 

Embrace the Future of Concierge Medicine and Remote Healthcare with Steth IO Health and the Steth IO Device

CMS’s digital transformation came just in time for overwhelmed home care agencies and hospitals trying to reduce the number of patients in the emergency rooms. Now, you can stay connected, you can involve your clinical staff more, and you can be paid or reimbursed for using new technology, like Steth IO, to solve old issues and keep your patients healthier at home.

Buy the Steth IO and move your healthcare practice into the future today.