CCP CCP Transitional Care & Care Transitions 1 — Questions and Answers
Question 1: The PRIMARY goal of transitional care management (TCM) for chronic disease patients is to:
- Reduce the number of medications prescribed
- Prevent hospital readmissions by ensuring continuity of care after discharge (Correct answer)
- Transfer care entirely to specialists
- Increase the frequency of diagnostic imaging
Correct answer: Prevent hospital readmissions by ensuring continuity of care after discharge
TCM focuses on bridging care gaps immediately after hospital discharge to prevent avoidable readmissions and ensure patients remain stable in the community.
Question 2: Under CMS billing guidelines, a TCM 99496 code requires a face-to-face visit within how many days of discharge?
- 30 days
- 14 days
- 7 days (Correct answer)
- 3 days
Correct answer: 7 days
CPT 99496 requires a face-to-face visit within 7 days of discharge and is used for patients with high medical complexity.
Question 3: A CCP contacts a patient within 2 business days of hospital discharge. This contact is PRIMARILY intended to:
- Complete a full annual wellness visit
- Assess the patient's condition, confirm follow-up, and address immediate post-discharge needs (Correct answer)
- Conduct a medication therapy management session only
- Determine eligibility for hospice care
Correct answer: Assess the patient's condition, confirm follow-up, and address immediate post-discharge needs
The 2-business-day post-discharge contact is a TCM requirement to assess patient stability, confirm appointments, and address urgent needs before complications develop.
Question 4: Which intervention has the STRONGEST evidence for reducing 30-day readmissions in heart failure patients?
- Increasing inpatient length of stay
- Early follow-up within 7 days combined with patient education on warning signs (Correct answer)
- Restricting patient access to emergency departments
- Switching all patients to once-daily diuretics
Correct answer: Early follow-up within 7 days combined with patient education on warning signs
Evidence consistently shows that early post-discharge follow-up combined with heart failure education on symptom monitoring significantly reduces 30-day readmission rates.
Question 5: The Coleman Care Transitions Intervention® focuses on developing which key patient skill?
- Advanced surgical decision-making
- Self-advocacy and self-management through the use of a personal health record (Correct answer)
- Requesting specialist-only care
- Understanding insurance billing codes
Correct answer: Self-advocacy and self-management through the use of a personal health record
The Coleman model uses transition coaches and a Personal Health Record to build patients' self-advocacy skills across four care domains: medications, red flags, follow-up, and patient knowledge.
Question 6: During a care transition, medication reconciliation is considered MOST critical because:
- Patients always refuse post-discharge medications
- Discrepancies between inpatient and outpatient medication lists are a leading cause of adverse events (Correct answer)
- Pharmacies require reconciliation before dispensing any drug
- Hospitals automatically transmit complete medication lists to all outpatient providers
Correct answer: Discrepancies between inpatient and outpatient medication lists are a leading cause of adverse events
Medication discrepancies at discharge are one of the most common causes of preventable adverse drug events and hospital readmissions in the post-transition period.
CCP CCP Transitional Care & Care Transitions 1
The PRIMARY goal of transitional care management (TCM) for chronic disease patients is to: