Care transition documentation practice improvements

Activity ID


Activity Weighting


Subcategory Name

Care Coordination

Activity Description

In order to receive credit for this activity, a MIPS eligible clinician must document practices/processes for care transition with documentation of how a MIPS eligible clinician or group carried out an action plan for the patient with the patient’s preferences in mind (that is, a “patient-centered” plan) during the first 30 days following a discharge. Examples of these practices/processes for care transition include: staff involved in the care transition; phone calls conducted in support of transition; accompaniments of patients to appointments or other navigation actions; home visits; patient information access to their medical records; real time communication between PCP and consulting clinicians; PCP included on specialist follow-up or transition communications.


Patient-centered, care transition action plan for is carried out for first 30 days following a discharge

Suggested Documentation

Documentation of care transition practices/processes including a patient-centered action plan for first 30 days following a discharge

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