The C21 measure has a 2026 national numeric average of 61 percent, the lowest of the Stars measures in this series. It is scored entirely from administrative claims with no chart-review fallback, so a follow-up visit that happens but whose claim never carries a qualifying code does not count. The unit of measurement is the ED visit rather than the patient: each qualifying visit opens its own seven-day window, and a patient with three visits generates three separately scored episodes.
AAVBC's Follow-Up After ED Visit for People with Multiple High-Risk Chronic Conditions Quick Reference Guide equips primary care clinicians and care teams with a comprehensive, evidence-aligned reference covering the episode-based measure specification, the seven-day window and qualifying service settings, telehealth and case-management pathways, risk stratification for outreach prioritization, common pitfalls and practical fixes, patient-side and workflow barriers, disparity gaps requiring targeted action, and billing codes reference. Grounded in current CMS and HEDIS specifications, this guide supports consistent, individualized clinical decision-making, helping care teams reach high-risk patients in the days that matter most after an ED visit, with the clarity and continuity that durable outcomes require.
AAVBC’s Deep-Dive series offers a comprehensive, structured analysis of C21 performance — moving far beyond quick-reference essentials. These guides provide an integrated review of measurement importance and impact, clinical integrations, technical details, challenges and barriers, strategies for team coordination and quality improvement as well as regulatory and financial considerations. The Deep-Dives combine evidence-informed clinical guidance with practical operational tools to support a deeper understanding of C21 performance and provide care teams with strategies to thrive within a value-based model.
The C21 measure has a 2026 national numeric average of 61 percent, the lowest of the Stars measures in this series. It is scored entirely from administrative claims with no chart-review fallback, so a follow-up visit that happens but whose claim never carries a qualifying code does not count. The unit of measurement is the ED visit rather than the patient: each qualifying visit opens its own seven-day window, and a patient with three visits generates three separately scored episodes.
AAVBC's Follow-Up After ED Visit for People with Multiple High-Risk Chronic Conditions Quick Reference Guide equips primary care clinicians and care teams with a comprehensive, evidence-aligned reference covering the episode-based measure specification, the seven-day window and qualifying service settings, telehealth and case-management pathways, risk stratification for outreach prioritization, common pitfalls and practical fixes, patient-side and workflow barriers, disparity gaps requiring targeted action, and billing codes reference. Grounded in current CMS and HEDIS specifications, this guide supports consistent, individualized clinical decision-making, helping care teams reach high-risk patients in the days that matter most after an ED visit, with the clarity and continuity that durable outcomes require.
AAVBC’s Deep-Dive series offers a comprehensive, structured analysis of C21 performance — moving far beyond quick-reference essentials. These guides provide an integrated review of measurement importance and impact, clinical integrations, technical details, challenges and barriers, strategies for team coordination and quality improvement as well as regulatory and financial considerations. The Deep-Dives combine evidence-informed clinical guidance with practical operational tools to support a deeper understanding of C21 performance and provide care teams with strategies to thrive within a value-based model.
