An acute or nonacute inpatient discharge on or between January 1 and December 1 of the measurement period.

Note:

• The measure is based on episodes; therefore, it is possible for the denominator to include multiple events for the same person.
• The denominator is based on the discharge date found in administrative/ claims data, but organizations may use other systems (including data found during medical record review) to identify data errors and make corrections.
• If the admission date and the discharge date for an acute inpatient stay occur between the admission and discharge dates for a nonacute inpatient stay, include only the nonacute inpatient discharge.
• If a person remains in an acute or nonacute facility through December 1 of the measurement period, the discharge is not included in the measure, but the organization must have a method for identifying the person’s status for the remainder of the measurement period, and may not assume the person remained admitted based only on the absence of a discharge before December 1.
• If the organization is unable to confirm the person remained in the acute or nonacute care setting through December 1, disregard the readmission or direct transfer and use the initial discharge date.

Administrative reporting is not available. Medical Record only.
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).

Administrative reporting is not available. Medical Record only.
Documentation of receipt of discharge information on the day of discharge through 2 days after the discharge (3 total days).

• Patient engagement within 30 days after discharge. Do not include engagement on the date of discharge. Either of the following meets criteria:
• An outpatient visit, telephone visit, e-visit or virtual check-in (Outpatient and Telehealth Value Set).
• Transitional care management services (Transitional Care Management Services Value Set).

Medication reconciliation (Medical Reconciliation Encounter Value Set, Medication Reconciliation Intervention Value Set) 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).

• Communication between inpatient providers/staff and the patient’s PCP/OCP via phone call/e-mail/fax.
• Communication about admission between emergency department and the patient’s PCP or OCP via phone call/e-mail/fax.
• Communication about admission to the patient’s PCP/OCP through HIE/ADT alert system/ shared EMR system.
• Communication about admission with the patient’s PCP or ongoing care provider through a shared electronic medical record (EMR) system.
  • If PCP / OCP document in the same EMR where the admission occurred, the scan date is not required since the documentation is present real time.
• Communication about admission to the patient’s PCP or ongoing care provider from the patient’s health plan.
• Patient’s PCP/OCP admitted the patient to the hospital.
• Specialist admitted the patient to the hospital and notified the patient’s PCP/OCP.
• PCP/OCP placed orders for tests and treatments during the patient’s inpatient stay.
• PCP/OCP performed a preadmission exam or received communication about a planned inpatient admission up to 30 days prior to surgery/admission date.
  • The planned admission documentation or preadmission exam must clearly pertain to the denominator event.
• Evidence of receipt notification via a “Scan Date/Time” into the patient’s Medical Record/EMR.
  
  • Scanned documents into the Medical Record/EMR within 48 hours of Admission (which includes the admission/discharge information).
  • If a scanned date/time is not populated in the EMR once the documents are scanned in the patient’s Medical Record, please enter note in the Medical Record when the documents were placed with a date and time.
  • If unable to scan, include a progress note stating that notification documents were placed in the Medical Record on that specific date/time.

• Documentation that the patient or the patient’s family notified the patient’s PCP or OCP of admission.
• Documentation of notification that does not include a date when documentation was received or accessible to PCP or OCP.
• Documentation which only references Provider sending the patient to the ED.

Discharge information may be included in, but not limited to, a discharge summary, summary of care record, or located in structured fields in an EMR.

• Discharge information must include ALL of the following:
  •  The practitioner responsible for the patient’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 are pending.
  • Instructions for patient care post-discharge.
• Compliance through Medical Record Review only. Ensure admission / discharge notifications are saved in the patient’s outpatient chart within the required timeframe of 3 days total.

• Instructions for patient care post discharge given to the PCP, OCP, patient , or family/caregiver.
• Discharge instructions that direct the patient to follow-up with the PCP.
• Even when the PCP or OCP is the discharging provider, required discharge information must be documented in the appropriate medical record within timeframe.
• Evidence of receipt notification via a “Scan Date/Time” into the patient’s Medical Record/EMR.
  • Scanned documents into the Medical Record/EMR within 48 hours of discharge (which includes the admission/discharge information).
  • If a scanned date/time is not populated in the EMR once the documents are scanned in the patient’s Medical Record, please enter note in the Medical Record when the documents were placed with a date and time.
  • If unable to scan, include a progress note stating that notification of documents were placed in the Medical Record on that specific date/time.
  • A scan date is not required in a shared EMR, as documentation is recorded in real time.

• Documentation the patient or the patient’s family notified the patient’s PCP or OCP of discharge.
• Documentation of notification that does not include a time frame or date when documentation received and integrated into the patient’s medical record.

• Evidence of medication reconciliation and the date when it was performed by either:
  • prescribing practitioner
  • clinical pharmacist
  • physician’s assistant
  • registered nurse
• Evidence the provider was aware of the hospitalization. It is best practice to have both of the below in note:
  • Mention of “hospitalization,” “admission” or “inpatient stay” in the note.
  • Reference to reconciliation of current and discharge medications in the note.
• Only documentation in the outpatient chart meets the intent of the measure:
  • Provider or OCP speaks to member patient or caregiver via telephone and documents reference to hospitalization and medication reconciliation, which is documented in outpatient chart.
    • Example: “Conversation with patient after recent hospitalization (include date of admission / discharge). Reviewed discharge medications and reconciled with current medication list. Patient is aware of medication list.”
  • Care managers complete the MRP
  • Be sure to include in documentation:
    • Reference to hospitalization with the dates of admission and D/C in case there are multiple admissions/ discharges.
    • Reference discharge medications reviewed and reconciled with current medication list. Patient aware of medication list.
    • Always include PCP/OCP name, EMR system, location, phone and fax.
    • Include where MRP was routed to (doctor/EMR).
    • Include any supporting documentation, which confirms PCP/OCP received and entered into member’s patient’s chart.
    • If documentation is faxed to PCP/OCP, request fax is shared with PCP/OCP and is added to member patient’s chart.
    • Example: “Transition of Care Medication Reconciliation Completed on (DATE) by (name). Conversation with (patient name / DOB) after recent hospitalization (include date of admission / discharge and facility discharged from if available). Reviewed discharge medications and reconciled with current medication list. Patient is aware of medication list. THIS COMMUNICATION MUST BE ADDED TO THE  PATIENT’S OUTPATIENT CHART / EMR SYSTEM AS EVIDENCE OF MEDICATION RECONCILIATION POST DISCHARGE. Please save fax in member’s outpatient chart and have (provider name) review.

• Current medication list available & provider reconciled the current and discharge medications.
  • Mention of “hospitalization,” “admission” or “inpatient stay” in note is not required.
• 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).
  • Mention of “hospitalization,” “admission” or “inpatient stay” in note is not required.
• Current medications list available and discharge medications were reviewed.
  • Mention of “hospitalization,” “admission” or “inpatient stay” in note is not required.
• Current medication list, discharge medication list are available and both lists were reviewed on the same date of service.
  • Mention of “hospitalization,” “admission” or “inpatient stay” in note is not required.
  • The act of documenting the medication list is considered evidence the provider reviewed the medications.
• Current medications list available, patient had post-discharge hospital follow-up and medications were reconciled/reviewed.
  • Documentation must indicate the provider was aware of the patient’s hospitalization/discharge.
  • The act of documenting the medication list during a follow-up visit is considered evidence the provider reviewed the medications.
• Discharge summary reads discharge medications were reconciled with the most recent medication list and it was filed (in the PCP/OCP’s outpatient chart) on the date of discharge through 30 days after discharge (31 total days).
  • There must be evidence that the discharge summary was filed in the PCP/OCP’s outpatient chart on the date of discharge through 30 days after discharge (31 total days).
  • Utilizing this discharge summary is the last resort, attempt to find documentation of an office visit, home visit (possibly RN), e-visit etc.
• Notation that No medications were prescribed or ordered upon discharge.

Notes:

• A medication list may include medication names only or may include medication names, dosages and frequency, over-the counter (OCT) medications, and herbal or supplemental therapies.
• The Medication Reconciliation Post-Discharge sub-measure assesses whether medication reconciliation occurred, not the quality of the med list or the process used to reconcile the medications.

• Documentation of “post-op/surgery follow-up’’ without a reference to “hospitalization”, “admission” or “inpatient stay’’ does not imply there was a hospitalization and is not considered evidence that the provider was aware of the hospitalization.
• Documentation indicating only that the provider was aware of the surgery (even if the procedure/surgery is typically performed inpatient) or if the provider performed the surgery is not sufficient to show that the provider was aware of the “hospitalization” at the time of the follow-up visit.
• The presence of a discharge notification or discharge summary in the medical record alone does not count as evidence that the provider was aware of the hospitalization at the time of the follow-up visit (even if the provider was the discharging provider).

Easy Compliance with acceptable codes: (Add appropriate Medication Reconciliation Post-Discharge Code to Patient Engagement visit to meet MRP compliance.)