Post-Discharge Transition Calls in Primary Care

Medicare's transitional care management codes, CPT 99495 and 99496, require interactive contact with the patient or caregiver within two business days of discharge, so a Saturday call is already inside the window
Those same codes require a face-to-face visit within fourteen days for 99495 and within seven days for 99496, which means the scheduling ask on that call is time-bound in a way ordinary follow-up is not
Captures what the transition workflow needs: discharge date, facility name, whether the patient has their paperwork, whether the new prescriptions were actually filled, and who is helping at home
Flags the medication conflict that dominates these calls, where the hospital list and the home list disagree, without ever reconciling the two or telling the patient which bottle to take
Handles the calls that are not from the patient at all: the discharge planner, the home health intake nurse, the skilled nursing facility, all of which land on your main line and need a different destination
Time-stamps the contact attempt and what was discussed, so the record supporting your follow-up window is not reconstructed from memory a week later

How it pays back

The Two-Day Window Does Not Wait for Monday

Hospitals discharge on Friday evenings and over holiday weekends. A practice whose phones roll to voicemail at 5pm loses two of the days it has, and the patient who could not reach anyone stops trying. Calls are answered around the clock, and the contact is logged when it happens.

Medication Changes Surface Before the Visit

The most common post-discharge call is a patient holding two lists that disagree. The system captures exactly what the patient says changed, which bottles they still have, and what the pharmacy did or did not fill, then routes it to your nurse or clinical pharmacist. It never reconciles anything itself.

The Calls That Are Not From the Patient

Discharge planners, home health agencies and facility nurses call the same main number as everyone else, then wait on hold behind refill requests. These callers are identified by your rules and routed straight to care coordination with the facility, patient and reason already captured.

Documentation That Actually Supports the Work

Whether a contact happened, when it happened, and what was covered are the details that get argued about later. Every transition call produces a timestamped structured record in a consistent format, delivered where your team already works.

24/7 coverage

Friday-evening and holiday discharges reach a live voice inside the follow-up window

Under 1 second to answer

Discharge planners and facility nurses are not held behind the routine call queue

HIPAA BAA included

Discharge, medication and facility detail encrypted with AES-256 at rest and TLS in transit

Frequently asked questions

Does this bill transitional care management for us?

No. It captures and time-stamps the contact and what was discussed, and delivers that record to your team. Whether the code requirements were met, including the interactive contact inside two business days and the face-to-face visit inside seven or fourteen days, is a determination your clinicians and billing staff make.

Can the AI perform the medication reconciliation?

No. It captures what the patient reports about their medications and flags the discrepancy for a clinician. It never tells a patient which list is correct, which drug to stop, or that a change is expected. Reconciliation is clinical work and stays with your team.

What if the patient sounds unwell on the discharge call?

The call is routed by the rule set your clinicians authored, the same as any other symptom call, and your standing emergency instruction plays at the start. The system makes no assessment of the patient's condition and never characterises how a caller sounds.

Where does the discharge information come from?

From the caller. The system does not pull records from a hospital or a health information exchange, so it asks for discharge date, facility and paperwork status rather than assuming them. Where your EMR supports it, the captured detail can be written back through API or FHIR.

Can it make outbound post-discharge calls instead of waiting?

Yes, where your practice supplies the list of recently discharged patients. Outbound contact attempts are logged the same way as inbound calls. The system does not identify who was discharged on its own, and it does not conduct a clinical assessment on an outbound call.

How does it handle a call from a skilled nursing facility?

The caller is asked who they are and which patient they are calling about, then routed to the destination your rules name for facility callers, typically care coordination rather than the general message pool. The facility, patient and reason are all captured up front.

Catch the Post-Hospital Discharge Call in Family Medicine