Transitions of Care Measure Explained: What Practices Must Do

Updated November 2026. Written by Matteo Grassi, clinical psychologist and cofounder of HANA Health.

The Transitions of Care (TRC) measure is a quality measure that checks whether a patient's outpatient team knew about a hospital stay and followed up after it. It has four parts: admission notice, discharge information, patient engagement, and medication reconciliation. CMS counts it in the 2027 Medicare Advantage Star Ratings with a weight of 1.

The weeks after discharge are when patients are least sure who to call. This measure checks whether your practice reached them first.

Key facts

• TRC measures discharges, not patients, so one patient can count several times in a year. Discharges from January 1 to December 1 of the measurement year are eligible, per the BCBSM TRC tip sheet.
• Admission notice and discharge information each have a 3 day window: the day of the event plus 2 days after, per NCQA.
• Patient engagement must happen within 30 days after discharge, and a contact on the discharge date itself doesn't count, per the BCBSM tip sheet.
• Medication reconciliation counts from the discharge date through 30 days after, which is 31 days total, per NCQA.
• Admission notice and discharge information can only be met through medical record review. Engagement and reconciliation can be met through claims or the record, per the MVP coding guide.
• TRC is a process measure with a weight of 1 in the 2027 Star Ratings, per the CMS 2027 measures and weights.
• The average plan Star rating on TRC rose from 2.5 in 2024 to 3.4 in 2027, per the CMS 2027 Star Ratings fact sheet.

What is the Transitions of Care measure?

TRC is a HEDIS measure from NCQA that asks what share of adult inpatient discharges had all four follow up pieces documented in the outpatient record. Health plans report it, and CMS uses it in the Medicare Advantage Star Ratings.

Your practice isn't scored on it directly. Your plan partners are, and many of them send you gap lists and chart requests because of it. Our post on how Medicare Advantage plans pay practices for Star Ratings covers what that can mean for your contract.

The eligible population is members 18 and older with an acute or nonacute inpatient discharge from January 1 through December 1 of the measurement year. Members in hospice or who die during the year are excluded, per the BCBSM tip sheet.

Here's the part that surprises people. A patient only counts as a success when the record shows the right documentation for that discharge. Calling the patient the day after discharge is good care, but if it isn't written down with a date, the measure can't see it.

What are the four parts of TRC and their deadlines?

Each part has its own clock, and all four sit in the outpatient record. Here's the checklist, using NCQA's definitions and the plan guides that apply them:

• Notification of inpatient admission: documented receipt of the admission notice on the day of admission through 2 days after. A call, email or fax from the inpatient team or ED can count, per the BCBSM tip sheet.
• Receipt of discharge information: documented receipt on the day of discharge through 2 days after, with the date you got it.
• Patient engagement after discharge: an outpatient visit, home visit, telephone visit, video visit, or e-visit within 30 days after discharge, per the MVP guide. The discharge date doesn't count.
• Medication reconciliation post discharge: discharge medications reconciled with your current list, from the discharge date through 30 days after.

The discharge information has to be complete to count. The MVP guide lists the minimum: the provider responsible for the inpatient stay, procedures or treatment provided, diagnoses at discharge, the current medication list, test results or a note that none are pending, and instructions for patient care after discharge.

Which parts can claims close, and which need chart documentation?

Two parts need the chart and two can use claims. That split decides where your workflow effort goes.

Admission notice and discharge information are medical record review only. No claim can satisfy them, per the MVP guide. If nobody timestamps the ADT alert or the discharge summary on arrival, the plan will ask for charts later, or mark the discharge as a miss.

Patient engagement and medication reconciliation can be met by claims or the record. Two details help:

• CPT 99495 and 99496 are listed as medication reconciliation encounters, per the MVP guide.
• CPT II code 1111F reports that discharge medications were reconciled with the current list, and it can be billed without a visit, per the same guide.

Who can reconcile matters too. A prescribing practitioner, clinical pharmacist, PA or RN counts. An MA or LPN can do the work if one of those clinicians signs off, per the BCBSM tip sheet. The patient doesn't have to be present, and a face to face visit isn't required. A post surgery follow up note that never mentions a hospital stay doesn't count.

How does TCM line up with the TRC measure?

TCM (99495 and 99496) and TRC overlap a lot, but they aren't the same thing. TCM is a billing service. TRC is a quality measure. Doing TCM well makes most of TRC easier, because the steps cover similar ground.

Per the CMS TCM booklet, TCM requires:

1. Contact with the patient or caregiver within 2 business days of discharge.
2. A face to face visit within 7 calendar days (99496, high complexity) or 14 calendar days (99495, at least moderate complexity).
3. Medication reconciliation on or before the date of that visit.
4. Review of discharge information, which is a listed non face to face service.

The gaps are worth knowing. TCM asks you to review discharge information, but TRC wants the date you received it written in the chart within 3 days. TCM covers only patients who meet its service rules, while TRC counts every eligible discharge. And a patient who gets a visit on day 20 can satisfy TRC engagement but not TCM timing. Our guides to TCM requirements for 99495 and 99496 and the two business day contact rule cover the billing side.

How much does TRC count in Medicare Advantage Star Ratings?

TRC counts as a process measure with a weight of 1 in 2027, per CMS. In the same rating, Controlling Blood Pressure, Diabetes Care Blood Sugar Controlled and Plan All Cause Readmissions each carry a weight of 3.

CMS also removed Medication Reconciliation Post Discharge as its own Star measure beginning with the 2027 Star Ratings. It still lives inside TRC as one of the four parts, per the CMS measures document and NCQA.

So is it worth your time? Yes, for two reasons. The documentation habits are cheap compared with chasing a blood pressure number. And readmissions carry a weight of 3, which is the outcome good transitions are meant to protect.

The evidence for each habit is real but modest. NCQA's measure page notes that in one study, discharge summaries reached PCPs within 48 hours only 55% of the time. Those summaries were missing test results 40% of the time, discharge medications 22% of the time, and pending tests 75% of the time. NCQA also describes a 2018 study of about 50,000 patients where those with a scheduled follow up appointment they attended were readmitted less often. That's an association, not proof that a call causes fewer readmissions. Our review of what trials show on outreach calls walks through how small those effects can be.

The 2027 Star Ratings posted on October 8, 2026 and feed 2028 quality bonus payments, per CMS. For practices in an ACO, the same follow up ideas show up in other scorecards. See our guide to ACO quality measures for practices.

What this means for your practice

Build one transition routine and make it leave a paper trail. Here's a simple version:

1. Route hospital alerts to one inbox or worklist. Stamp the date you received each one.
2. File the discharge summary in the chart the day it arrives, and note the date.
3. Have clinical staff reach the patient within 2 business days, and schedule the visit inside 7 or 14 days when TCM applies.
4. Reconcile medications against the discharge list. Let a prescriber, pharmacist, PA or RN complete or sign the reconciliation.
5. Use 1111F when you reconcile, and bill 99495 or 99496 when the full TCM service happened.
6. Each month, pull the discharges and check all four dates.

Start by auditing five recent discharges against that list. You'll quickly see which part fails most often. Check the receipt date on the discharge summary first, because it's easy to skip.

At HANA, my company, we call patients for practices and write a structured note your clinician can review. That can support the engagement step, and your own clinical staff still own the reconciliation. You can see how that works on the HANA Remote page.

Frequently asked questions

Does a patient have to be seen in the office to count for TRC engagement?

No. A telephone visit, video visit, e-visit or virtual check in can count within 30 days after discharge, per the MVP guide. The discharge date doesn't count.

Can an MA do the medication reconciliation for TRC?

An MA or LPN can do the work, but a prescribing practitioner, clinical pharmacist, PA or RN has to sign off on it, per the BCBSM tip sheet. The reconciliation has to sit in the outpatient record.

What counts as proof of admission notice?

You need the date you received the notice and evidence of what it was, such as a call, email or fax from the inpatient team or ED, per the BCBSM tip sheet. A patient telling your front desk later may not meet the spec, so check your plan's guide.

Is TRC the same as the TCM billing codes?

No. TRC is a quality measure and TCM is a billing service. Billing 99495 or 99496 helps with reconciliation and engagement, but admission notice and discharge information still need their own documentation.

What happens if a patient is discharged more than once in a year?

Each discharge counts on its own. The denominator is discharges, not patients, so you need all four parts documented for every discharge.

Sources

1. NCQA, Transitions of Care (TRC), State of Health Care Quality Report, 2025. https://www.ncqa.org/report-cards/health-plans/state-of-health-care-quality-report/transitions-of-care-trc/
2. CMS, 2027 Star Ratings Measures and Weights. https://www.cms.gov/files/document/2027-star-ratings-measures.pdf
3. CMS, 2027 Medicare Advantage and Part D Star Ratings fact sheet, October 8, 2026. https://www.cms.gov/files/document/2027-star-ratings-fact-sheet.pdf
4. CMS Medicare Learning Network, MLN908628, Transitional Care Management Services. https://www.cms.gov/files/document/mln908628-transitional-care-management-services.pdf
5. Blue Cross Blue Shield of Michigan, Transitions of Care (TRC) 2026 Star Measure Tips. https://www.bcbsm.com/amslibs/content/dam/public/providers/documents/star-measure-tip-sheet-transitions-of-care.pdf
6. MVP Health Care, Coding Reference Guide Measurement Year 2025, Transitions of Care (TRC). https://www.mvphealthcare.com/providers/-/media/project/mvp/healthcare/documents/hedis/2025/transitions-of-care-trc.pdf

This article is educational and isn't billing, coding, clinical or legal advice. Check current CMS guidance and your MAC before you bill. If you'd like to talk through your own post discharge workflow, you can book a discovery call with me.