RN Care Coordination and Transition Management Through Telehealth
Comprehensive Service Guide for Registered Nurses delivering care coordination and transition management services through telehealth platforms, ensuring seamless care transitions and continuity across settings.
Patient Identification and Risk Assessment
Before initiating care coordination and transition management sessions, RNs must complete comprehensive pre-service preparation to ensure effective telehealth delivery. This foundational step determines service eligibility and establishes the framework for successful transitions.
Patient Eligibility Assessment
Identify patients being discharged from inpatient settings (acute hospital, rehabilitation hospital, skilled nursing facility, observation status) to community settings. Verify patient identity using multiple identifiers including name, date of birth, medical record number, and discharge location.
Medical Complexity Evaluation
Assess patient's medical complexity using standardized criteria for moderate vs. high complexity medical decision-making. Review discharge diagnosis, length of stay, and risk factors for readmission including multiple chronic conditions, previous readmissions, and medication changes.
Technology Setup and Care Team Coordination
Technology Infrastructure
- Secure video conferencing with encryption protocols
- Mobile-friendly platforms for accessibility
- Integration with electronic health records
- Backup communication methods (telephone)
Care Team Components
Hospital Discharge Team
Collaborate with discharge planners, case managers, and bedside nurses for comprehensive discharge information.
Primary Care Providers
Establish communication channels with receiving providers for seamless handoff and continuity.
Community Services
Connect with home health agencies, pharmacy services, and DME providers for post-discharge support.
Medical History and Discharge Planning Review
Comprehensive review of medical history and discharge planning documentation forms the foundation for effective transition management.
Discharge Summary Analysis
Review complete hospital discharge summary including diagnoses, treatment, and medications.
Medication Reconciliation
Identify medication changes, new prescriptions, and potential drug interactions.
Discharge Instructions
Assess clarity and comprehensiveness of discharge instructions.
Follow-Up Coordination
Review scheduled appointments and referrals to specialty providers.
Initial Contact and Assessment Protocol
The initial contact within 48 hours of hospital discharge represents the most critical intervention in the transition management process.
Contact Timeline
- 0-5 minutes: Professional introduction and role explanation
- 5-10 minutes: Relationship building and emotional assessment
- 10-35 minutes: Comprehensive transition assessment
- 35-45 minutes: Clinical status evaluation and risk screening
Comprehensive Transition Assessment Framework
Assessment Components
- Discharge instructions review and teach-back validation
- Medication reconciliation and barrier identification
- Follow-up appointment verification and scheduling
- Social and environmental assessment
Ongoing Care Coordination Activities
Provider Communication
Communicate transition assessment findings to primary care providers and relevant specialists. Collaborate on development of individualized care plans addressing identified needs and barriers.
Patient Education
Provide comprehensive education on disease process, recovery expectations, and self-management strategies. Demonstrate proper medication administration techniques and educate on recognizing warning signs.
Resource Coordination
Connect patients with community resources including home health services, transportation assistance, and social services. Coordinate durable medical equipment delivery and facilitate referrals.
Face-to-Face Visit Coordination Requirements
Regulatory Requirements
- High complexity: 7-day requirement
- Moderate complexity: 14-day requirement
- Telehealth options available for 2025
- Comprehensive medication reconciliation required
Visit Components
Schedule face-to-face office visit within required timeframe and prepare comprehensive visit summary including transition assessment findings and care coordination activities.
Quality Assurance and Outcome Monitoring
Monitor patient outcomes including emergency department visits, hospital readmissions, and medication adherence rates. Track achievement of transition goals and successful community integration.
Primary TCM Billing Codes and Reimbursement
CPT 99495 - Moderate Complexity
- 2025 Medicare Reimbursement: $201.20 national average
- Communication within 2 business days of discharge
- Face-to-face visit within 14 calendar days
- 30 days of non-face-to-face services included
CPT 99496 - High Complexity
- 2025 Medicare Reimbursement: $272.68 national average
- Communication within 2 business days of discharge
- Face-to-face visit within 7 calendar days
- Enhanced services for complex patients
Chronic Care Management and Additional Revenue Codes
CCM Codes
- CPT 99490: Basic CCM - $60.49/month (first 20 minutes)
- CPT 99439: Additional CCM - $45.93 per 20-minute increment
- CPT 99487: Complex CCM - $126.29/month (first 60 minutes)
Remote Patient Monitoring Integration
- CPT 99453: Device setup and education ($19.73)
- CPT 99457: Treatment management services ($48.14 for first 20 minutes)
- CPT 99458: Additional 20 minutes ($39.20)
New 2025 Telehealth Billing Opportunities
Enhanced Telehealth Options
New telehealth codes for 2025 provide billing opportunities for TCM face-to-face visits delivered via telehealth platforms. These codes maintain clinical quality while improving patient access.
CPT 98004-98007
- New telehealth codes for established patients
- Real-time interactive communication required
- Slightly lower practice expense component
- Professional component at full value
Cash Pay Market Rates and Value-Based Pricing
Individual Session Pricing
- Initial transition assessment (45-60 minutes): $125-$200
- Follow-up coordination calls (20-30 minutes): $75-$125
- Complex care coordination (60+ minutes): $150-$250
- Medication reconciliation: $100-$150 per review
Package Pricing
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Implementation Success and Future Opportunities
Successful implementation of RN-delivered care coordination and transition management through telehealth requires systematic approach, ongoing quality improvement, and strategic adaptation to evolving healthcare delivery models.
Key Success Factors
- Clinical Excellence: 46% reduction in readmissions with 95% patient satisfaction demonstrates clinical effectiveness
- Financial Sustainability: 300-500% ROI with diversified reimbursement options
- Technology Integration: Advanced telehealth platforms and remote monitoring capabilities
- Care Team Coordination: Seamless integration between hospital and community providers
- Continuous Improvement: Systematic outcome monitoring and quality assurance
- Scalable Model: Proven framework supports expansion across multiple settings