Timely Follow-Up (TFU) alerts now include more detailed guidance to help your practice take action on high-priority discharges.
What is the Timely Follow-Up Quality Measure?
This alert supports the ACO REACH quality measure: Timely Follow-Up After Acute Exacerbations of Chronic Conditions (TFU). This CMS quality measure tracks whether patients discharged from the ED, inpatient, or observation settings after an acute event receive a follow-up appointment within a clinically appropriate timeframe.
Meeting this measure may help:
Prevent avoidable readmissions
Improve patient outcomes
Boost your shared savings potential
Who qualifies?
Patients may be eligible if they were recently discharged and have one of the following chronic conditions:
Asthma
Coronary artery disease (CAD)
Congestive heart failure (CHF)
Chronic obstructive pulmonary disease (COPD)
Diabetes
Hypertension
The alert identifies the patient’s condition and acuity level, and provides the timeframe CMS expects for follow-up care (e.g., 7, 14, or 30 days).
Condition | TFU Visit Timeframe |
Hypertension (HTN) | 14 days (high acuity) 30 days (medium acuity) |
Asthma | 14 days |
Heart failure (HF) | 14 days |
Coronary artery disease (CAD) | 7 days (high acuity) 6 weeks (low acuity) |
Chronic obstructive pulmonary disease (COPD) | 30 days |
Diabetes | 14 days (high acuity) |
⏱ Note: An appointment must be completed and billed within the CMS-recommended timeframe to count toward the measure.
What action should I take?
Review the Pearl Platform discharge alerts and contact patients to schedule a visit.
Schedule a follow-up visit within the suggested window (e.g., 7–14 days depending on condition and acuity)
Bill the visit using any PQEM code—this does not need to be a TCM visit
We recommend contacting the patient within 2 days to reduce the risk of readmission and ensure the visit happens on time.
Why this matters
✔ Following up within CMS guidelines helps close critical care gaps
✔ Eligible visits may contribute to your quality performance and shared savings
✔ Early follow-up can reduce readmissions by up to 4.7%