Transitional Care Management

Help high-risk patients stay out of the hospital

DocIndy is a comprehensive Transitional Care Management (TCM) solution that helps healthcare providers track and report hospital discharges, coordinate patient transitional care services, meet Medicare’s rules and requirements, and simplify reimbursement. TCM is an initiative started by the Centers for Medicare and Medicaid (CMS) to provide patients with services involving a transition of care during those 30 days after discharge from one of the following settings: inpatient acute care hospital, inpatient psychiatric hospital, long-term care hospital, nursing home, inpatient rehabilitation center, hospital outpatient observation/partial hospitalization. DocIndy's platform provides the digital infrastructure to leverage fee-for-service programs while promoting value-based care objectives. DocIndy supports end-to-end workflow for TCM, including tracking and reporting hospital discharges, coordinating time-sensitive transitional care services, and providing non-face-to-face services to the patient unless determined medically unnecessary.

For Doctors

A comprehensive platform to optimize care delivery

Handle care transitions with tools to monitor and report discharge actions, record patient communication, and fill care gaps.

  • Coordinate time-sensitive service requirements to ensure care is provided at a critical time

  • Create and share discharge reports to inform decision-makers every step of the way

  • Simplify CPT codes and billing with an audit trail to capture reimbursement


Inform stakeholders at every stage

Send discharge reports that describe every step of a patient's change. Use reports to back up billing requests for TCM and secure compensation.

Track patients' transitions

Record calls with patients to facilitate workflow and update all members of the care team.


Manage medications at a critical time

Improve patient engagement and adherence, collect and record their medication data.

Simplify billing

Use Transitional Care Management CPT codes, such as 99495 and 99496, and assign them automatically.