Administrative bulletin: 2026-09-003 Quality information

Professional and facility Providers

Transitions of Care (TRC)

KEY POINT: Reducing avoidable readmissions starts with a strong transition of care process that includes timely receipt of admission and discharge notifications, prompt patient engagement after discharge, and comprehensive medication reconciliation.

Measure specifications: Medicare measure weight: 1.

NOTE: The Transitions of Care (TRC) measure is based on the percentage discharges of persons 18 years and older who had each of the following and there are 4 rates reported. The definitions below outline the 4 rates reported:

• Patient Engagement After Inpatient (TRC-PED):
  • Measure description: This measure evaluates the percentage of members that receive patient engagement (e.g., office visits, visits to the home, or telehealth) within 30 days after discharge. Do not include patient engagement that occurs on the date of discharge.
  • Routes of closure: Claims or supplemental data submission via Theon™.
  • Numerator compliant: Patient engagement is documented in the outpatient medical record provided within 30 days after discharge. Any of the following would meet compliance:
    • An outpatient visit.
    • A telephone visit.
    • A synchronous telehealth visit where real-time interaction occurred between the person and provider using audio and video communication.
    • An e-visit or virtual check-in (asynchronous telehealth where two-way interaction, which was not in real-time, occurred between the person and provider).
  • Numerator noncompliant: Members who had engagement on the date of discharge. Engagement cannot be same day.
• Medication Reconciliation Post- (TRC-MRP):
  • Measure description: This measure evaluates the percentage of discharges for members 18 years of age and older who had documentation of medication reconciliation on the date of discharge through 30 days after discharge (31 total days) between January 1 and December 1 of the measurement year.
  • Routes of closure: Claims, CPTII, or supplemental data submission via Theon™.
  • Numerator compliant:
    • Medication reconciliation conducted by a prescribing practitioner, clinical pharmacist, physician assistant, or registered nurse on the date of discharge through 30 days after discharge (31 total days).
    • Proof that medications upon discharge are reconciled with the most recent medication list in the outpatient medical record.
    • Documentation of the current medications with a notation that the provider reconciled the current and discharge medications.
    • Documentation of the current medications with a notation that references the discharge medications. (e.g., no changes in medications since discharge, same medications at discharge, discontinue all discharge medications)
    • Documentation of the member’s current medications with a notation that the discharge medications were reviewed.
    • Documentation of a current medication list, a discharge medication list, and notation that both lists were reviewed on the same date of service.
    • Documentation of the current medications with evidence that the member was seen for post-discharge hospital follow-up with evidence of medication reconciliation or review. Evidence that the member was seen for post-discharge hospital follow-up requires documentation that indicates the provider was aware of the member’s hospitalization or discharge.
    • Documentation in the discharge summary that the discharge medications were reconciled with the most recent medication list in the outpatient medical record. There must be evidence that the discharge summary was filed in the outpatient chart on the date of discharge through 30 days after discharge (31 total days).
    • Notation that no medications were prescribed or ordered upon discharge.
• Notification of Inpatient Admission (TRC-NOIA): (Not currently in the VBP program)
  • Measure description: This measure evaluates the percentage of members that have documentation of receipt of notification of inpatient admission on the day of admission or on the day of admission through 2 days after the admission (3 total days).
  • Routes of closure: Administrative reporting is not available for this indicator; medical record/supplemental data only.
  • Supplemental data submission available in Theon™: Yes.
  • Numerator compliant: Documentation in the outpatient medical record must include the following evidence:
    • Receipt of notification of inpatient admission, AND
    • The date when the documentation was received (on the day of admission through 2 days after discharge). The information must show evidence of being integrated into the appropriate medical record and is accessible to the PCP or ongoing provider on the day of admission through 2 days after admission (3 total days).
• Receipt of Discharge (TRC-RDI) (Not currently in the VBP program)
  • Measure description: This measure evaluates the percentage of members that have documentation of the receipt of discharge information on the day of discharge through 2 days after the discharge (3 total days).
  • Routes of closure: Administrative reporting is not available for this indicator; medical record/supplemental documentation only. Supplemental data submission available in Theon™: Yes. Numerator compliant: Documentation in the outpatient medical record must include evidence of receipt of discharge information on the day of discharge through 2 days after the discharge (3 total days) WITH evidence of the date when the documentation was received.
  • Discharge information may be included in, but not limited to, a discharge summary or be located in structured fields in an EHR. Discharge information must include all of the following:
    • The practitioner responsible for the member’s care during the inpatient stay.
    • Procedures or treatment provided.
    • Diagnoses at discharge.
    • Current medication list.
    • Testing results, or documentation of pending tests or no tests pending.
    • Instructions for patient care post-discharge.

NOTE: When using a shared EMR system, documentation of a “received date” in the EMR is not required to meet criteria. Evidence that the information was filed in the EMR and is accessible to the PCP or ongoing care provider on the day of discharge, through 2 days after the discharge (3 total days) meets criteria.

Best practices:

• Document notification dates clearly. Ensure the date and time your practice receives both the patient's admission notification and discharge information are clearly documented and easily accessible.
• Maintain timely coverage for care transitions. Establish processes that allow your team to receive, review, and act on admission and discharge information consistently, including during weekends, holidays, and other periods of reduced staffing.
• Leverage technology to support notifications. Utilize a Health Information Exchange (HIE), automated admission/discharge alert systems, or a shared Electronic Medical Record (EMR) platform to facilitate timely receipt of patient transition data.
• Implement a standardized workflow for tracking admission and discharge notifications to ensure timely follow-up and compliance with TRC requirements.
• Educate members and caregivers on value of making and keeping follow-up appointments.
• Ensure follow-up appointments are confirmed prior to discharge.
• Care management collaboration.

Exclusions:

Patients are excluded from this measure if they have any of the following:

• Utilized hospice or hospice services in the measurement year.
• Persons with a date of death in the measurement year.

Please refer to the Comprehensive Performance Guide Version 10.0.pdf for more information related to applicable coding guidance. The guidelines will be periodically updated to include new coverage guidance.