GenIC #48 - Section 223 Demonstration Programs to Improve Community Mental Health Services

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GenIC #48 - Section 223 Demonstration Programs to Improve Community Mental Health Services

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Metrics and Quality
Measures for Behavioral
Health Clinics
Technical Specifications
and Resource Manual

(Volume 1)
April 2016
1

ACKNOWLEDGMENTS
For AMA-PCPI measures:
Physician Performance Measures (Measures) and related data specifications have been
developed by the American Medical Association (AMA)-convened Physician Consortium for
Performance Improvement® (PCPI®). These performance Measures are not clinical guidelines
and do not establish a standard of medical care and have not been tested for all potential
applications. The Measures, while copyrighted, can be reproduced and distributed, without
modification, for noncommercial purposes, e.g., use by health care providers in connection with
their practices. Commercial use is defined as the sale, license, or distribution of the Measures for
commercial gain, or incorporation of the Measures into a product or service that is sold, licensed,
or distributed for commercial gain. Commercial uses of the Measures require a license agreement
between the user and the AMA (on behalf of the PCPI). Neither the AMA, PCPI nor its members
shall be responsible for any use of the Measures.
THE MEASURES AND SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT
WARRANTY OF ANY KIND
© 2014 American Medical Association. All Rights Reserved.
Limited proprietary coding is contained in the Measure specifications for convenience. Users of
the proprietary code sets should obtain all necessary licenses from the owners of these code sets.
The AMA, the PCPI and its members disclaim all liability for use or accuracy of any Current
Procedural Terminology (CPT[R]) or other coding contained in the specifications.
For Minnesota Community Measurement measure:
© MN Community Measurement, 2014. All rights reserved.
PHQ-9: Copyright: Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke
and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce,
translate, display or distribute.
For National Committee for Quality Assurance (NCQA) measures:
NCQA Notice of Copyright and Disclaimers
These performance measures were developed and are owned by the National Committee for
Quality Assurance ("NCQA"). These performance measures are not clinical guidelines and do
not establish a standard of medical care. NCQA makes no representations, warranties, or
endorsement about the quality of any organization or physician that uses or reports performance
measures and NCQA has no liability to anyone who relies on such measures. NCQA holds a
copyright in this measure and can rescind or alter this measure at any time. Users of the measure
shall not have the right to alter, enhance, or otherwise modify the measure, and shall not
disassemble, recompile, or reverse engineer the source code or object code relating to the
measure. Anyone desiring to use or reproduce the measure without modification for a
noncommercial purpose may do so without obtaining any approval from NCQA. All commercial
uses must be approved by NCQA and are subject to a license at the discretion of NCQA. Use by
health care providers in connection with their own practices is not commercial use. A
"commercial use" refers to any sale, license, or distribution of a measure for commercial gain, or
incorporation of a measure into any product or service that is sold, licensed, or distributed for

commercial gain, even if there is no actual charge for inclusion of the measure. ©2004-2016
National Committee for Quality Assurance, all rights reserved.
CPT® contained in the Measures Specifications is copyright American Medical Association.
UB Codes contained in the Measures Specifications is copyright American Hospital Association.
For Proprietary Codes:
CPT® codes copyright 2004-2014 American Medical Association. All rights reserved. CPT is a
trademark of the American Medical Association.
This material contains content from LOINC®. The LOINC table, LOINC codes, and LOINC
panels and forms file are copyright © 1995-2015, Regenstrief Institute, Inc. and the Logical
Observation Identifiers Names and Codes (LOINC) Committee and available at no cost under
the license on the LOINC® Terms of Use web page.
The International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) is
published by the World Health Organization (WHO). ICD-9-CM is an official Health Insurance
Portability and Accountability Act standard.
The International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
is published by the World Health Organization (WHO). ICD-10-CM is an official Health
Insurance Portability and Accountability Act standard. ICD-10-CM copyright 2014 World
Health Organization. All Rights Reserved.
The International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10PCS) is published by the World Health Organization (WHO) ICD-10-PCS is an official Health
Insurance Portability and Accountability Act standard. ICD-10-CM copyright 2014 World
Health Organization. All Rights Reserved.
This material contains Uniform Billing (UB) codes which are the product of the National
Uniform Billing Committee. Uniform Bill Codes (“UB Codes”) are protected under federal
copyright laws and are owned by the American Hospital Association (AHA). The UB Codes in
the HEDIS specifications are included with the permission of the AHA. The UB Codes
contained in the HEDIS specifications may be used by health plans and other health care
delivery organizations for the purpose of calculating and reporting HEDIS results or using
HEDIS measure results for their internal quality improvement purposes. All other uses of the UB
Codes require a license from the AHA. Software vendors and all others desiring to use the UB
Codes in a commercial product to generate HEDIS results, or for any other use, must obtain a
commercial use license directly from the AHA. To inquire about licensing, contact
[email protected].
For United States Government Publications and Codes:
The Centers for Medicare & Medicaid Services (CMS) is the steward for certain measures upon
which this material relies. It also is the publisher of the Core Set of Adult Health Care Quality
Measures for Medicaid, the Core Set of Children’s Health Care Quality Measures for Medicaid
and CHIP, and the Physician Quality Reporting System (PQRS) measures upon which some of
this material relies.
3

The CMS measure in this manual, Screening for Clinical Depression and Follow-Up Plan, that
is part of the Core Set of Adult Health Care Quality Measures for Medicaid, was developed by
Quality Insights of Pennsylvania as a special project under the Quality Insights' Medicare
Quality Improvement Organization (QIO) contract HHSM-500-2005-PA001C with CMS. This
measure is in the public domain.
Limited proprietary coding is contained in the measure specifications for convenience. Users of
the proprietary code sets should obtain all necessary licenses from the owners of these code sets.
Quality Insights of Pennsylvania disclaims all liability for use or accuracy of any Current
Procedural Terminology (CPT®) or other coding contained in the specifications. CPT®
contained in the Measures specifications is copyright 2004-2014 American Medical Association.
All Rights Reserved. These performance measures are not clinical guidelines and do not
establish a standard of medical care, and have not been tested for all potential applications.
HCPCS is the Healthcare Common Procedure Coding System used by CMS. The Level II
HCPCS codes, which are established by CMS's Alpha-Numeric Editorial Panel, primarily
represent items and supplies and non-physician services not covered by the American Medical
Association's Current Procedural Terminology-4 (CPT-4) codes; Medicare, Medicaid, and
private health insurers use HCPCS procedure and modifier codes for claims processing. Level II
alphanumeric procedure and modifier codes comprise the A to V range.
CMS Place of Service Codes are two-digit codes placed on health care professional claims to
indicate the setting in which a service was provided. The Centers for Medicare & Medicaid
Services (CMS) maintain POS codes used throughout the health care industry.
The Value Set Authority Center (VSAC) is provided by the National Library of Medicine
(NLM), in collaboration with the Office of the National Coordinator for Health Information
Technology and the Centers for Medicare & Medicaid Services. The VSAC provides
downloadable access to all official versions of vocabulary value sets contained in the 2014
Clinical Quality Measures (CQMs). Each value set consists of the numerical values (codes) and
human-readable names (terms), drawn from standard vocabularies such as SNOMED CT® ,
RxNorm, LOINC and ICD-10-CM, which are used to define clinical concepts used in clinical
quality measures. Viewing or downloading value sets from the VSAC requires a free Unified
Medical Language System® Metathesaurus License, due to usage restrictions on some of the
codes included in the value sets.
The Substance Abuse and Mental Health Services Administration (SAMHSA) is the steward of
measures developed expressly for this manual and provided the funding for re-specification or
re-formatting of all measures included in this manual. Limited proprietary coding is contained in
the measure specifications for convenience. Users of the proprietary code sets should obtain all
necessary licenses from the owners of these code sets. CPT® contained in the Measures
specifications is copyright 2004-2014 American Medical Association. All Rights Reserved.

Table of Contents
VOLUME 1
ACKNOWLEDGMENTS ............................................................................................................................ 2
Table of Contents .......................................................................................................................................... 5
I. BEHAVIORAL HEALTH CLINIC QUALITY MEASURES ................................................................. 8
Background ........................................................................................................................................... 8
The Behavioral Health Clinic Quality Measures .................................................................................... 9
II. DATA COLLECTION AND REPORTING OF THE BEHAVIORAL HEALTH CLINIC QUALITY
MEASURES ............................................................................................................................................... 14
Definitions ........................................................................................................................................... 14
Data Collection and Preparation for Reporting .................................................................................. 16
Reporting and Submission of Measures ............................................................................................. 21
III. TECHNICAL SPECIFICATION COMPONENTS ............................................................................. 23
IV.

TECHNICAL SPECIFICATIONS -- CLINIC-REPORTED MEASURES ................................... 26
Routine Care Needs (ROUT) ................................................................................................................. 27
Time to Initial Evaluation (I-EVAL) ........................................................................................................ 30
Time to Comprehensive Person- and Family-Centered Diagnostic and Treatment Planning Evaluation
(TX-EVAL) .............................................................................................................................................. 34
Deaths by Suicide (SUIC)....................................................................................................................... 37
Documentation of Current Medications in the Medical Record (DOC) ............................................... 40
Preventive Care & Screening: Body Mass Index (BMI) Screening & Follow-Up (BMI-SF) .................... 44
Weight Assessment for Children/Adolescents: Body Mass Index Assessment for
Children/Adolescents (WCC-BH) .......................................................................................................... 50
Controlling High Blood Pressure (CBP-BH) ........................................................................................... 55
Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention (TSC) ..................... 66
Preventive Care & Screening: Unhealthy Alcohol Use: Screening & Brief Counseling (ASC) .............. 69
Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment (SRA-BH-C) ........ 74
Adult Major Depressive Disorder (MDD): Suicide Risk Assessment (SRA-A) ....................................... 82
Screening for Clinical Depression and Follow-Up Plan (CDF-BH) ......................................................... 91
Depression Remission at Twelve Months (DEP-REM-12)..................................................................... 95

TECHNICAL SPECIFICATIONS -- STATE-REPORTED MEASURES ...................................... 100
5

Housing Status (HOU) ......................................................................................................................... 101
Suicide Attempts (SU-A) ..................................................................................................................... 106
Patient Experience of Care Survey (PEC) ............................................................................................ 109
Youth/Family Experience of Care Survey (Y/FEC)............................................................................... 111
Follow-up After Emergency Department Visit for Mental Illness (FUM) ........................................... 113
Follow-up After Emergency Department Visit for Alcohol and Other Drug Dependence (FUA) ....... 118
Plan All-Cause Readmissions Rate (PCR-BH) ...................................................................................... 123
Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic
Medications (SSD) .............................................................................................................................. 130
Diabetes Care For People With Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control
(>9.0%) (SMI-PC)................................................................................................................................. 137
Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM) ................................ 144
Cardiovascular Monitoring for People With Cardiovascular Disease and Schizophrenia (SMC) ....... 147
Adherence to Mood Stabilizers for Individuals with Bipolar I Disorder (AMS-BD) ........................... 152
Adherence to Antipsychotic Medications for Individuals with Schizophrenia (SAA-BH) ................... 157
Follow-Up After Hospitalization for Mental Illness (FUH-BH-A) ........................................................ 164
Follow-Up after Hospitalization for Mental Illness (FUH-BH-C) ......................................................... 171
Follow-Up Care for Children Prescribed Attention-Deficit Hyperactivity Disorder (ADHD) Medication
(ADD-BH) ............................................................................................................................................ 178
Antidepressant Medication Management (AMM-BH) ....................................................................... 186
Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (IET-BH) ................ 192

VOLUME 2
GENERAL APPENDICES ........................................................................................................................... 4
Appendix A. Measurement Period for Denominators and Numerators for the BHC Metrics and
Quality Measures .................................................................................................................................... 5
Appendix B. BHC Value Set Directory User Manual .......................................................................... 16
Appendix C. Guidance for Selecting Sample Sizes for HEDIS® Hybrid Measures............................ 21
Appendix D. Definitions of Practitioner Types .................................................................................... 23
APPENDICES FOR SPECIFIC MEASURES ........................................................................................... 25
Appendix ROUT: Routine Care Needs ................................................................................................ 26
Appendix I-EVAL: Time to Initial Evaluation..................................................................................... 28
Appendix TX-EVAL: Time to Comprehensive Person and Family-Centered Diagnostic and
Treatment Planning Evaluation ............................................................................................................ 33
Appendix SUIC: Deaths by Suicide ..................................................................................................... 36
6

Appendix DOC.A: Documentation of Current Medications in the Medical Record............................ 37
Appendix DOC.B: Documentation of Current Medications in the Medical Record ............................ 40
Appendix BMI-SF.A: Preventive Care & Screening: Body Mass Index (BMI) Screening & FollowUp ......................................................................................................................................................... 41
Appendix BMI-SF.B. Codes Relevant to Preventive Care & Screening: Adult Body Mass Index
(BMI) Screening and Follow-Up.......................................................................................................... 44
Appendix CBP-BH. Controlling High Blood Pressure ........................................................................ 45
Appendix TSC.A: Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention 47
Appendix TSC.B: Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention 50
Appendix ASC.A: Preventive Care & Screening: Unhealthy Alcohol Use: Screening & Brief
Counseling ............................................................................................................................................ 51
Appendix ASC.B: Preventive Care & Screening: Unhealthy Alcohol Use: Screening & Brief
Counseling ............................................................................................................................................ 54
Appendix SRA-BH-C: eCQM Flow for Reporting the Suicide Risk Assessment (SRA-BH-C)
Measure ................................................................................................................................................ 55
Appendix SRA-A.A: eCQM Flow for Reporting the Suicide Risk Assessment (SRA-A) Measure ... 62
Appendix SRA-A.B: Major Depressive Disorder (MDD): Suicide Risk Assessment ......................... 67
Appendix CDF-BH.A: Screening for Clinical Depression and Follow-Up Plan ................................. 71
Appendix CDF-BH.B: Screening for Clinical Depression and Follow-Up Plan ................................ 74
Appendix DEP-REM-12. Depression Remission at Twelve Months.................................................. 75
Appendix HOU: Housing Status .......................................................................................................... 78
Appendix SU-A. ICD-10-CM Codes Relevant to Calculating Suicide Attempts ............................... 79
Appendix PCR-BH: Plan All-Cause Readmissions Rate ................................................................... 133
Appendix AMS-BD: Adherence to Mood Stabilizers for Individuals with Bipolar I Disorder ........ 135
Appendix SAA-BH: Adherence to Antipsychotics for Individuals with Schizophrenia................... 139
Appendix ADD-BH: Follow-Up Care for Children Prescribed Attention-Deficit Hyperactivity
Disorder (ADHD) Medication ............................................................................................................ 141
Appendix AMM-BH: Antidepressant Medication Management ....................................................... 142

I. BEHAVIORAL HEALTH CLINIC QUALITY MEASURES
Background
This manual provides the specifications for and general information related to quality measures
and other metrics developed to be used at the provider level by Behavioral Health Clinics
(BHCs). We refer to these collectively as measures in this document, unless there is a need to
distinguish them (see Chapter II for a definition of each).
The measures included in this document are rooted in the requirements placed on Certified
Community Behavioral Health Clinics (CCBHCs) as part of the Demonstration Program to
Improve Community Mental Health Services, found in Section 223 of the federal Protecting
Access to Medicare Act of 2014 (PAMA). The measures in this document are intended for use
by BHCs generally as well as by the CCBHCs. Where relevant, we indicate if the requirements
placed on CCBHCs differ from the standards discussed in this introductory material or elsewhere
in these specifications. Some of these quality measures are re-specifications of existing
measures that are now designed to be used at the clinic level. Other measures are new and are
designed to address aspects of care important for BHCs in general and the CCBHCs specifically.
For more information on the requirements for quality measure reporting applicable to the
CCBHCs, see Program Requirement 5 of the CCBHC Certification Criteria which identifies 32
specific measures, and the section of this Chapter entitled “The Behavioral Health Clinic Quality
Measures,” which clarifies changes made to those requirements. Of these quality measures, 11
will or may be used by states to make Quality Bonus Payments (QBPs) under the Section 223
behavioral health demonstration.
Data and quality measure reporting have multiple objectives. Collection and reporting of this
information offer providers, states, and other stakeholders a better method for assessing the
manner in which care is accessed and provided. The information can be used for internal quality
improvement (QI) processes to determine the degree of progress achieved or to determine where
new or additional improvement is needed. The data can be used for accountability, to grantors or
regulatory entities, for example. Some quality measures can be used as part of incentive
programs, such as the QBPs that are part of the Section 223 behavioral health demonstration
Prospective Payment System (PPS) methodology. The data and measures reported also may be
used to evaluate programs, such as the national evaluation of the CCBHC Demonstration
Program. In general, the data collected will help states and the federal government to have a
better understanding of the quality of health care that consumers at BHCs receive.
Specification sources. This manual includes specifications for quality measures derived from
multiple sources. In most cases, the original measures were designed for reporting at the state or
health plan level. Each measure has been re-specified to enable reporting at the BHC level. This
manual includes the most current version of the measure specifications available as of December
2015, altered to enable reporting at the BHC level. For Healthcare Effectiveness Data and
8

Information Set (HEDIS) measures, this manual follows HEDIS 2016 specifications, with the
exception of the Follow-Up After Emergency Department Visit for Mental Illness (FUM) and
Follow-Up After Emergency Department Visit for Alcohol and Other Drug Dependence (FUA)
measures, which are draft 2017 HEDIS measures. For non-HEDIS measures, this manual
includes the most applicable version of the specifications available from the measure steward for
reporting 2015 data, re-specified where necessary at the BHC level. Some measures were
developed by SAMHSA specifically for this document.
Measure testing on measures that are not derived from National Quality Forum (NQF)-endorsed
measures is limited. Some of the measures that are derived from NQF-endorsed measures were
originally specified at the health plan level and for purposes of this demonstration have been respecified at the clinic level (e.g., PCR-BH). Data from these measures (and all of the quality
measures) will be reviewed in an on-going manner to insure the integrity of the measures.

The Behavioral Health Clinic Quality Measures
Tables 1 and 2 identify the Behavioral Health Clinic measures. These measures are rooted in
those specified in Program Requirement 5 of the CCBHC Certification Criteria for the Section
223 behavioral health demonstration. The measures that pertain to QBPs made through the
CCBHC demonstration and the six measures which must be achieved in order for a clinic to
receive a QBP payment (see PPS guidance, Table 3) are specifically identified. Table 1 is
composed of BHC-lead measures while Table 2 lists measures requiring data collection by the
state (state-lead measures).
Three primary changes have been made from the original measures identified in the CCBHC
Certification Criteria. First, three measures (Patient Experience of Care Survey (PEC),
Youth/Family Experience of Care Survey (Y/FEC), and Initiation and Engagement of Alcohol
and Other Drug Dependence Treatment (IET-BH)) were specified in Program Requirement 5 of
the CCBHC Certification Criteria as BHC-lead but have been moved from BHC reporting to
state reporting. Second, two other measures enumerated in the Certification Criteria also have
changed. The measure Cardiovascular Health Screening for People With Schizophrenia or
Bipolar Disorder Who Are Prescribed Antipsychotic Medications (NQF #1927) was dropped as
it is no longer in accordance with treatment guidelines. The measure Follow-up after Discharge
from the Emergency Department for Mental Health or Alcohol or Other Drug Dependence was
dropped and replaced with two measures, Follow-Up After Emergency Department Visit for
Mental Illness (FUM) and Follow-Up After Emergency Department Visit for Alcohol and Other
Drug Dependence (FUA). The follow-up measure that originally was to be included is no longer
maintained by the steward and is being replaced by the two newer measures designed to be used
as HEDIS measures in 2017. The substitution of two measures does not expand the extent of
reporting because the original measure contained 4 rates (7-day and 30-day follow-up after being
seen in an emergency department for mental illness or, separately, alcohol and other drug
dependence). The replacement measures merely separate the reasons for the emergency visit
9

into distinct measures. Third, the number of measures required as part of the CCBHC
demonstration program is now 22. The remainder of the measures in this manual are available
for use by states, BHCs or CCBHCs as states or other entities may wish. The lists of measures in
Tables 1 and 2 identify those that are or are not required of CCBHCs.
The technical specifications in Chapters IV and V of this manual provide additional details for
each measure.

Table 1. Behavioral Health Clinic, Clinic-Lead Measures
Measure Name

Measure
Stewarda

CCBHC
NQF # Demonstration
Measure

CMS Medicaid
Core Set

Routine Care Needs (ROUT)

SAMHSA

Time to Initial Evaluation (I-EVAL)

SAMHSA

Yes

Time to Comprehensive Person and FamilyCentered Diagnostic and Treatment Planning
Evaluation (TX-EVAL)

SAMHSA

Deaths by Suicide (SUIC)

SAMHSA

CMS

0419

CMS

0421

Yes

NCQA

0024

Yes

Child Core

NCQA

0018

Adult Core

AMA-PCPI

0028

Yes

AMA-PCPI

2152

Yes

AMA-PCPI

1365

Yes

Child Core

AMA-PCPI

0104

Yes

CMS

0418

Yes

Adult Core

Documentation of Current Medications in the
Medical Records (DOC)
Preventive Care and Screening: Adult Body Mass
Index (BMI) Screening and Follow-Up (BMI-SF)
Weight Assessment and Counseling for Nutrition
and Physical Activity for Children/Adolescents
(WCC-BH)
Controlling High Blood Pressure (CBP-BH)
Preventive Care & Screening: Tobacco Use:
Screening & Cessation Intervention (TSC)
Preventive Care and Screening: Unhealthy Alcohol
Use: Screening and Brief Counseling (ASC)
Child and Adolescent Major Depressive Disorder
(MDD): Suicide Risk Assessment (SRA-BH-C)
Major Depressive Disorder: Suicide Risk
Assessment (SRA-A)
Screening for Clinical Depression and Follow-Up
Plan (CDF-BH)

CCBHC
QBM

Measure Name
Depression Remission at Twelve Months (DEPREM-12)

Measure
Stewarda

CCBHC
NQF # Demonstration
Measure

CMS Medicaid
Core Set

Minnesota
Community
Measurement

0710

Yes

CCBHC
QBM

Abbreviations: AMA-PCPI, American Medical Association-Physician Consortium for Performance Improvement; CMS, Centers for Medicare & Medicaid
Services; NA, not applicable; NCQA, National Committee for Quality Assurance; NQF, National Quality Forum; NR, Not required to be a QBM; QBM,
Quality Bonus Measure in the CCBHC Demonstration Program; R, Required; SAMHSA, Substance Abuse and Mental Health Services Administration
a
The measure steward is the organization responsible for maintaining a particular measure or measure set. Responsibilities of the measure steward include
updating the codes that are tied to technical specifications and adjusting measures as the clinical evidence changes.

Table 2. Behavioral Health Clinic State-Lead Measures
Measure Name
Housing Status (HOU)
Suicide Attempts (SU-A)
Patient Experience of Care Survey (PEC)
Youth/Family Experience of Care Survey (Y/FEC)
Follow-Up After Emergency Department Visit for
Mental Illness (FUM)
Follow-Up After Emergency Department Visit for
Alcohol and Other Drug Dependence (FUA)
Plan All-Cause Readmission Rate (PCR-BH)
Diabetes Screening for People with Schizophrenia or
Bipolar Disorder who Are Using Antipsychotic
Medications (SSD)

Measure
Stewarda

NQF
#

CCBHC
Demonstration
Measure

CMS Medicaid
Core Set

CCBHC
QBM

SAMHSA
SAMHSA
SAMHSA
SAMHSA

NA
NA
NA
NA

Yes
No
Yes
Yes

NA
NA
NA
NA

NCQA

Yes

NCQA

Yes

NCQA

1768

Yes

Adult Core

NCQA

1932

Yes

Measure Name
Diabetes Care for People with Serious Mental Illness:
Hemoglobin A1c (HbA1c) Poor Control (>9.0%)
(SMI-PC)
Metabolic Monitoring for Children and Adolescents
on Antipsychotics (APM)
Cardiovascular Monitoring for People with
Cardiovascular Disease and Schizophrenia (SMC)
Adherence to Mood Stabilizers for Individuals with
Bipolar I Disorder (AMS-BD)
Adherence to Antipsychotic Medications for
Individuals with Schizophrenia (SAA-BH)
Follow-Up After Hospitalization for Mental Illness,
ages 21+ (adult) (FUH-BH-A)
Follow-Up After Hospitalization for Mental Illness,
ages 6 to 21 (child/adolescent) (FUH-BH-C)
Follow-up care for children prescribed ADHD
medication (ADD-BH)
Antidepressant Medication Management (AMM-BH)
Initiation and Engagement of Alcohol and Other
Drug Dependence Treatment (IET-BH)

Measure
Stewarda

NQF
#

CCBHC
Demonstration
Measure

CMS Medicaid
Core Set

CCBHC
QBM

NCQA

2607

NCQA

1933

CMS

1880

CMS

Yes

Adult Core

NCQA

0576

Yes

Adult Core

NCQA

0576

Yes

Child Core

NCQA

0108

Yes

Child Core

NCQA
NCQA

0105

Yes

Adult Core

0004

Yes

Adult Core

Abbreviations: CMS, Centers for Medicare & Medicaid Services; NA, not applicable; NCQA, National Committee for Quality Assurance; NQF, National
Quality Forum; NR, Not required to be a QBM; QBM, Quality Bonus Measure in the CCBHC Demonstration Program; R, Required; SAMHSA, Substance
Abuse and Mental Health Services Administration
a
The measure steward is the organization responsible for maintaining a particular measure or measure set. Responsibilities of the measure steward include
updating the codes that are tied to technical specifications and adjusting measures as the clinical evidence changes.

II. DATA COLLECTION AND REPORTING OF THE
BEHAVIORAL HEALTH CLINIC QUALITY MEASURES
To support consistency in reporting the BHC measures, this chapter provides general guidelines
for data collection, preparation, and reporting. Technical specifications, which provide detailed
information on how to calculate each measure, are presented in Chapters IV and V. For
technical assistance with calculating and reporting these measures, contact the technical
assistance (TA) mailbox at [email protected].
Definitions
•

BHC. A BHC is a Behavioral Health Clinic. These measures are broadly specified to be
applicable to BHCs.

•

BHC Client, Consumer, or Patient. An individual (adult or child) receiving services
from a BHC program.

•

BHC Provider. Any entity (provider) engaged in the delivery of health care services and
who is legally authorized to do so by the state in which the individual or entity delivers
the services and who delivers services as a BHC (entity) or part of a BHC (provider). See
Appendix D for definitions of certain practitioner types.

•

CCBHC. A Certified Community Behavioral Health Clinic (CCBHC) is a clinic
certified by the state to participate in demonstration programs to improve community
mental health services authorized by Section 223 of the federal Protecting Access to
Medicare Act. See the Certification Criteria for more information.

•

Data-Reporting Template. In addition to the measures specified in this manual, datareporting templates have been developed for reporting these measures. Those templates
will be available on the SAMHSA website. Within each template, specific fields are
provided for required data elements. Those fields are as follows:
A. Measurement Year: Identifies the year to which the report corresponds (e.g.,
Demonstration Year 1, Fiscal Year 2017)
B. Data Source: Identifies whether the data are derived from administration claims
data, medical records, a hybrid source, or a survey
C. Date Range: Identifies the Measurement Period in which data were collected that
are used in calculating the denominator and numerator (not necessarily the same
as the Measurement Year)
D. Performance Measure: The description of, and table for calculation of, the
measure

E. Adherence to Measure Specifications: Allows the reporter to indicate the
population measured and ways in which data collection or reporting might differ
from the specifications
F. Additional Notes: Allows the reporter to provide additional information
•

Eligible Population for Measurement. In the broadest sense, the eligible population for
these measures includes all BHC consumers served by a BHC provider. The
denominator-eligible population for each measure includes BHC consumers who satisfy
the measure-specific eligibility criteria that may include requirements such as age and
continuous enrollment. The specifications in Chapters IV and V indicate the population
that should be included in each measure and the reporting unit for the measure. For all
measures, the denominator includes consumers (or visits) that satisfy measure-specific
eligibility criteria (e.g., all consumers aged 12 years and older seen at least once at the
BHC during the measurement year (Suicide Attempts (SU-A)); all episodes of care
during the measurement year for consumers 6–17 years of age with a new or recurrent
episode of Major Depressive Disorder (Child and Adolescent Major Depressive Disorder
(MDD): Suicide Risk Assessment (SRA-BH-C))).
States will derive data on populations eligible for measurement from their Medicaid
Management Information Systems (MMIS) for state-reported measures. Behavioral
health clinics will rely on internal records for data to support BHC-reported measures.
Because these measures are specified and aggregated at the BHC level, the eligible
population differs from that in many of the source measures which are specified at the
health plan level.

•

Measure. Quality or performance measures follow a particular formula; the denominator
indicates the eligible population (with the exceptions of any exclusions specific to the
measure), and the numerator indicates the part of the eligible population that received the
service or had the outcome to which the measure relates.

•

Metric. The word “metrics,” as used in this manual, refers to statistics designed to allow
the collection of data distinct from a quality or performance measure (e.g., the mean
number of days until initial evaluation for new consumers (I-EVAL)). Unless the
context makes it necessary to distinguish them, metrics in this manual are referred to as
measures.

•

Quality Bonus Measure (QBM). QBMs are the subset of measures that have been
selected for incentive payments (Quality Bonus Payments or QBPs) as part of the
CCBHC Demonstration Program. These measures are discussed in more detail below in
the section of this Chapter (II) related to Data Collection and Preparation for Reporting.

Data Collection and Preparation for Reporting
Data reporting time frames. Data reporting involves “measurement years.” For reporting
related to the CCBHC Demonstration Program, measurement year (MY) is defined as the
Demonstration Year (DY) and is reported as DY1 or DY2. The CCBHC DYs will both be full
12 month years. Hence, if DY1 begins on March 1, 2017, it will continue through February 28,
2018. For non-CCBHC-related reporting, the entity requiring reporting will specify the period of
time, but annual collection of data typically will align with the calendar year prior to the
reporting year; for example, calendar year 2016 data would be reported for Federal Fiscal Year
(FFY) 2017.
•

Reporting: For all measures, states and BHCs should indicate start and end dates for the
measurement year using Section A (Measurement Year) of the data-reporting templates.
For CCBHCs, this time frame would be the 12-month period identified as DY1 or DY2.
The data-reporting templates are discussed in detail below.

Data collection time frames. Data collection involves “measurement periods.” A measurement
period (MP) often corresponds with the measurement year. Some measurement periods,
however, are indexed to a specific date or event or may require some other modification to
collection that corresponds with the measurement year (e.g., Depression Remission at Twelve
Months (DEP-REM-12), which is indexed to the time of diagnosis or recurrence of an episode of
depression within the measurement year). States and BHCs should adhere to the measurement
periods identified in the technical specification for each measure. In addition to information
provided about measurement periods in each specification, measurement periods for each
measure are summarized in Appendix A. For the sake of simplicity, examples in Appendix A
reflect the calendar year. For a CCBHC, however, because the measurement year will vary by
state in terms of start and end date (e.g., March 1, 2017 through February 28, 2018), the MP must
be adjusted to reflect that measurement year. For example, for a measurement year beginning
March 1, 2017, the MP for the denominator for Follow-up After Hospitalization for Mental
Illness (FUH-BH-A) would run from March 1, 2017 until January 29, 2018 (the measurement
year less 30 days). To assist CCBHCs where measurement years may begin at some point after
January 1, MPs for all measures for DY1 and DY2 are provided in the final worksheet of the
data-reporting templates, entitled “Measurement Periods.”
•

Reporting: For all measures, states and BHCs should indicate start and end dates for the
MP for the denominator and numerator using Section C (Date Range) of the datareporting templates. CCBHCs should use the final worksheet (Measurement Periods) in
the templates for guidance on MPs.

Unit of reporting. The unit of reporting in these measures is always the BHC. The measures
are specified at the clinic/clinician office setting level. This means that both states and BHCs
should collect data across all consumers that are served by the BHC and aggregate it at the BHC
16

level. In the case of the CCBHCs, the unit of reporting is at the CCBHC level regardless of how
many clinics or entities comprise the CCBHC, and depending on the data required for the
measure and the structure of the CCBHC, will include data from Designated Collaborating
Organizations (DCOs) (e.g., a DCO might be the entity undertaking screening for Hemoglobin
A1c and the DCO data would be needed for computation of the related diabetes quality
measure). For other BHCs, the unit of reporting may be single clinics or groups of clinics,
depending on the level of analysis that may be required by the state or other entity to which it is
reported.
For state-lead measures, in particular, this is different than the norm, as states tend to report
numbers aggregated from multiple sources encompassing the state’s Medicaid program or health
plans within the state Medicaid program. As a result, the state must be able to identify and
attribute data to specific clinics and consumers at specific clinics (i.e., each clinic will need a
unique identification number assigned to it by the state).
Consumer attribution. States or other entities requiring reporting may decide how to attribute
consumers to BHCs depending on the specific impetus for data reporting. For the CCBHC
Demonstration Program, attribution of consumers for purposes of data reporting required by the
CCBHC criteria requires only one visit by a person to the CCBHC during the measurement
period. The state is responsible for providing guidance to clinics on what activities constitute a
visit that may be enumerated. Attribution to a CCBHC requires one enumerated visit that falls
within the CCBHC scope of services (whether or not provided within the four walls of the
clinic). It is possible in some states that a consumer may visit more than one CCBHC during a
year; the consumer will be attributed to both.
The population eligible for measurement. In the broadest sense, the eligible population for
these measures includes all BHC consumers served by a BHC provider. The denominator
includes BHC consumers who satisfy measure-specific eligibility criteria that may include
requirements such as age and continuous enrollment. The specifications in Chapters IV and V
indicate the population that should be included in each measure and the reporting unit for the
measure.
BHCs should report data on all of the populations they serve and stratify the data according to
whether clinic users are: (1) Medicaid beneficiaries including Title 19-eligible CHIP
beneficiaries, (2) dually eligible under Medicare and Medicaid, and (3) others enrolled in neither
program, including Title 21-eligible CHIP beneficiaries. States also are required to report data
stratified for Medicaid beneficiaries, including Title 19-eligible CHIP beneficiaries, and, to the
extent possible, clinic users who are dually eligible for Medicare and Medicaid. The distinction
between Title 21 and Title 19-eligible CHIP beneficiaries is based upon the restrictions found in
PAMA Section 223 (d)(5)(A). The requirement to report data stratified by insurance payer does
not apply to reporting of data on housing status and the two patient experience of care measures.
17

•

Reporting: If a state lacks access to data for dually eligible individuals, please note this in
Section E of the data-reporting template (Adherence to Measure Specifications)

Continuous enrollment requirements apply to many measures, including some of the BHC-lead
measures. If a measure specification does not include requirements for continuous enrollment,
the insurance status at the time of the first visit during the measurement year will be applied for
the entire year. For any measure with a continuous enrollment requirement that is BHCreported, Medicaid enrollees and those who are dual enrollees in Medicare and Medicaid should
be counted if applicable within those categories if they satisfy the continuous enrollment criteria.
Those who do not satisfy those criteria are to be counted in the “other” category.
For purposes of CCBHC QBM/QBP reporting and payment, only consumers who are Medicaid
beneficiaries, including Title 19-eligible CHIP beneficiaries, will be counted towards payment.
Data will be drawn from the stratified rates for those groups. Reporting on all consumers,
stratified by payer category, is required for CCBHC-reported measures.
•

Reporting: Section E of the data-reporting template (Adherence to Measure
Specifications) provides space for the state or BHC to clearly report if only certain payer
categories are included in the measure calculation.

Representativeness of data. States and BHC providers should use the most complete data
available and ensure that the rates reported are representative of the entire population served by
the BHC. For a measure based on administrative data, all BHC consumers who meet the eligible
population requirements for the measure should be included. For a measure based on a sampling
methodology, states and BHC providers should ensure that the sample used to calculate the
measure is representative of the entire BHC eligible population for the measure.
Population size requirements. For purposes of the CCBHC Demonstration Program, all
measures must be reported regardless of the size of the eligible population. However, if the
denominator is less than 30, measure results will not be used for any public reporting or for
purposes of the national evaluation.
•

Reporting: For reporting that is not related to the CCBHC Demonstration Program, if a
measure has a denominator less than 30 and the state and BHCs choose not to report the
measure due to small numbers, please note this in Section E of the data-reporting
template (Adherence to Measure Specifications) and specify the denominator size.

Data collection methods. Other than the patient experience of care measures, the measures
included in this manual have three possible data collection methods: administrative, hybrid, and
medical records, the latter of which may include electronic health records (e-measures). The
specifications for each measure indicate which method is to be used.

•

Administrative: The administrative method uses transaction data (for example, claims or
encounters) or other administrative data sources to calculate the measure. These data can
be used in cases where the data are known to be complete, valid, and reliable. When
administrative data are used, the entire eligible population is included in the denominator.

•

Hybrid: The hybrid method uses both administrative data sources and medical record
(paper or electronic health records (EHRs) or registry) data to determine numerator
compliance. The denominator sometimes consists of a sample of the measure’s eligible
population. When possible, the hybrid method should be used when administrative data
are incomplete or may be of poor quality or the data elements for the measure are not
captured in administrative data (e.g., Controlling High Blood Pressure [CBP-BH]
measure). Samples should be representative of the eligible population, including, when
stratified by age, the relevant age groups.

•

Medical records: The medical records method uses the BHC medical records or other
clinic transaction data sources, such as electronic health records (EHRs), paper medical
records, clinic registries, or scheduling software. The e-measure method uses medical
record data only, including data from EHRs, to calculate the measure. This electronic
data collection method applies to the Child and Adolescent Suicide Risk Assessment
measure (SRA-BH-C) and is an option for the collection of the Adult Major Depressive
Disorder (MDD): Suicide Risk Assessment measure (SRA-A).

•

Reporting: The method used should be reported in Section B of the data-reporting
template (Data Source).

Sampling. For measures that use the hybrid method and that require sampling, sampling
guidance is included in the technical specification if available from the measure steward.
Sampling should be systematic and random to ensure that all eligible individuals have an equal
chance of inclusion. The sample should be representative of the eligible population, and, in
situations where reporting is by age group, random samples should be selected within each age
group, to insure sufficient sample size of each age group.
•

HEDIS measures: For HEDIS measures that use the hybrid method, the sample size
should be 411, unless special circumstances apply. If a BHC has less than 411
consumers, all consumers should be included in the denominator. States and BHC
providers may reduce the sample size using information from the current year's
administrative rate or the prior year's audited hybrid rate, if one exists. Regardless of the
selected sample size, the National Committee for Quality Assurance (NCQA)
recommends an oversample to allow for substitution in the event that cases in the original
sample turn out to be ineligible for the measure. For additional information on using a
reduced sample size, refer to Appendix C, Guidance for Selecting Sample Sizes for
Hybrid Measures.
19

•

Technical Assistance: Additional guidance on sampling for hybrid measures is available
in the following CMS technical assistance brief designed to assist reporters of the CMS
Child or Adult Core Sets for Medicaid/CHIP measures: “Approaches to Using the Hybrid
Method to Calculate Measures from the Child and Adult Core Sets” (October 2014). 1

•

Reporting: States and BHC providers should describe the sampling approach used for
each hybrid measure in Section F (Additional Notes) and the sample size and size of the
measure-eligible population in Section B (Data Source) in the data-reporting template.

Alternative data collection methods and data sources. States and BHCs should report the
measures using the methods listed in the specifications to the extent possible, or using an
alternative method (e.g., medical record review without systematic sample) or data source if the
specified method or source are not feasible.
•

Reporting: Any deviations from the measure specifications should be explained in
Section E of the data-reporting template (Adherence to Measure Specification) and, if
necessary, in Section F (Additional Notes).

•

Inclusion of paid, suspended, pending, and denied claims. A key aspect of the
assessment of quality for some measures is to capture whether or not a service was
provided. For such measures, the inclusion of all claims would be appropriate, regardless
of whether they were paid, denied, or voided. For HEDIS measures that rely on claims as
a data source, the HEDIS Volume 2 manual, available on the NCQA HEDIS 2016 web
page, provides guidance on which claims to include. The specifications acknowledge
that it may be difficult to obtain all such data and indicate that the reporter should, to the
extent possible, include all paid, suspended, pending, and denied claims.

Value sets and codes. Many measures require the use of billing or diagnostic codes for
calculation. Many measures rely on value sets to identify codes required for calculation. A
value set is the complete set of codes used to identify a service or condition included in a
measure. Where required, either value set references or codes are included for all technical
specifications. Value set references are underlined in the specifications (e.g., BMI Percentile
Value Set). Value set information for measures derived from different sources is provided
below:
•

BHC Value Set: For calculation of the HEDIS measures that are part of the CMS Child
or Adult Core Sets for Medicaid/CHIP, CMS makes available on-line a Value Set
Directory (VSD) which includes all value sets and codes needed to report those measures.
The BHC VSD will be available on the CMS Medicaid Quality site and on the SAMHSA
website. Appendix B contains a Value Set Directory User Manual for the BHC Value
Set.

Medicaid Core Measure Technical Assistance briefs can be found at the Medicaid quality website.

•

HEDIS-derived measures that are not part of the CMS Child or Adult Core Sets for
Medicaid/CHIP: HEDIS Value sets are available from NCQA HEDIS 2016 for all
HEDIS measures, including those that are not part of the Medicaid Core sets.

•

Other measures:
o Value sets for the e-measure specifications of the Child and Adolescent Suicide
Risk Assessment (SRA-BH-C) and the Adult Suicide Risk Assessment (SRA-A)
measures are available from the U.S. National Library of Medicine Value Set
Authority Center (VSAC). Access to the VSAC requires a Unified Medical
Language System (UMLS) license; states or BHCs may apply for a UMLS license
on the UMLS Metathesaurus License webpage. When searching for value sets for
the SRA-BH-C measure, use the measure’s associated e-Measure number (177) or
NQF number (1365). For the SRA-A measure, use the measure’s associated eMeasure number (161) or NQF number (0104).
o Values sets for the Depression Remission at Twelve Months (DEP-REM-12)
measure are available from the website of the measure steward, Minnesota
Community Measurement, at the Cycle A DDS Guides page on the MN
Community Measurement.
o Value sets for the Diabetes Care For People With Serious Mental Illness:
Hemoglobin A1c (HbA1c) Poor Control (>9.0%) (SMI-PC) measure will be
available on the SAMHSA website.

•

Measures without value sets: Measure specifications without value sets reference the
pertinent diagnostic and procedure codes (Current Procedural Terminology [CPT®] or
Healthcare Common Procedure Coding System [HCPCS]).

Risk adjustment. Among the measures that are part of the Medicaid Core Set, one measure,
Plan All-Cause Readmissions (PCR-BH), requires risk adjustment. This measure currently does
not have a risk adjustor specific to the Medicaid population. It is suggested that states and BHCs
report unadjusted rates for this measure until a standardized risk adjustor is made available.
Please note that the specification for this measure includes, in Appendix PCR-BH, two tables
(PCR-A and PCR-B). Those tables are part of the original measure and are retained in this
manual to avoid modification that alters the original measure specification. Because the
information that would be included in those tables is either unavailable because of lack of risk
adjustment or duplicated in the data-reporting templates, the reporter should focus on completing
the data-reporting template rather than the tables in Appendix PCR-BH unless and until risk
adjustment is available.

Reporting and Submission of Measures
Procedures for reporting the BHC measures are provided below.
21

Submission deadline. For non-CCBHC reporting, data should be submitted as required by the
state or other entity to which it is reported. For the CCBHC Demonstration Program, data for the
BHC-lead measures should be submitted within 9 months after the end of the DY and for the
state-lead measures within 12 months after the end of the DY. Submitted data should be
complete and final at the submission deadline. The state may set separate timeframes for the
submission of data by CCBHCs that support the Quality Bonus Payments.
Who collects and reports the data. These measures are designed to be calculated and reported
by either the BHC or the state, but all of them are specified to capture information at the BHC
level rather than at a higher level of aggregation. The division of responsibility for calculation
and reporting reflects the fact that some measures require access to data that the BHCs will not
have (e.g., Number of Suicide Attempts Requiring Medical Services by Patients Engaged in
Behavioral Health Treatment).
•

BHC-responsibilities: For BHC-lead measures (Table 1), the BHC should report the
measures to the entity that requested it. In the case of the CCBHC Demonstration
Program, CCBHCs report the required measures to their designated state agency and the
state agency reports them to SAMHSA. This is true for all required measures, including
the QBMs, although QBPs based on those measures will be calculated only from
consumers who are Medicaid eligible, including Title 19-eligible CHIP program
beneficiaries (but not Title 21-eligible CHIP beneficiaries).

•

State-responsibilities: The state should report the measures that it collects and/or
calculates (whether received from the BHCs (Table 1) or calculated by the state using
administrative or other data (Table 2)) to the entity that requested it. In the case of the
CCBHC Demonstration Program, any data that the state is required to report (either on its
own or as a conduit for the CCBHCs) should be reported to SAMHSA. The data
submitted to SAMHSA will be reported for each CCBHC separately using the datareporting templates. As aggregated at the CCBHC level in the templates, the data will
not permit the identification of individuals served by the CCBHC.

Data-reporting templates. Data-reporting templates have been developed for each measure.
For the CCBHC Demonstration Program, CCBHCs and states reporting the measures must use
the templates to report on the measures. The templates are not part of an automated electronic
system. Rather, the templates are worksheets that are to be completed and submitted by email to
[email protected].
In addition to guidance provided in this document, detailed instructions for completion of the
templates are included in the template document. For purposes of the CCBHC Demonstration
Program, CCBHCs and states should complete every field for each measure to meet reporting
requirements and to ensure consistent reporting across CCBHCs and states. The templates are
separated into BHC-reported and state-reported measures, both of which have the same fields.
22

Clinics also are provided a worksheet to report on caseload characteristics. A final roll-up
worksheet automatically includes the results for each measure.
•

Reporting: States and BHC providers are strongly encouraged to use the methods and
data sources listed in the specification for each measure; however, if states and BHC
providers use alternative methods or data sources, the deviations should be indicated in
Section E (Adherence to Measure Specification) of the pertinent data-reporting template.

Data auditing. Individual states may have specific data auditing requirements.
•

Reporting: If the state has current mechanisms for external quality review reporting, or if
the state validates its measures, the states should note these processes in Section F
(Additional Notes) of the data-reporting template.

III. TECHNICAL SPECIFICATION COMPONENTS
This chapter presents the technical specification components for the measures specified for
BHCs. Each specification includes a description of the measure and information about the
eligible population, key definitions, data collection method(s), instructions for calculating the
measure, and other relevant information. For BHC-reported measures, examples typically also
are provided. A brief introduction to each component of the specifications follows this
paragraph, with the technical specifications themselves found in Chapters IV and V.
Description. The description section in each specification includes a narrative description of the
measure, the applicable data collection method, guidance on reporting, and an explanation of the
measurement period. The applicable data collection method is either administrative, hybrid,
medical records, or survey. Topics included in guidance on reporting vary by measure, but they
typically address the following components: 1) stratification by payer and/or age particular to the
measure; 2) information about multiple rates included in the measure, if applicable; 3)
information on potential sources of data for BHC-reported measures; 4) information on relevant
value sets if the measure relies on administrative data; 5) a reminder to refer to the data-reporting
template pertinent to the measure; and 6) miscellaneous relevant information. The explanation
of the measurement period provides information on the time period(s) for data used to compute
the denominator and numerator, respectively, information that also is available in a succinct table
in Appendix A.
Definitions. The definitions section of the specification defines key terms relevant to the
measure.
Eligible Population. The section defining the eligible population provides information on
computation of the denominator, including relationship to the clinic, age, and insurance
requirements for claims-based data, and a step-by-step guide (Event/Diagnosis) for determining
the eligible population.
23

•

Age requirements and stratification: The age criteria vary by measure. Some
measures have an upper age limit, while others include an age range above age 64
and/or under age 18. States and BHCs should calculate and report rates for the total
age-eligible population and, if age-stratified, any age group indicated in the measure
specification.

•

Insurance requirements: Some measures include requirements related to continuous
enrollment in Medicaid or dually in Medicare and Medicaid, allowable insurance
gaps, and an anchor date. A few of those measures specify when those requirements
are to be entered into the process of determining the eligible population. For the
majority of measures which do not, continuous enrollment, allowable gap and anchor
date should enter the calculation of the eligible population as early in the process as
possible.
o Continuous enrollment: This requirement refers to the time frame during
which a consumer must be enrolled for Medicaid benefits or dually eligible
for Medicare and Medicaid benefits to be included in the eligible population.
The technical specifications provide the continuous enrollment requirement
for each measure, if applicable.
o Allowable gap: Some measures specify an allowable gap that can occur
during continuous enrollment for Medicaid, or for dually eligible Medicare
and Medicaid enrollment. For example, the Controlling High Blood Pressure
(CBP) measure, which requires continuous enrollment throughout the
measurement year (using the calendar year, January 1–December 31), allows
one gap in enrollment of up to 45 days. Thus, a BHC consumer who enrolls in
Medicaid for the first time on February 8 of the measurement year is
considered continuously enrolled as long as there are no other gaps in
enrollment throughout the remainder of the measurement year, because this
consumer has one 38-day gap (January 1, 2017-February 7, 2017).
o Anchor date: If a measure requires a Medicaid beneficiary, or a dually
eligible Medicare and Medicaid beneficiary, to be enrolled and to have a
benefit on a specific date, the allowable gap must not include that date; the
individual must have the benefit on that date.

•

Reporting: States and BHCs should note any deviations from the specifications in
Section E of the data-reporting template (Adherence to Measure Specifications) and,
if necessary, Section F (Additional Notes).

Measure Specification. The measure specification explains how to compute: 1) the
denominator (the eligible population with any relevant exclusions) and 2) the numerator (some
subset of the denominator that typically has received the service or achieved the outcome being
24

measured). If the measure requires reporting of multiple rates or other types of measures,
specifications for each are included. Relevant measurement periods also are addressed.
•

Exclusions: Some measure specifications contain required or optional exclusions.
A BHC consumer who meets required exclusion criteria should be removed from
the eligible population as stated in the technical specification. Most exclusions
are to the denominator and numerator, but some apply only to the numerator.
Some exclusions are optional. Three measures (ASC, TSC, and BMI-SF) exclude
individuals for whom certain documentation is not available in the medical
record. This is not a general practice but is used by the original stewards for these
measures only.

•

Reporting: If an optional exclusion is used, this fact should be so stated in Section
E (Adherence to Measure Specification) of the data-reporting template.

Other Information. This section contains additional information relevant to the measure such as
measure interpretation and measure limitations.
Example Calculation. For most BHC-reported measures, simple examples are provided of the
calculation process for the measure in measure-specific appendices. Examples are not provided
for the BHC-reported measures that are stewarded by NCQA. For e-Measures, flow diagrams
are provided.

IV.

TECHNICAL SPECIFICATIONS -- CLINIC-REPORTED
MEASURES

Routine Care Needs (ROUT)

Routine Care Needs (ROUT)
SAMHSA-Developed Metric
A. DESCRIPTION
Percentage of new consumers requesting services who were determined to need routine
care
Data Collection Method: Medical Records
Guidance for Reporting:
•

This metric is stratified by whether the consumer is a Medicaid beneficiary,
eligible for both Medicare and Medicaid, and other.

•

Provider entities will rely on medical records to compile this information. There
are several potential sources of information that may be used individually or
together:
o Electronic health records (including billing records)
o Paper health records
o A registry
o An electronic scheduling system that is separate from the medical record
and that is used to schedule and monitor appointments and critical time
frames
o A system similar to one developed by NIATx (the NIATx Outpatient
Spreadsheet).

•

Refer to the specific data-reporting template for the reporting requirements
applicable to each measure and to the Appendices in Volume 2 of this manual.

Measurement Period: The measurement period for the denominator is the measurement
year plus the preceding 6 months. The measurement period for the numerator is the
measurement year.
B. DEFINITIONS
TERM
New Consumer
Provider Entity

DEFINITION
An individual not seen at the clinic in the past 6 months
The provider entity that is being measured (i.e., BHC)

Routine Care Needs (ROUT)

TERM

Routine Care Needs

DEFINITION
Care needs that, based upon a preliminary screening and
risk assessment, are determined not to be of an
emergency or urgent nature, within the commonly
accepted meaning of those terms in a behavioral health
setting

C. ELIGIBLE POPULATION
CRITERIA
Age

REQUIREMENTS
Consumers of all ages
Follow the steps below to identify the eligible
population:

Event/Diagnosis

Step 1
Identify new consumers who contacted the provider
entity seeking services during the measurement year.

D. MEDICAL RECORD SPECIFICATION
Denominator
The number of consumers in the eligible population (Section C)
Note: Although the denominator measures those who made first contact during the
measurement year, the clinic must look back 6 months from the point of first contact
during that time to determine if the person is a new consumer.
Numerator
The number of new consumers in the eligible population during the measurement year
who were determined to need routine care.
Note: The numerator calculation considers data only from the measurement year.
Exclusions
None.
Example Calculation
See Appendix ROUT to this measure.

Routine Care Needs (ROUT)

E. ADDITIONAL NOTES
This measure is designed to require provider-level reporting but is not tested at the
provider level.
Interpretation of score:
This percentage cannot be viewed as representing either high or low quality;
rather it provides a snapshot of new consumer acuity.

Time to Initial Evaluation (I-EVAL)

Time to Initial Evaluation (I-EVAL)
SAMHSA-Developed Metric
A. DESCRIPTION
Metric #1: The percentage of new consumers with initial evaluation provided
within 10 business days of first contact
Metric #2: The mean number of days until initial evaluation for new consumers
Data Collection Method: Medical Records
Guidance for Reporting:
•

This is a two-part measure and requires two different calculations.

•

This metric is stratified by age (12–17 years, 18 years and older) and by whether
the consumer is a Medicaid beneficiary, eligible for both Medicare and Medicaid,
and other.

•

Refer to the specific data-reporting template for the reporting requirements
applicable to each measure and to the Appendices in Volume 2 of this manual.

Measurement Period: For both metrics, the measurement period for the denominator is
the measurement year excluding the last 30 days of the measurement year and
30

Time to Initial Evaluation (I-EVAL)

including the 6 months preceding the measurement year. The measurement period
for the numerator is the measurement year.
B. DEFINITIONS
TERM
Business Days

Initial Evaluation

New Consumer

Provided

Provider Entity

DEFINITION
Monday through Friday, excluding state and federal
holidays (regardless of days of operation)
Some certification standards, such as the CCBHC
certification criteria, require that an initial evaluation be
carried out for new consumers within a specified time
frame based on the acuity of needs. In the case of a
CCBHC, the initial evaluation is due within 10 business
days of first contact for those who present with “routine”
non-emergency or non-urgent needs. That standard is
used in this specification. Other standards may exist for
other entities and this specification can be adapted
accordingly.
An individual not seen at the clinic in the past 6 months
As used in the context of the initial evaluation being
“provided” by the clinic, the word “provided” means
“received.” The clinic is to record the number of
business days from initial contact until the initial
evaluation was received by or completed for the
consumer.
The provider entity that is being measured (i.e., BHC)

C. ELIGIBLE POPULATION
CRITERIA

Age

REQUIREMENTS
Consumers of all ages
Report two age stratifications and a total rate:
•

12–17 years as of the end of the measurement year

•

18 years and older as of the end of the measurement
year

•

Total (both age groups)

Time to Initial Evaluation (I-EVAL)

CRITERIA

Event/Diagnosis

REQUIREMENTS
Follow the steps below to identify the eligible
population:
Step 1
Identify new consumers who contacted the provider
entity seeking services during the measurement year.
Step 2
Identify consumers from step 1 aged 12 years and older
as of the end of the measurement year.

D. MEDICAL RECORD METRIC SPECIFICATION #1
Percentage of new consumers with initial evaluation provided within 10 business days of
first contact
Denominator
The number of consumers in the eligible population (Section C)
Note: The measurement period for the denominator is the measurement year excluding
the last 30 days of the measurement year and including the 6 months preceding the
measurement year.
Numerator
The number of consumers in the eligible population who received an initial evaluation
within 10 business days of the first contact with the provider entity during the
measurement year.
Note: The measurement period for the numerator is the measurement year.
Exclusions
None.
Example Calculation
See Appendix I-EVAL to this measure.
E. MEDICAL RECORD METRIC SPECIFICATION #2
The mean number of days until initial evaluation for new consumers

Time to Initial Evaluation (I-EVAL)

Denominator
The number of consumers in the eligible population (Section C)
Note: The measurement period for the denominator is the measurement year excluding
the last month of the measurement year and including the 6 months preceding the
measurement year.
Numerator
The total number of days between first contact and initial evaluation for all members of
the eligible population seen at the provider entity during the measurement year
Note: The measurement period for the numerator is the measurement year. Any who
received an initial evaluation after the last day of the measurement year are treated as
having been evaluated 31 days after initial contact.
Exclusions
None.
Example Calculation
See Appendix I-EVAL to this measure.
F. ADDITIONAL NOTES
This measure is designed to require provider-level reporting but is not tested at the
provider level.
It is likely that some new consumers will not have an appointment within 10 days
because of their own schedules and non-urgent need. This situation is a recognized
limitation of this measure that will affect all clinics. Trying to adjust for non-consumers
who are offered but do not accept an appointment within 10 business days complicates
the calculation unnecessarily.
Interpretation of scores:
Percentage of new consumers with initial evaluation provided within 10
business days: Better quality = Higher score
Mean number of days until initial evaluation for new consumers:
Better quality = Lower number

Time to Comprehensive Person- and Family-Centered Diagnostic and Treatment Planning Evaluation (TXEVAL)

Time to Comprehensive Person- and Family-Centered Diagnostic and
Treatment Planning Evaluation (TX-EVAL)
SAMHSA-Developed Metric
A. DESCRIPTION
The mean number of days after first contact until comprehensive person-centered and
family-centered diagnostic and treatment planning evaluation is performed for new
consumers
Data Collection Method: Medical Records
Guidance for Reporting:
•

This metric is stratified by age (12–17 years, 18 years and older) and by whether
the consumer is a Medicaid beneficiary, eligible for both Medicare and Medicaid,
and other.

•

Provider entities will rely on medical records to compile this information. There
are several potential sources of information that may be used individually or
together:
o Electronic health records (including billing records)
o Paper health records
o A registry
o An electronic scheduling system that is separate from the medical record and
that is used to schedule and monitor appointments and critical time frames
o A system similar to one developed by NIATx (the NIATx Outpatient
Spreadsheet)

•

Refer to the specific data-reporting template for the reporting requirements
applicable to each measure and to the Appendices in Volume 2 of this manual.

Measurement Period: The measurement period for the denominator is the measurement
year excluding the last 90 days of the measurement year and including the 6 months
preceding the measurement year. The measurement period for the numerator is the
measurement year.

Time to Comprehensive Person- and Family-Centered Diagnostic and Treatment Planning Evaluation (TXEVAL)

B. DEFINITIONS
TERM

Comprehensive PersonCentered and FamilyCentered Diagnostic and
Treatment Planning
Evaluation

New Consumer
Provider Entity

DEFINITION
Some certification standards, such as the CCBHC
certification criteria, establish time requirements for
completion of comprehensive treatment planning
evaluations. In the case of a CCBHC, the certification
criteria require that all new consumers receive a
comprehensive person-centered and family-centered
diagnostic and treatment planning evaluation to be
completed within 60 calendar days of the first request
for services. That standard is used in this specification.
Other standards may exist for other entities and this
specification can be adapted accordingly.
An individual not seen at the clinic in the past 6 months
The provider entity that is being measured (i.e., BHC)

C. ELIGIBLE POPULATION
CRITERIA

Age

Event/Diagnosis

REQUIREMENTS
Consumers of all ages
Report two age stratifications and a total rate:
• 12–17 years as of the end of the measurement year
• 18 years and older as of the end of the measurement
year
• Total (both age groups)
Follow the steps below to identify the eligible
population:
Step 1
Identify new consumers who contacted the provider
entity seeking services during the measurement year.
Step 2
Identify consumers from step 1 aged 12 years and older
as of the end of the measurement year.

Time to Comprehensive Person- and Family-Centered Diagnostic and Treatment Planning Evaluation (TXEVAL)

D. MEDICAL RECORD SPECIFICATION
Denominator
The number of consumers in the eligible population (Section C)
Note: The measurement period for the denominator is the measurement year excluding
the last 90 days of the measurement year and including the 6 months preceding the
measurement year.
Numerator
The total number of days between first contact and completion of the comprehensive
person-centered and family-centered diagnostic and treatment planning evaluation for all
members of the eligible population seen at the provider entity during the measurement
year
Note: The measurement period for the numerator is the measurement year. Any who
received a comprehensive evaluation after the first 90 days of the following year are
treated as having been evaluated 91 days after initial contact.
Exclusions
None.
Example Calculation
See Appendix TX-EVAL to this measure.
E. ADDITIONAL NOTES
This measure is designed to require provider-level reporting but is not tested at the
provider level.
Interpretation of score:
Mean number of days until comprehensive diagnostic and treatment
planning evaluation for new consumers: Better quality = A number less than or
equal to 60 days. For some consumers, it may take up to 60 days to develop a
comprehensive diagnostic and treatment planning evaluation, so the objective is
not to get the lowest possible number.
Of course, it is important that the
consumer receive services in the interim as the evaluation is being completed.

Deaths by Suicide (SUIC)

Deaths by Suicide (SUIC)
SAMHSA-Developed Metric
A. DESCRIPTION
Percentage of consumers aged 12 years and older who died by suicide during the
measurement year
Data Collection Method: Medical Records
Guidance for Reporting:
•

This metric is stratified by age (12–17 years, 18–64 years, 65 years and older) and
by whether the consumer is a Medicaid beneficiary, eligible for both Medicare
and Medicaid, and other. An exclusion applies if the provider entity does not
know the consumer’s cause of death.

•

Refer to the specific data-reporting template for the reporting requirements
applicable to each measure and to the Appendices in Volume 2 of this manual.

Measurement Period: The measurement period for the denominator and numerator is
the measurement year.
B. DEFINITIONS
TERM

DEFINITION

Provider Entity

The provider entity that is being measured (i.e., BHC)

Deaths by Suicide (SUIC)

TERM
Suicide

DEFINITION
Death caused by self-directed, injurious behavior with
any intent to die as a result of the behavior

C. ELIGIBLE POPULATION
CRITERIA
Age

REQUIREMENTS
All consumers aged 12 years and older as of the end of
the measurement year.
Report three age stratifications and a total rate:
•

12–17 years

•

18–64 years

•

65 years and older

•

Event/Diagnosis

Total (all age groups)
Follow the steps below to identify the eligible
population:
Step 1
Identify consumers seen at the provider entity at least
once during the measurement year.
Step 2
Identify consumers from step 1 aged 12 years and older
as of the end of the measurement year.

D. MEDICAL RECORDS SPECIFICATION
Denominator
The number of consumers in the eligible population (Section C)
Numerator
The number of consumers in the eligible population who were identified as dying by
suicide during the measurement year.
Exclusions
Deaths where cause of death is unknown to provider entity.

Deaths by Suicide (SUIC)

Example Calculation
See Appendix SUIC to this measure.
E. ADDITIONAL NOTES
This measure is designed to require provider-level reporting but is not tested at the
provider level.
This measure has the following limitations. Complete accuracy depends on knowledge
of consumer intent and cause of death for all consumers seen in the measurement year.
We acknowledge that coroner’s data will be more accurate and state’s should feel free to
compare the results of this metric to those data. The data reported for this metric,
however, should follow the specifications herein.
Interpretation of score: Better quality = Lower score. The goal is zero.

Documentation of Current Medications in the Medical Record (DOC)

Documentation of Current Medications in the Medical Record (DOC)
Based on a measure stewarded by the Centers for Medicare & Medicaid Services
(NQF #0419, PQRS #130)
A. DESCRIPTION
Percentage of visits for consumers aged 18 years and older for which the eligible
professional attests to documenting a list of current medications using all immediate
resources available on the date of the encounter. This list must include ALL known
prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional)
supplements AND must contain the medications’ name, dosage, frequency, and route of
administration.
Data Collection Method: Medical Records
Guidance for Reporting:
•

This measure is stratified by whether the consumer is a Medicaid beneficiary,
eligible for both Medicare and Medicaid, and other.

•

This measure is to be reported for every encounter during the measurement year.

•

If documentation is not available for one or more numerator or exclusion data
elements for a specific visit, the consumer is considered to not meet the criteria
for the numerator or exclusion, respectively.

•

Refer to the specific data-reporting template for the reporting requirements
applicable to each measure and to the Appendices in Volume 2 of this manual.

Measurement Period: The measurement period for both the denominator and the
numerator is the measurement year.

Documentation of Current Medications in the Medical Record (DOC)

B. DEFINITIONS
TERM

Current Medications

Eligible Professional

DEFINITION
Medications the consumer is presently taking, including
all prescriptions, over-the-counters, herbals, and
vitamin/mineral/dietary (nutritional) supplements with
each medication’s name, dosage, frequency and
administered route.
A licensed professional eligible to prescribe medication
as defined by the respective state in which the provider
entity is located

Provider Entity

The provider entity that is being measured (i.e., BHC)

Route

Documentation of the way the medication enters the
body (some examples include but are not limited to:
oral, sublingual, subcutaneous injections, and/or
topical).

C. ELIGIBLE POPULATION
CRITERIA
Age

Event/Diagnosis

REQUIREMENTS
Consumers aged 18 years or older on the date of the
encounter
Follow the steps below to identify the eligible
population:
Step 1
Identify consumers who had an encounter at the
provider entity during the measurement year. Relevant
codes (Current Procedural Terminology [CPT ®]
or Healthcare Common Procedure Coding System
[HCPCS]) are identified in Appendix DOC.B.
Note: Unlike many BHC measures, this one begins by
limiting the types of visits or encounters that qualify
consumers for the eligible population.
Step 2
Identify consumers from step 1 who were aged 18 years
and older on the date of the encounter.
41

Documentation of Current Medications in the Medical Record (DOC)

D. MEDICAL RECORD SPECIFICATION
Denominator
The number of visits by consumers in the eligible population (Section C)
Exclusion: Medical Reason: Consumer is in an urgent or emergent medical
situation where time is of the essence and to delay treatment would jeopardize the
consumer’s health status. The clinical exclusion code is HCPCS G8430 (Current
Medications not Documented, Patient not Eligible), whereby an eligible
professional attests to documenting in the medical record the consumer is not
eligible for a current list of medications being obtained, updated, or reviewed by
the eligible professional.
Numerator
The number of consumers for whom an eligible professional attests to documenting,
updating, or reviewing consumer´s current medications using all immediate resources
available on the date of the encounter. This list must include ALL prescriptions, overthe-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must
contain the medications’ name, dosages, frequency, and route.
Numerator Options: The options below indicate the coding possibilities related
to the numerator. The first, where performance is met, indicates a situation where
the data point is included in the numerator. The second, where performance is not
met, means that the data point is excluded. If neither code is included in a record,
the record should be retained in the denominator but treated as performance not
met.
Performance Met: Eligible professional attests to documenting in the
medical record they obtained, updated, or reviewed the consumer’s current
medications (G8427)
OR
Performance Not Met: Current list of medications not documented as
obtained, updated, or reviewed by the eligible professional, reason not
given (G8428).
Example Calculation
See Appendix DOC.A.

Documentation of Current Medications in the Medical Record (DOC)

E. ADDITIONAL NOTES
Both this measure and the source measure were specified at the provider level. Neither is
risk adjusted. This measure is modified from the source measure to provide a
specification consistent in format to other measures in this set of BHC measures.
Interpretation of score: Better quality = Higher score

Preventive Care & Screening: Adult Body Mass Index (BMI) Screening & Follow-Up (BMI-SF)

Preventive Care & Screening: Body Mass Index (BMI) Screening & FollowUp (BMI-SF)
Based on a measure stewarded by the Centers for Medicare & Medicaid Services (NQF #0421,
PQRS #128)
A. DESCRIPTION
Percentage of consumers aged 18 years and older with a BMI documented during the
current encounter or during the previous six months AND with a BMI outside of normal
parameters, a follow-up plan is documented during the encounter or during the previous
six months of the current encounter
Normal Parameters:

Age 65 years and older BMI > 23 and < 30 kg/m2
Age 18 - 64 years BMI > 18.5 and < 25 kg/m2

Data Collection Method: Medical Records
Guidance for Reporting:
• This measure is stratified by whether the consumer is a Medicaid beneficiary,
eligible for both Medicare and Medicaid, and other.
• There is no diagnosis associated with this measure. This measure is to be
reported a minimum of once per measurement year for patients seen during the
reporting year. This measure may be reported by eligible professionals who
perform the quality actions described in the measure based on the services
provided at the time of the qualifying visit and the measure-specific denominator
coding. The BMI may be documented in the medical record of the provider or in
outside medical records obtained by the provider. If the most recent documented
BMI is outside of normal parameters, then a follow-up plan must be documented
during the encounter or during the previous six months of the current encounter.
The documented follow-up plan must be based on the most recent documented
BMI outside of normal parameters, example: “Consumer referred to nutrition
counseling for BMI above normal parameters” (See Definitions for examples of a
follow-up plan treatments). If more than one BMI is reported during the measure
period, the most recent BMI will be used to determine if the performance has been
met.
• Provider entities will rely on medical records to compile this information. There
are several potential sources of information that may be used individually or
together:
44

Preventive Care & Screening: Adult Body Mass Index (BMI) Screening & Follow-Up (BMI-SF)

•

o Electronic health records (including billing records)
o Paper health records
o A registry
Refer to the specific data-reporting template for the reporting requirements
applicable to each measure and to the Appendices in Volume 2 of this manual.

Measurement Period: The measurement period for the denominator is the measurement
year. The measurement period for the numerator is the measurement year and the
previous 6 months.
B. DEFINITIONS
TERM

DEFINITION
BMI is a number calculated using the Quetelet index—
weight divided by height squared (W/H2)—and is
commonly used to classify weight categories. BMI can be
calculated using:

Body Mass Index (BMI)

Metric Units: BMI = Weight (kg) / (Height [m] x Height
[m])
OR
English Units: BMI = (Weight [lbs] x 703) / (Height [in]
× Height [in])
Proposed outline of treatment to be conducted as a result
of a BMI out of normal parameters. A follow-up plan
may include, but is not limited to:
• Documentation of education
•

Referral (for example a registered dietician,
nutritionist, occupational therapist, physical
therapist, primary care provider, exercise
physiologist, mental health professions, or
surgeon)

•

Pharmacological interventions

•

Dietary supplements

•

Exercise counseling

•

Nutrition counseling

Follow-Up Plan

Preventive Care & Screening: Adult Body Mass Index (BMI) Screening & Follow-Up (BMI-SF)

TERM

Not eligible for BMI
Calculation or FollowUp Plan

DEFINITION
A consumer is not eligible if one or more of the following
reasons are documented:
•

Consumer is receiving palliative care

•

Consumer is pregnant

•

Consumer refuses BMI measurement (refuses
height and/or weight)

•

Any other reason documented in the medical
record by the provider why BMI measurement was
not appropriate

•

Provider Entity

Consumer is in an urgent or emergent medical
situation where time is of the essence, and to delay
treatment would jeopardize the consumer’s health
status
The provider entity that is being measured (i.e., BHC)

C. ELIGIBLE POPULATION
CRITERIA
Age

REQUIREMENTS
Consumers aged 18 years and older on the date of service
during the measurement year
Follow the steps below to identify the eligible population:
Step 1
Identify consumers flagged as having been seen at the
provider entity at least once during the measurement year

Event/Diagnosis

Step 2
Identify consumers from step 1 who are aged 18 years or
older on the date of service during the measurement year.
Relevant codes (Current Procedural Terminology
[CPT ®] or Healthcare Common Procedure Coding
System [HCPCS]) are identified in Appendix BMISF.B.
Note: The types of eligible encounters are limited to
those listed.

Preventive Care & Screening: Adult Body Mass Index (BMI) Screening & Follow-Up (BMI-SF)

D. MEDICAL RECORDS SPECIFICATION
Denominator
The number of consumers in the eligible population (Section C)
Note: The measurement period for the denominator is the measurement year.
Numerator
The number of consumers in the eligible population with a documented BMI during the
encounter or during the previous six months AND, when the BMI is outside of normal
parameters, a follow-up plan is documented during the encounter or during the previous
six months of the current encounter.
Numerator Quality-Data Coding Options: The options below indicate the coding
possibilities related to the numerator. The first three, where performance is met, indicate
situations where the data point is included in the numerator. The fourth and fifth, where
performance is not met, means that the data point is excluded from the numerator.
Performance Met: BMI is documented within normal parameters and no follow
up plan is required (G8420)
OR
Performance Met: BMI is documented above normal parameters and a follow-up
plan is documented (G8417)
OR
Performance Met: BMI is documented below normal parameters and a followup plan is documented (G8418)
Performance Not Met: BMI not documented and no reason is given (G8421)
OR
Performance Not Met: BMI documented outside normal parameters, no followup plan documented, no reason given (G8419)
Numerator Instructions:
•

Height and Weight: An eligible professional or their staff is required to measure
both height and weight. Both height and weight must be measured within six
months of the current encounter and may be obtained from separate encounters.
Self-reported values cannot be used.

Preventive Care & Screening: Adult Body Mass Index (BMI) Screening & Follow-Up (BMI-SF)

•

Follow-Up Plan: If the most recent documented BMI is outside of normal
parameters, then a follow-up plan is documented during the encounter or during
the previous six months of the current encounter. The documented follow-up
plan must be based on the most recent documented BMI, outside of normal
parameters, example: “Consumer referred to nutrition counseling for BMI above
normal parameters.” (See Definitions for examples of a follow-up plan
treatments)

•

Performance Met for G8417 and G8418
o If the provider documents a BMI and a follow-up plan at the current visit
OR
o If the consumer has a documented BMI within the previous six months of
the current encounter, the provider documents a follow-up plan at the
current visit OR
o If the consumer has a documented BMI within the previous six months of
the current encounter AND the consumer has a documented follow-up
plan for a BMI outside normal parameters within the previous six months
of the current visit

Note: The measurement period for the numerator is the measurement year and the
previous 6 months.
Exclusions: A consumer is not eligible for BMI calculation or development of a followup plan if one or more of the following reasons are documented:
•

Consumer is receiving palliative care

•

Consumer is pregnant

•

Consumer refuses BMI measurement (refuses height and/or weight)

•

Any other reason documented in the medical record by the provider why BMI
measurement was not appropriate

•

Consumer is in an urgent or emergent medical situation where time is of the
essence and to delay treatment would jeopardize the consumer’s health status

Relevant quality-data codes for non-eligibility include:
BMI Documented, Consumer not Eligible: BMI not documented, with
documentation the consumer is not eligible for BMI calculation (G8422)
OR

Preventive Care & Screening: Adult Body Mass Index (BMI) Screening & Follow-Up (BMI-SF)

BMI Documented Outside of Normal Limits, Follow-Up Plan not
Documented, Consumer not Eligible: BMI is documented as being outside of
normal limits, follow-up plan is not documented, documentation shows the
consumer is not eligible (G8938)
Incomplete Reporting Exclusion: Failure to record quality-data codes necessary for
computing the numerator means that the consumer is excluded from the denominator.
Example Calculation
See Appendix BMI-SF.A.
E. ADDITIONAL NOTES
The source measure is designed for the Medicare population and is not risk adjusted. The
source measure was specified at both the provider and other levels. This measure is
modified from the source measure to provide a specification consistent in format to other
measures in this set of BHC measures.
Interpretation of score: Better quality = Higher score

Weight Assessment for Children/Adolescents: Body Mass Index Assessment for Children/Adolescents
(WCC-BH)
Please see NCQA Notice of Copyright and Disclaimers in front matter to this manual.

Weight Assessment for Children/Adolescents: Body Mass Index Assessment
for Children/Adolescents (WCC-BH)
Based on a measure stewarded by the
National Committee for Quality Assurance (NQF #0024, HEDIS 2016)

A. DESCRIPTION
The percentage of children ages 3 to 17 who had an outpatient visit with a primary care
practitioner (PCP) or obstetrical/gynecological (OB/GYN) practitioner and who had
evidence of body mass index (BMI) percentile documentation during the measurement
year
Because BMI norms for youth vary with age and gender, this measure evaluates whether
BMI percentile is assessed rather than the absolute BMI value.
Data Collection Method: Administrative or Hybrid
Guidance for Reporting:
•

This measure is stratified by whether the consumer is a Medicaid beneficiary,
eligible for both Medicare and Medicaid, and other. This measure also is
stratified by age. Report two age stratifications (3-11 years, 12-17 years) and a
total. The total is the sum of the age stratifications. For purposes of determining
whether a consumer is a Medicaid beneficiary or a dual Medicare and Medicaid
enrollee, see Continuous Enrollment, Allowable Gap, and Anchor Date
requirements below in section C.

•

Only the BMI percentile component is included in this measure; the physical
activity/nutrition counseling components are not included.
The eligible population (denominator) for this measure includes children ages 3 to
17 who have an outpatient visit and meet the continuous enrollment criteria.
A BMI percentile is included in the numerator count if the specified
documentation is present, regardless of the primary intent of the visit. A BMI
without a percentile is not acceptable for inclusion in the numerator count.

•
•

•

For BHCs reporting a measure that is also an Electronic Health Record (EHR)
Medicaid Incentive Program measure, indicate whether any information was
extracted from EHRs. Report this information in Section F (Additional Notes) of
the data-reporting template.

•

The height, weight, and BMI must be from the same data source.
50

Weight Assessment for Children/Adolescents: Body Mass Index Assessment for Children/Adolescents
(WCC-BH)
Please see NCQA Notice of Copyright and Disclaimers in front matter to this manual.

•

The height and weight measurement should be taken during the measurement
year.

•

If using hybrid specifications, documentation in the medical record should
indicate the weight and BMI value, dated during the measurement year or year
prior to the measurement year.
This measure may be calculated using sampling, but measure-specific guidelines
on sampling are not available. Providers should review information in the
introductory material to this manual related to sampling and hybrid measures and
describe their sampling methodology in Section F (Additional Notes) of the datareporting template.
Referenced Value Sets may be found in the BHC Value Set Directory.

•

To the extent possible, include all paid, suspended, pending, and denied claims.

•

Refer to Appendix D for definitions of a PCP and OB/GYN practitioner.

•

Refer to the specific data-reporting template for the reporting requirements
applicable to each measure and to the Appendices in Volume 2 of this manual.

•

Measurement Period: The measurement period is the measurement year. Hypertension
diagnosis: Confirm anytime during the enrollee’s history on or before the first six months
of the measurement year
B. DEFINITIONS
TERM
BMI

BMI percentile
Provider Entity

DEFINITION
Body mass index: A statistical measure of the weight of
a person scaled according to height
The percentile ranking based on the CDC’s BMI-for-age
growth charts, which indicates the relative position of
the consumer’s BMI number among others of the same
gender and age
The provider entity that is being measured (i.e., BHC)

Weight Assessment for Children/Adolescents: Body Mass Index Assessment for Children/Adolescents
(WCC-BH)
Please see NCQA Notice of Copyright and Disclaimers in front matter to this manual.

C. ELIGIBLE POPULATION
CRITERIA

Age

Continuous Enrollment

Allowable Gap

Anchor Date
Benefits

REQUIREMENTS
Consumers aged 3–17 years as of the end of the
measurement year. Report two age stratifications and a
total:
•

3 to 11

•

12 to 17

• Total
The total is the sum of the age stratifications.
The measurement year
No more than one gap in continuous enrollment of up
to 45 days during the measurement year. To determine
continuous enrollment for a consumer for whom
enrollment is verified monthly, the child may not have
more than a 1-month gap in coverage (i.e., a child
whose coverage lapses for 2 months [60 days] is not
considered continuously enrolled).
The last day of the measurement year
Medical
Follow the steps below to identify the eligible
population:
Step 1
Identify consumers flagged as having been seen at the
provider entity at least once during the measurement
year.

Event/Diagnosis

Step 2
Identify consumers from step 1 who were aged 3–17
years as of the end of the measurement year.
Step 3
Identify consumers from step 2 who had an outpatient
visit (Outpatient Value Set) with a primary care
practitioner (PCP) or obstetrical/gynecological
(OB/GYN) practitioner during the measurement year.

Weight Assessment for Children/Adolescents: Body Mass Index Assessment for Children/Adolescents
(WCC-BH)
Please see NCQA Notice of Copyright and Disclaimers in front matter to this manual.

D. ADMINISTRATIVE SPECIFICATION
Denominator
The number of consumers in the eligible population (Section C)
Numerator
BMI percentile (BMI Percentile Value Set) during the measurement year
Note: Records that do not include documentation of BMI percentile, or that include
notation of BMI value only, or height and weight only do not count as numerator
compliant.
Exclusions (optional)
Consumers who have a diagnosis of pregnancy (Pregnancy Value Set) during the
measurement year.
E. HYBRID SPECIFICATION
Denominator
A systematic sample drawn from the eligible population for the Total age band (ages 3 to
17). The Total sample is stratified by age to report rates for ages 3 to 11 and ages 12 to
17 and, separately, by whether the consumer is a Medicaid beneficiary, eligible for both
Medicare and Medicaid, and other.
Use a sample size of 411, unless special circumstances apply or the eligible population is
smaller. BHCs may reduce the sample size using information from the current year’s
administrative rate or the prior year audited, hybrid rate, if one exists. Regardless of the
selected sample size, the National Committee for Quality Assurance (NCQA)
recommends an oversample to allow for substitution in the event that cases in the original
sample turn out to be ineligible for the measure. For additional information on using a
reduced sample size, refer to Appendix C, Guidance for Selecting Sample Sizes for
Hybrid Measures.
Numerator
BMI percentile during the measurement year as identified by administrative data or
medical record review.
•

For those relying on administrative data rather than medical record review to
calculate the numerator as part of the hybrid specification, refer to Administrative
Specification to identify positive numerator hits from the administrative data.
53

Weight Assessment for Children/Adolescents: Body Mass Index Assessment for Children/Adolescents
(WCC-BH)
Please see NCQA Notice of Copyright and Disclaimers in front matter to this manual.

•

For those relying on medical record review rather than administrative data to
calculate the numerator as part of the hybrid specification, documentation must
include height, weight, and BMI percentile during the measurement year. The
height, weight, and BMI percentile must be from the same data source.
Either of the following meets criteria for BMI percentile:
o BMI percentile OR
o BMI percentile plotted on an age-growth chart
Note: Only evidence of the BMI percentile or BMI percentile plotted on an agegrowth chart meets criteria.
Note: Ranges and thresholds do not meet criteria. A distinct BMI percentile or
value, if applicable, is required for numerator compliance. Documentation of >99
percent or <1 percent meet criteria because a distinct BMI percentile is evident
(i.e., 100 percent or 0 percent).

Exclusions (optional)
Refer to the Administrative Specification for exclusion criteria. Exclusionary evidence in
the medical record must include a note indicating a diagnosis of pregnancy. The
diagnosis must have occurred during the measurement year.
F. ADDITIONAL NOTES
Records that do not include documentation of BMI percentile, or that include notation of
BMI value only, or height and weight only do not count as numerator compliant.
Services may be rendered during a visit other than a well-child visit. These services
count if the specified documentation is present, regardless of the primary intent of the
visit.
The source measure is designed for the Medicaid population and is not risk adjusted. The
source measure was specified and tested at the health plan level. This measure is
modified to require clinic-level reporting, and to be consistent in format with other
measures in this set of BHC measures, but is not tested at the clinic level.
Interpretation of score: Better quality = Higher score

Controlling High Blood Pressure (CBP-BH)
Please see NCQA Notice of Copyright and Disclaimers in front matter to this manual.

Controlling High Blood Pressure (CBP-BH)
Based on a measure stewarded by the
National Committee for Quality Assurance (NQF #0018, HEDIS 2016)
A. DESCRIPTION
Percentage of consumers ages 18 to 85 who had a diagnosis of hypertension (HTN) and
whose blood pressure (BP) was adequately controlled during the measurement year based on
the following criteria:
•

Consumers ages 18 to 59 whose BP was <140/90 mm Hg

•

Consumers ages 60 to 85 with a diagnosis of diabetes whose BP was <140/90 mm
Hg

•

Consumers ages 60 to 85 without a diagnosis of diabetes whose BP was <150/90 mm
Hg

A single rate is reported and is the sum of all three groups.
Data Collection Method: Hybrid
Guidance for Reporting:
•

This measure is stratified by whether the consumer is a Medicaid beneficiary,
eligible for both Medicare and Medicaid, and other. It also is stratified by age as
discussed immediately below. For purposes of determining whether a consumer
is a Medicaid beneficiary or a dual Medicare and Medicaid enrollee, see
Continuous Enrollment, Allowable Gap, and Anchor Date requirements below in
section C.

•

This measure applies to consumers 18 to 85 years of age. BHCs should calculate
and report this measure for two age groups (as applicable): ages 18 to 64 and ages
65 to 85. The numerator for consumers ages 18 to 64 will include consumers 18
to 59 years of age who meet the first criterion added to consumers 60 to 64 years
of age who meet the second or third criteria. The rate for consumers 65 to 85
years of age will include all consumers in that age group who meet the second or
third criteria: diagnosis of diabetes with BP < 140/90 mm Hg or no diagnosis of
diabetes with BP of <150/90 mm Hg.

•

To identify the eligible population for this measure, BHCs should use
administrative data to select all consumers who had an outpatient visit with a
diagnosis of hypertension during the first six months of the measurement year.
55

Controlling High Blood Pressure (CBP-BH)
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To identify the denominator, BHCs should then review the consumer’s medical
record to confirm the hypertension diagnosis, which can be recorded anytime
during the consumer’s history on or before the end of the sixth month of the
measurement year. If the consumer’s diagnosis cannot be confirmed then exclude
the consumer.
•

This measure requires use of the hybrid method.

•

This measure may be calculated using sampling, but measure-specific guidelines
on sampling are not available from the steward. Providers should review
information in the introductory material to this manual related to sampling and
hybrid measures and describe their sampling methodology in Section F
(Additional Notes) of the data-reporting template.

•

Referenced Value Sets may be found in the BHC Value Set Directory.

•

Table CBP-A corresponds to National Drug Code (NDC) Table CDC-A that is
posted to NCQA HEDIS Final NDC Lists.

•

Refer to the specific data-reporting template for the reporting requirements
applicable to each measure and to the Appendices in Volume 2 of this manual.

Measurement Period: The measurement period for the denominator is the first 6 months
of the measurement year. The measurement period for the numerator is the measurement
year. For the hypertension diagnosis, confirm any time during the consumer’s history
during or before the first 6 months of the measurement year.
B. DEFINITIONS
TERM

Adequate Control

DEFINITION
Adequate control is defined as meeting any of the
following criteria:
•

Consumers ages 18 to 59 whose BP was <140/90
mm Hg

•

Consumers ages 60 to 85 with a diagnosis of
diabetes whose BP was <140/90 mm Hg

•
BP
HTN

Consumers ages 60 to 85 without a diagnosis of
diabetes whose BP was <150/90 mm Hg
Blood pressure
Hypertension

Controlling High Blood Pressure (CBP-BH)
Please see NCQA Notice of Copyright and Disclaimers in front matter to this manual.

TERM

Representative BP

Provider Entity

DEFINITION
The most recent BP reading during the measurement
year (as long as it occurred after the diagnosis of
hypertension). If multiple BP measurements occur on
the same date, or are noted in the chart on the same date,
use the lowest systolic and lowest diastolic BP reading.
If no BP is recorded during the measurement year,
assume that the consumer is “not controlled.”
The provider entity that is being measured (i.e., BHC)

C. ELIGIBLE POPULATION
CRITERIA
Age
Continuous Enrollment

Allowable Gap

Anchor Date
Benefit

REQUIREMENTS
Consumers aged 18 to 85 years as of the last day of the
measurement year
The measurement year
No more than one gap in enrollment of up to 45 days
during the measurement year. To determine
continuous enrollment for a consumer for whom
enrollment is verified monthly, the consumer may not
have more than a 1-month gap in coverage (i.e., a
consumer whose coverage lapses for 2 months [60
days] is not considered continuously enrolled).
The last day of the measurement year
Medical

Controlling High Blood Pressure (CBP-BH)
Please see NCQA Notice of Copyright and Disclaimers in front matter to this manual.

CRITERIA

REQUIREMENTS
Follow the steps below to identify the eligible
population:
Step 1
Identify consumers flagged as having been seen at the
provider entity at least once during the measurement
year.

Event/diagnosis

Step 2
Identify consumers from step 1 who were 18 to 85
years of age as of the end of the measurement year.
Step 3
Identify consumers from step 2 who are hypertensive
by identifying those with at least one outpatient visit
(Outpatient Without UBREV Value Set) with a
diagnosis of hypertension (Essential Hypertension
Value Set) during the first six months of the
measurement year.

Controlling High Blood Pressure (CBP-BH)
Please see NCQA Notice of Copyright and Disclaimers in front matter to this manual.

CRITERIA

REQUIREMENTS
After the Eligible Population is identified, assign each
consumer a diabetic or not diabetic flag using only
administrative data and the steps below. The flag is
used to determine the appropriate BP threshold to use
during numerator assessment (the threshold for
consumers with diabetes is different than the threshold
for consumers without diabetes).
Step 1
Assign a flag of diabetic to consumers who were
identified as diabetic using claims/encounter data or
pharmacy data. The BHC must use both methods to
assign the diabetes flag, but a consumer only needs to
be identified by one method. Consumers may be
identified as having diabetes during the measurement
year or the year prior to the measurement year.

Diabetes flag for the
numerator (cont’d)

1. Claims/encounter data. Consumers who met any
of the following criteria during the measurement
year or the year prior to the measurement year
(count services that occur over both years):
•

At least two outpatient visits (Outpatient Value
Set), observation visits (Observation Value
Set), ED visits (ED Value Set), or nonacute
inpatient encounters (Nonacute Inpatient Value
Set) on different dates of service, with a
diagnosis of diabetes (Diabetes Value Set).
Visit type need not be the same for the two
visits.

OR
•

At least one acute inpatient encounter (Acute
Inpatient Value Set) with a diagnosis of
diabetes (Diabetes Value Set).

2. Pharmacy data. Consumers who were dispensed
insulin or hypoglycemics/antihyperglycemics on an
ambulatory basis during the measurement year or
the year prior to the measurement year (refer to
Table CBP-A in Appendix CBP-BH).
59

Controlling High Blood Pressure (CBP-BH)
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CRITERIA

REQUIREMENTS
Step 2

Diabetes flag for the
numerator (cont’d)

From consumers identified in Step 1, assign a flag of
“not diabetic” to consumers who do not have a
diagnosis of diabetes (Diabetes Value Set), in any
setting, during the measurement year or year prior to
the measurement year and who had a diagnosis of
gestational diabetes or steroid-induced diabetes
(Diabetes Exclusions Value Set), in any setting, during
the measurement year or the year prior to the
measurement year.
Note: Consumers classified as diabetic in step 1 based
on pharmacy data alone and who had a diagnosis of
gestational or steroid-induced diabetes as specified
above are re-classified as not diabetic in this step.
Step 3
For consumers who were not assigned a flag in step 1
or step 2, assign a flag of “not diabetic.”

D. HYBRID SPECIFICATION
Denominator
The number of consumers representing a systematic sample from the eligible population
(Section C) whose diagnosis of hypertension is confirmed by chart review. Use a sample
size of 411, unless special circumstances apply or the eligible population is smaller.
BHCs may reduce the sample size using information from the current year’s
administrative rate or the prior year audited, hybrid rate, if one exists. Regardless of the
selected sample size, the National Committee for Quality Assurance (NCQA)
recommends an oversample to allow for substitution in the event that cases in the
original sample turn out to be ineligible for the measure. For this measure, NCQA
recommends that BHCs use an oversample of 10 to 15 percent to ensure enough
confirmed cases of hypertension.
To confirm the diagnosis of hypertension, there must be a notation of one of the
following in the medical record anytime during the consumer’s history on or before the
end of the sixth month of the measurement year:
•

Hypertension

•

HTN

•

High BP (HBP)
60

Controlling High Blood Pressure (CBP-BH)
Please see NCQA Notice of Copyright and Disclaimers in front matter to this manual.

•

Elevated BP (BP)

•

Borderline HTN

•

Intermittent HTN

•

History of HTN

•

Hypertensive vascular disease (HVD)

•

Hyperpiesia

•

Hyperpiesis

It does not matter if hypertension was treated or is currently being treated. The notation
indicating a diagnosis of hypertension may be recorded in any of the following
documents:
•

Problem list (this may include a diagnosis prior to the seventh month of the
measurement year or an undated diagnosis that is not part of the office visit note;
see Note at the end of this section)

•

Office note

•

Subjective, Objective, Assessment, Plan (SOAP) note

•

Encounter form

•

Diagnostic report

•

Hospital discharge summary

Statements such as “rule out HTN,” “possible HTN,” “white-coat HTN,” “questionable
HTN,” and “consistent with HTN” are not sufficient to confirm the diagnosis if such
statements are the only notations of hypertension in the medical record.
If the diagnosis of hypertension cannot be confirmed, the consumer is excluded and
replaced by the next consumer from the oversample.
Identifying the Medical Record
BHCs should use one medical record for both the confirmation of the diagnosis of
hypertension and the representative BP. All eligible BP measurements recorded in the
record must be considered. If a BHC cannot find the medical record, the consumer
remains in the measure denominator and is considered noncompliant for the numerator.
BHCs should use the following steps to find the appropriate medical record to review.
Step 1
•

Identify the consumer’s PCP.

•

If the consumer had more than one PCP for the time period, identify the PCP who
most recently provided care to the consumer.
61

Controlling High Blood Pressure (CBP-BH)
Please see NCQA Notice of Copyright and Disclaimers in front matter to this manual.

•

If the consumer did not visit a PCP for the time period or does not have a PCP,
identify the practitioner who most recently provided care to the consumer.

•

If a practitioner other than the consumer’s PCP manages the hypertension, the
BHC may use the medical record of that practitioner.

Step 2
•

Use one medical record to both confirm the diagnosis for the denominator and
identify the representative BP level for the numerator. There are circumstances in
which the BHC may need to go to a second medical record to either confirm the
diagnosis or obtain the BP reading, as in the following two examples.
Example 1: If a consumer sees one PCP during the denominator confirmation
period (before the seventh month of the measurement year) and another PCP after
June 30, the diagnosis of hypertension and the BP reading may be identified
through two different medical records.
Example 2: If a consumer has the same PCP for the entire measurement year, but
it is clear from claims or medical record data that a specialist (e.g., cardiologist)
manages the adult’s hypertension after the sixth month of the measurement year,
the BHC may use the PCP’s chart to confirm the diagnosis and use the specialist’s
chart to obtain the BP reading. For example, if all recent claims coded with 401
came from the specialist, the BHC may use this chart for the most recent BP
reading. If the consumer did not have any visit with the specialist prior to the
seventh month of the measurement year, the BHC must go to another medical
record to confirm the diagnosis.

Note: The measurement period for the denominator is the first six months of the
measurement year.
Numerator
The number of consumers in the denominator whose most recent BP (both systolic and
diastolic) is adequately controlled during the measurement year based on the following
criteria:
•

Consumers ages 18 to 59 as of December 31 of the measurement year whose BP
was <140/90 mm Hg

•

Consumers ages 60 to 85 as of December 31 of the measurement year and flagged
with a diagnosis of diabetes whose BP was <140/90 mm Hg

•

Consumers ages 60 to 85 as of December 31 of the measurement year and flagged
as not having a diagnosis of diabetes whose BP was <150/90 mm Hg
62

Controlling High Blood Pressure (CBP-BH)
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To determine if a consumer’s BP is adequately controlled, the representative BP must be
identified.
Note: The measurement period for the numerator is the measurement year using the
medical records specification below. The blood pressure reading indicating adequate control
must occur after the diagnosis of hypertension was made.

E. MEDICAL RECORDS SPECIFICATION
Follow the steps below to determine representative BP.
Step 1
Identify the most recent BP reading noted during the measurement year. The reading
must occur after the date when the diagnosis of hypertension was confirmed. Do not
include BP readings:
•

Taken during an acute inpatient stay or an ED visit

•

Taken during an outpatient visit which was for the sole purpose of having a
diagnostic test or surgical procedure performed (e.g., sigmoidoscopy, removal of
a mole)

•

Obtained the same day as a major diagnostic or surgical procedure (e.g., stress
test, administration of IV contrast for a radiology procedure, endoscopy)

•

Reported by or taken by the consumer

If multiple readings were recorded for a single date, use the lowest systolic and lowest
diastolic BP on that date as the representative BP. The systolic and diastolic results do
not need to be from the same reading.
Step 2
Determine numerator compliance based on the following criteria:
•

Consumers ages 18 to 59 as of December 31 of the measurement year whose BP
was <140/90 mm Hg

•

Consumers ages 60 to 85 as of December 31 of the measurement year and flagged
with a diagnosis of diabetes whose BP was <140/90 mm Hg

•

Consumers ages 60 to 85 as of December 31 of the measurement year and flagged
as not having a diagnosis of diabetes whose BP was <150/90 mm Hg

The consumer is not compliant if the BP reading does not meet the specified threshold or
is missing, or if there is no BP reading during the measurement year or if the reading is
incomplete (e.g., the systolic or diastolic level is missing).
63

Controlling High Blood Pressure (CBP-BH)
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Step 3
A single rate is reported for all three groups for each stratification (ages 18 to 64, ages 65
to 85, and total). Sum the numerator events from Step 2 to obtain a rate.
Note: The measurement period for the numerator is the measurement year.
Exclusions (optional)
•

Exclude from the eligible population all consumers with evidence of end-stage
renal disease (ESRD) (ESRD Value Set; ESRD Obsolete Value Set) or kidney
transplant (Kidney Transplant Value Set) on or prior to the last day of the
measurement year.
Note: Documentation in the medical record must include a dated note
indicating evidence of ESRD, kidney transplant, or dialysis.

•

Exclude from the eligible population all consumers with a diagnosis of pregnancy
(Pregnancy Value Set) during the measurement year.

•

Exclude from the eligible population all consumers who had a non-acute inpatient
admission during the measurement year. To identify non-acute inpatient
admissions:
o Identify all acute and non-acute inpatient stays (Inpatient Stay Value Set).
o Confirm the stay was for non-acute care based on the presence of a nonacute code (Non-acute Inpatient Stay Value Set) on the claim.
o Identify the admission date for the stay.

F. ADDITIONAL NOTES
Problem lists generally indicate established conditions; excluding undated entries might
hinder confirmation of the denominator. If a problem list is found in an office visit note
then it would be considered a dated problem list and the date of the visit must be used.
Only administrative data should be used to assign the diabetes flag. The intent of the flag
is to determine the appropriate BP threshold to use for the consumer during numerator
assessment. The only exception is if the consumer is flagged as a diabetic but medical
record evidence contains information that classifies the consumer as a valid data error.
To meet criteria as a valid data error, the medical record must contain no evidence of
diabetes and include a notation that refutes the diagnosis. In this case, the diabetes flag
may be changed to “not diabetic,” but the consumer may not be removed from the
sample.

Controlling High Blood Pressure (CBP-BH)
Please see NCQA Notice of Copyright and Disclaimers in front matter to this manual.

The source measure is designed for the Medicaid population and is not risk adjusted. The
source measure was specified and tested at the health plan level. This measure is
modified to require clinic-level reporting, and to be consistent in format with other
measures in this set of BHC measures, but is not tested at the clinic level.
Interpretation of score: Better quality = Higher score

Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention (TSC)

Preventive Care & Screening: Tobacco Use: Screening & Cessation
Intervention (TSC)
Based on a measure stewarded by the American Medical Association (AMA) and
CPI® Foundation (PCPI®) (NQF #0028, PQRS # 226)
A. DESCRIPTION
Percentage of consumers aged 18 years and older who were screened for tobacco use one
or more times within 24 months AND who received cessation counseling intervention if
identified as a tobacco user
Data Collection Method: Medical Records
Guidance for Reporting:
•

This measure is stratified by whether the consumer is a Medicaid beneficiary,
eligible for both Medicare and Medicaid, and other.

•

This measure is to be reported once per measurement year for consumers seen
during the measurement year.

•

This measure is intended to reflect the quality of services provided for preventive
screening for tobacco use.

•

Refer to the specific data-reporting template for the reporting requirements
applicable to each measure and to the Appendices in Volume 2 of this manual.

Measurement Period: The measurement period for the denominator is the measurement
year and, for the numerator, is the measurement year and the prior year.
B. DEFINITIONS
TERM
Provider Entity
Tobacco Cessation
Intervention

DEFINITION
The provider entity that is being measured (i.e., BHC)
Includes brief counseling (3 minutes or less) and/or
pharmacotherapy
66

Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention (TSC)

TERM
Tobacco Use

DEFINITION
Includes use of any type of tobacco

C. ELIGIBLE POPULATION
CRITERIA
Age

REQUIREMENTS
Consumers aged 18 years or older on the date of
service during the measurement year
Follow the steps below to identify the eligible
population:
Step 1
Identify consumers seen at the provider entity during
the measurement year.

Event/Diagnosis

Step 2
Identify consumers from step 1 who were aged 18
years and older on the date of service during the
measurement year.
Step 3
Identify consumers from step 2 who had an eligible
encounter at the provider entity during the
measurement year. Relevant codes (Current
Procedural Terminology [CPT®] or Healthcare
Common Procedure Coding System [HCPCS]) may be
found in Appendix TSC.B.

D. MEDICAL RECORD SPECIFICATION
Denominator
The number of consumers in the eligible population (Section C)
Note: The measurement period for the denominator is the measurement year.
Incomplete Reporting Exclusion: Failure to record quality-data codes necessary
for computing the numerator means that the consumer is excluded from the
denominator.

Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention (TSC)

Numerator
The number of consumers who were screened for tobacco use at least once within 24
months AND who received tobacco cessation intervention if identified as a tobacco user
Numerator Options: The options below indicate the coding possibilities related
to the numerator. The first two, where performance is met, indicate situations
where the data point is included in the numerator. The third, where performance
is not met, means that the data point represents a quality failure and is not counted
in the numerator.
Performance Met: Consumer screened for tobacco use AND received
tobacco cessation intervention (counseling, pharmacotherapy, or both), if
identified as a tobacco user (CPT II 4004F)
OR
Performance Met: Consumer screened for tobacco use and identified as a
non-user of tobacco (CPT II 1036F)
Performance Not Met: Tobacco screening OR tobacco cessation
intervention not performed, reason not otherwise specified (CPT II 4004F
with 8P)
Exception: 2 Documentation of medical reason(s) for not screening for tobacco
use (e.g., limited life expectancy, other medical reasons) (CPT II 4004F with 1P)
Note: The measurement period for the numerator is the measurement year and the prior
year. For CCBHCs that do not have access to this information for the year prior to
Demonstration Year 1 (DY1), screening should occur during DY1.
Example Calculation: See Appendix TSC.A.
E. ADDITIONAL NOTES
Both this measure and the source measure were specified at the provider level. Neither is
risk adjusted. This measure is modified from the source measure to provide a
specification consistent in format to other measures in this set of BHC measures. The
substance of the measure is unchanged.
Interpretation of score: Better quality = Higher score

The AMA PCPI specifications refer to “exceptions” in circumstances where many specifications would reference
“exclusions.” We retain the AMA PCPI language for consistency with the original measure. The AMA PCPI
measures also place exceptions in numerator calculations.

Preventive Care & Screening: Unhealthy Alcohol Use: Screening & Brief Counseling (ASC)

Preventive Care & Screening: Unhealthy Alcohol Use:
Screening & Brief Counseling (ASC)
Based on a measure stewarded by the American Medical Association (AMA) and PCPI®
Foundation (PCPI®) (NQF #2152, PQRS #431)
A. DESCRIPTION
Percentage of consumers aged 18 years and older who were screened at least once within
the last 24 months for unhealthy alcohol use using a systematic screening method AND
who received brief counseling if identified as an unhealthy alcohol user
Data Collection Method: Medical Records
Guidance for Reporting:
•

This measure is stratified by whether the consumer is a Medicaid beneficiary,
eligible for both Medicare and Medicaid, and other.

•

This measure is to be reported once per measurement year for consumers seen
during the measurement year. This measure is intended to reflect the quality of
services provided for preventive screening for unhealthy alcohol use. There is no
diagnosis associated with this measure. This measure may be reported by
clinicians who perform the quality actions described in the measure based on the
services provided and the measure-specific denominator coding.

•

Refer to the specific data-reporting template for the reporting requirements
applicable to each measure and to the Appendices in Volume 2 of this manual.

Measurement Period: The measurement period for the denominator is the measurement
year and, for the numerator, is the measurement year and the prior year.

Preventive Care & Screening: Unhealthy Alcohol Use: Screening & Brief Counseling (ASC)

B. DEFINITIONS
TERM
AUDIT and
AUDIT-C

Brief Counseling

Provider Entity

Systematic
Screening
Method

DEFINITION
The AUDIT is the Alcohol Use Disorders Identification Test and
the AUDIT-C is an abbreviated version of the AUDIT. Both were
developed by the World Health Organization.
Brief counseling for unhealthy alcohol use refers to one or more
counseling sessions, a minimum of 5–15 minutes, which may
include feedback on alcohol use and harms, identification of highrisk situations for drinking and coping strategies, increased
motivation, and the development of a personal plan to reduce
drinking.
The provider entity that is being measured (i.e., BHC)
For purposes of this measure, one of the following systematic
methods to assess unhealthy alcohol use must be utilized.
Systematic screening methods and thresholds for defining
unhealthy alcohol use include:
•

AUDIT Screening Instrument (score ≥ 8)

•

AUDIT-C Screening Instrument (score ≥4 for men; score
≥3 for women)

•

Single Question Screening - How many times in the past
year have you had 5 (for men) or 4 (for women and all
adults older than 65 years) or more drinks in a day?
(response ≥2)

C. ELIGIBLE POPULATION
CRITERIA
Age

REQUIREMENTS
Consumers aged 18 years or older on the date of service during the
measurement year

Preventive Care & Screening: Unhealthy Alcohol Use: Screening & Brief Counseling (ASC)

CRITERIA

REQUIREMENTS
Follow the steps below to identify the eligible population:
Step 1
Identify consumers seen at the provider entity during the
measurement year.
Step 2
Identify consumers from step 1 who were aged 18 years and older
on the date of service during the measurement year.
Step 3

Event/Diagnosis

1. Identify consumers from step 2 who met either of the
following criteria during the measurement year:
Had at least two encounters at the provider entity during
the measurement year. Relevant codes (Current Procedural
Terminology [CPT®] or Healthcare Common Procedure
Coding System [HCPCS]) may be found in Appendix
ASC.B.
OR
2. Had one preventive care visit. Relevant codes (Current
Procedural Terminology [CPT®] or Healthcare Common
Procedure Coding System [HCPCS]) may be found in
Appendix ASC.B.

D. MEDICAL RECORD SPECIFICATION
Denominator
The number of consumers in the eligible population (Section C)
Note: The measurement period for the denominator is the measurement year.
Incomplete Reporting Exclusion: Failure to record quality-data codes necessary
for computing the numerator means that the consumer is excluded from the
denominator.

Preventive Care & Screening: Unhealthy Alcohol Use: Screening & Brief Counseling (ASC)

Numerator
The number of consumers who were screened at least once within the last 24 months for
unhealthy alcohol use using a systematic screening method AND who received brief
counseling if identified as an unhealthy alcohol user.
Numerator Options: The options below indicate the coding possibilities related
to the numerator. The first two, where performance is met, indicate situations
where the data point is included in the numerator. The third, where performance
is not met, means that the data point represents a quality failure and is not counted
in the numerator.
Performance Met: Consumer identified as an unhealthy alcohol user
when screened for unhealthy alcohol use using a systematic screening
method and received brief counseling (G9621)
OR
Performance Met: Consumer not identified as an unhealthy alcohol user
when screened for unhealthy alcohol use using a systematic screening
method (G9622)
Performance Not Met: Consumer not screened for unhealthy alcohol
screening using a systematic screening method OR consumer did not
receive brief counseling, reason not given (G9624)
Exception: 3 Documentation of medical reason(s) for not screening for unhealthy
alcohol use in the measurement year or the year prior (e.g., limited life
expectancy, other medical reasons) (G9623)
Note: The measurement period for the numerator is the measurement year and the prior
year. For CCBHCs who do not have access to this information for the year prior to
Demonstration Year 1 (DY1), screening should occur during DY1.
Example Calculation: See Appendix ASC.A.
E. ADDITIONAL NOTES
Both this and the source measure were specified at the provider level. Neither is risk
adjusted. This measure is modified from the source measure to provide a specification
3

Preventive Care & Screening: Unhealthy Alcohol Use: Screening & Brief Counseling (ASC)

consistent in format to other measures in this set of BHC measures. The substance of the
measure is unchanged.
Interpretation of score: Better quality = Higher score

Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment (SRA-BH-C)

Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk
Assessment (SRA-BH-C)
Based on a measure stewarded by the
American Medical Association (AMA) and PCPI® Foundation (PCPI®) (NQF #1365, PQRS
#382)
A. DESCRIPTION
Percentage of consumer visits for those consumers aged 6 through 17 years with a
diagnosis of major depressive disorder with an assessment for suicide risk
Data Collection Method: Electronic Health Records
Guidance for Reporting:
•

•
•
•

•
•

•

This measure is stratified by whether the consumer is a Medicaid beneficiary,
eligible for both Medicare and Medicaid, other, and by total population. For
purposes of determining whether a consumer is a Medicaid beneficiary or a dual
Medicare and Medicaid enrollee, use their insurance status on the date of the
measured visit.
This measure is specified for calculation using electronic health records.
This measure is based on the percentage of consumer visits rather than
consumers.
More information about this measure is available in the eCQM Library (CMS
177v3), available at eCQM Library, Annual Updates, eCQM Electronic
Specifications page on CMS.gov.
More information about CMS177v3 is available in the Electronic Clinical Quality
Improvement Resource Center (eCQI Resource Center)
Value sets for this measure are available from the U.S. National Library of
Medicine Value Set Authority Center (VSAC).
Access to the VSAC requires a Unified Medical Language System (UMLS)
license; states may apply for a UMLS license at UMLS Metathesaurus License
webpage.
When searching for value sets for this measure, states should use the measure’s
associated e-Measure number (CMS177v3) or NQF number (1365).
The measure steward periodically releases updated value sets. Always use the
value set that corresponds with the specification release date. This specification
and associated value sets are part of the 07-01-2014 release.
Refer to Appendix SRA-BH-C for e-Measure flows for this measure.
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Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment (SRA-BH-C)

•

Refer to the specific data-reporting template for the reporting requirements
applicable to each measure and to the Appendices in Volume 2 of this manual.

Measurement Period: The measurement period for both the denominator and the
numerator is the measurement year (e.g., for CCBHCs, DY1 or DY2).
B. DEFINITIONS
TERM
Provider Entity

DEFINITION
The provider entity that is being measured (i.e., BHC)

C. ELIGIBLE POPULATION
CRITERIA
Age

REQUIREMENTS
Consumers 6–17 years of age as of the start of the measurement year
Follow the steps below to identify the eligible population:
Step 1
Identify consumers seen at the provider entity who were 6–17 years
of age as of the start of the measurement year.
Step 2
Identify consumers from step 1 who had at least two qualifying visits
during the measurement year.

Event/Diagnosis

Step 3
Identify consumers from step 2 who had an active diagnosis of Major
Depressive Disorder at the time of the encounter.
Note: One consumer may have multiple encounters with an active
diagnosis of Major Depressive Disorder and each encounter counts
separately.
Note: See Electronic Health Record Specification (section D) for the
logic in calculating the denominator.

D. ELECTRONIC HEALTH RECORD SPECIFICATION
Denominator
All consumer visits for those consumers 6–17 years of age with a diagnosis of major
depressive disorder

Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment (SRA-BH-C)

Denominator Logic
•

Initial Consumer Population =
o

AND: "Consumer Characteristic Birthdate: birth date" >= 6 year(s) starts
before start of "Measurement Period"

AND: "Consumer Characteristic Birthdate: birth date" < 17 year(s) starts
before start of "Measurement Period"

AND: Count >= 2 of:



OR: "Encounter, Performed: Office Visit"



OR: "Encounter, Performed: Outpatient Consultation"



OR: "Encounter, Performed: Patient Provider Interaction"



OR: "Encounter, Performed: Psych Visit - Diagnostic Evaluation"



OR: "Encounter, Performed: Psych Visit - Family Psychotherapy"



OR: "Encounter, Performed: Psychoanalysis"



OR: "Encounter, Performed: Group Psychotherapy"



OR: "Encounter, Performed: Psych Visit - Psychotherapy"



during "Measurement Period"

AND:




OR:
-

AND: "Occurrence A of Diagnosis, Active: Major Depressive
Disorder-Active" starts before or during "Occurrence A of
Encounter, Performed: Psych Visit - Diagnostic Evaluation"

AND: "Occurrence A of Encounter, Performed: Psych Visit Diagnostic Evaluation" during "Measurement Period"

AND NOT: "Occurrence A of Diagnosis, Active: Major
Depressive Disorder-Active" ends before start of "Occurrence
A of Encounter, Performed: Psych Visit - Diagnostic
Evaluation"

OR:
-

AND: "Occurrence A of Diagnosis, Active: Major Depressive
Disorder-Active" starts before or during "Occurrence A of
Encounter, Performed: Psych Visit - Family Psychotherapy"

AND: "Occurrence A of Encounter, Performed: Psych Visit Family Psychotherapy" during "Measurement Period"

AND NOT: "Occurrence A of Diagnosis, Active: Major
Depressive Disorder-Active" ends before start of "Occurrence

Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment (SRA-BH-C)

A of Encounter, Performed: Psych Visit - Family
Psychotherapy"




OR:
-

AND: "Occurrence A of Diagnosis, Active: Major Depressive
Disorder-Active" starts before or during "Occurrence A of
Encounter, Performed: Face-to-Face Interaction"

AND: "Occurrence A of Encounter, Performed: Face-to-Face
Interaction" during "Measurement Period"

AND NOT: "Occurrence A of Diagnosis, Active: Major
Depressive Disorder-Active" ends before start of "Occurrence
A of Encounter, Performed: Face-to-Face Interaction"

OR:
-

AND: "Occurrence A of Diagnosis, Active: Major Depressive
Disorder-Active" starts before or during "Occurrence A of
Encounter, Performed: Group Psychotherapy"

AND: "Occurrence A of Encounter, Performed: Group
Psychotherapy" during "Measurement Period"

AND NOT: "Occurrence A of Diagnosis, Active: Major
Depressive Disorder-Active" ends before start of "Occurrence
A of Encounter, Performed: Group Psychotherapy"

OR:
-

AND: "Occurrence A of Diagnosis, Active: Major Depressive
Disorder-Active" starts before or during "Occurrence A of
Encounter, Performed: Outpatient Consultation"

AND: "Occurrence A of Encounter, Performed: Outpatient
Consultation" during "Measurement Period"

AND NOT: "Occurrence A of Diagnosis, Active: Major
Depressive Disorder-Active" ends before start of "Occurrence
A of Encounter, Performed: Outpatient Consultation"

OR:
-

AND: "Occurrence A of Diagnosis, Active: Major Depressive
Disorder-Active" starts before or during "Occurrence A of
Encounter, Performed: Office Visit"

AND: "Occurrence A of Encounter, Performed: Office Visit"
during "Measurement Period"

Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment (SRA-BH-C)
-



•

AND NOT: "Occurrence A of Diagnosis, Active: Major
Depressive Disorder-Active" ends before start of "Occurrence
A of Encounter, Performed: Office Visit"

OR:
-

AND: "Occurrence A of Diagnosis, Active: Major Depressive
Disorder-Active" starts before or during "Occurrence A of
Encounter, Performed: Psychoanalysis"

AND: "Occurrence A of Encounter, Performed:
Psychoanalysis" during "Measurement Period"

AND NOT: "Occurrence A of Diagnosis, Active: Major
Depressive Disorder-Active" ends before start of "Occurrence
A of Encounter, Performed: Psychoanalysis"

OR:
-

AND: "Occurrence A of Diagnosis, Active: Major Depressive
Disorder-Active" starts before or during "Occurrence A of
Encounter, Performed: Psych Visit - Psychotherapy"

AND: "Occurrence A of Encounter, Performed: Psych Visit Psychotherapy" during "Measurement Period"

AND NOT: "Occurrence A of Diagnosis, Active: Major
Depressive Disorder-Active" ends before start of "Occurrence
A of Encounter, Performed: Psych Visit - Psychotherapy"

Denominator =
o AND: "Initial Consumer Population"

Numerator
The number of consumer visits with an assessment for suicide risk
Numerator Definition
The specific type and magnitude of the suicide risk assessment is intended to be at the
discretion of the individual clinician and should be specific to the needs of the consumer.
Suicide risk assessment can include:
•

specific inquiry about suicidal thoughts, intent, plans, means, and behaviors

•

identification of specific psychiatric symptoms (e.g., psychosis, severe anxiety,
substance use) or general medical conditions that may increase the likelihood of
acting on suicidal ideas

•

assessment of past and, particularly, recent suicidal behavior
78

Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment (SRA-BH-C)

•

delineation of current stressors and potential protective factors (e.g., positive
reasons for living, strong social support)

•

identification of any family history of suicide or mental illness

Low burden tools to track suicidal ideation and behavior such as the Columbia-Suicide
Severity Rating Scale can also be used.
Numerator Guidance
A suicide risk assessment should be performed at every visit for Major Depressive
Disorder during the measurement period.
This measure is an episode-of-care measure; the level of analysis for this measure is
every visit for Major Depressive Disorder during the measurement period. A minimum
of two encounters are required during the measurement period for a consumer to be
included in this measure to establish that the eligible professional has an existing
relationship with the consumer; if the consumer is only seen once by the eligible
professional, the consumer is not included in the measure. Once it has been established
that the consumer has been seen at least twice by the eligible professional, every visit for
Major Depressive Disorder should be counted as a measurable episode for the measure
calculation. For example, at every visit for MDD, the consumer should have a suicide
risk assessment.
Use of a standardized tool or instrument to assess suicide risk will meet numerator
performance. Standardized tools can be mapped to the concept “Intervention, Performed:
Suicide Risk Assessment” included in the numerator logic below.
Numerator Logic
•

AND: "Intervention, Performed: Suicide Risk Assessment" during
o

OR: "Occurrence A of Encounter, Performed: Office Visit"

OR: "Occurrence A of Encounter, Performed: Outpatient Consultation"

OR: "Occurrence A of Encounter, Performed: Face-to-Face Interaction"

OR: "Occurrence A of Encounter, Performed: Psych Visit - Diagnostic
Evaluation"

OR: "Occurrence A of Encounter, Performed: Psych Visit Psychotherapy"

OR: "Occurrence A of Encounter, Performed: Psych Visit - Family
Psychotherapy"

OR: "Occurrence A of Encounter, Performed: Psychoanalysis"

OR: "Occurrence A of Encounter, Performed: Group Psychotherapy"
79

Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment (SRA-BH-C)

Exclusions
None.
E. ADDITIONAL NOTES
Both this measure and the source measure were specified at the provider level. Neither is
risk adjusted. This measure is modified from the source measure to provide a
specification consistent in format to other measures in this set of BHC measures. The
substance of the measure is unchanged.
Interpretation of score: Better quality = Higher score
Data Criteria - Quality Data Model (QDM) Data Elements
Available in the SRA Value Set
"Diagnosis, Active: Major Depressive Disorder-Active" using "Major Depressive
Disorder-Active Grouping Value Set (2.16.840.1.113883.3.526.3.1491)"
"Encounter, Performed: Face-to-Face Interaction" using "Face-to-Face Interaction
Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1048)"
"Encounter, Performed: Group Psychotherapy" using "Group Psychotherapy Grouping
Value Set (2.16.840.1.113883.3.526.3.1187)"
"Encounter, Performed: Office Visit" using "Office Visit Grouping Value Set
(2.16.840.1.113883.3.464.1003.101.12.1001)"
"Encounter, Performed: Outpatient Consultation" using "Outpatient Consultation
Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1008)"
"Encounter, Performed: Patient Provider Interaction" using "Patient Provider Interaction
Grouping Value Set (2.16.840.1.113883.3.526.3.1012)"
"Encounter, Performed: Psych Visit - Diagnostic Evaluation" using "Psych Visit Diagnostic Evaluation Grouping Value Set (2.16.840.1.113883.3.526.3.1492)"
"Encounter, Performed: Psych Visit - Family Psychotherapy" using "Psych Visit - Family
Psychotherapy Grouping Value Set (2.16.840.1.113883.3.526.3.1018)"
"Encounter, Performed: Psych Visit - Psychotherapy" using "Psych Visit - Psychotherapy
Grouping Value Set (2.16.840.1.113883.3.526.3.1496)"
"Encounter, Performed: Psychoanalysis" using "Psychoanalysis Grouping Value Set
(2.16.840.1.113883.3.526.3.1141)"

Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment (SRA-BH-C)

"Intervention, Performed: Suicide Risk Assessment" using "Suicide Risk Assessment
Grouping Value Set (2.16.840.1.113883.3.526.3.1484)"
"Patient Characteristic Birthdate: birth date" using "birth date LOINC Value Set
(2.16.840.1.113883.3.560.100.4)"
Reporting Stratification
"Patient Characteristic Payer: Payer" using "Payer SOP Value Set
(2.16.840.1.114222.4.11.3591)"
Supplemental Data Elements
"Patient Characteristic Ethnicity: Ethnicity" using "Ethnicity CDC Value Set
(2.16.840.1.114222.4.11.837)"
"Patient Characteristic Race: Race" using "Race CDC Value Set
(2.16.840.1.114222.4.11.836)"
"Patient Characteristic Sex: ONC Administrative Sex" using "ONC Administrative Sex
Administrative Sex Value Set (2.16.840.1.113762.1.4.1)"

Adult Major Depressive Disorder (MDD): Suicide Risk Assessment (SRA-A)

Adult Major Depressive Disorder (MDD): Suicide Risk Assessment (SRA-A)
Based on a measure stewarded by the American Medical Association (AMA) and PCPI®
Foundation (PCPI®) (NQF #0104, PQRS #107 (electronic version only))
A. DESCRIPTION
Percentage of consumers aged 18 years and older with a diagnosis of major depressive
disorder (MDD) with a suicide risk assessment completed during the visit in which a new
diagnosis or recurrent episode was identified
Data Collection Method: Electronic Health Records or Medical Records
Guidance for Reporting:
•

This measure is stratified by whether the consumer is a Medicaid beneficiary,
eligible for both Medicare and Medicaid, and other. For purposes of determining
whether a consumer is a Medicaid beneficiary or a dual Medicare and Medicaid
enrollee, use their insurance status on the date of the measured visit.

•

This measure is specified two ways, for calculation either using electronic health
records or using medical records.

•

This measure is based on the percentage of consumer visits rather than
consumers.

•

For those using the Electronic Health Records Specification:
o More information about this measure is available in the eCQM Library
(CMS 161v3), available at eCQM Library, Annual Updates, eCQM
Electronic Specifications page on CMS.gov.
o . More information about CMS161v3 is available at the Electronic Clinical
Quality Improvement Resource Center (eCQI Resource Center)

o Value sets for this measure are available from the U.S. National Library of
Medicine Value Set Authority Center (VSAC) are available from the U.S.
National Library of Medicine Value Set Authority Center (VSAC)
o Access to the VSAC requires a Unified Medical Language System
(UMLS) license; states may apply for a UMLS license at the UMLS
Metathesaraus License webpage.
o When searching for value sets for this measure, states should use the
measure’s associated e-Measure number (CMS161v4) or NQF number
(0104).
82

Adult Major Depressive Disorder (MDD): Suicide Risk Assessment (SRA-A)

o The measure steward periodically releases updated value sets. Always use
the value set that corresponds with the specification release date. This
specification and associated value sets are part of the 07-01-2014 release.
o Refer to Appendix SRA-A.A for e-Measure flows for this measure.
•

For those using the Medical Records Specification:
o For provider entities who rely on medical records to compile this
information, there are several potential sources of information that may be
used individually or together:

•



Electronic health records (including billing records)



Paper health records



A registry

Refer to the specific data-reporting template for the reporting requirements
applicable to each measure and to the Appendices in Volume 2 of this manual.

Measurement Period: The measurement period for both the denominator and the
numerator is the measurement year (e.g., for CCBHCs, DY1 or DY2).
B. DEFINITIONS
TERM
Initial Consumer
Population
Provider Entity

DEFINITION
All consumers aged 18 years and older with a diagnosis of
major depressive disorder (MDD)
The provider entity that is being measured (i.e., BHC)
A suicide risk assessment must include questions about the
following:
1. Suicidal ideation

Suicide Risk
Assessment

2. Consumer’s intent of initiating a suicide attempt
AND, if either is present:
3. Consumer plans for a suicide attempt
4. Whether the consumer has means for completing
suicide

C. ELIGIBLE POPULATION
CRITERIA
Age

REQUIREMENTS
Consumers aged 18 years and older at the time of the
episode
83

Adult Major Depressive Disorder (MDD): Suicide Risk Assessment (SRA-A)

CRITERIA

REQUIREMENTS
Follow the steps below to identify the eligible population:
Step 1
Identify consumers seen at the provider entity who were
aged 18 and older at the start of the measurement year.

Event/Diagnosis for
Those Using the
Electronic Health
Records Specification

Step 2
Identify consumers from step 1 who had at least one
qualifying visit during the measurement year.
Step 3
Identify consumers from step 2 who had an active
diagnosis of Major Depressive Disorder at the time of the
encounter.
Note: One consumer may have multiple encounters with
an active diagnosis of Major Depressive Disorder and each
encounter counts separately.
Note: See Electronic Health Record Specification (section
D) for the logic in calculating the denominator.

Adult Major Depressive Disorder (MDD): Suicide Risk Assessment (SRA-A)

CRITERIA

REQUIREMENTS
Follow the steps below to identify the eligible population:
Step 1
Identify consumers seen at the provider entity at least once
during the measurement year.
Step 2
Identify consumers from step 1 aged 18 and older at the
time of the first encounter identified in step 3.
Step 3

Event/Diagnosis for
Those Using the
Medical Records
Specification

Identify consumers from step 2 with a new diagnosis or
recurrent episode of MDD identified by the provider entity
during the measurement year. Relevant codes
(International Classification of Diseases, Tenth Revision,
Clinical Modification ([CD-10-CM] and Current
Procedural Terminology [CPT®]) may be found in
Appendix SRA-A.B.
Step 4
Identify the number of times, for the consumers in step 3,
there was a new diagnosis or recurrent episode of MDD
identified by the clinic during the measurement year.
Note: It is expected that a suicide risk assessment will be
completed at the visit during which a new diagnosis is
made or at the visit during which a recurrent episode is
first identified. This is an episode-of-care measure and
should be reported for each instance of a new or recurrent
episode of MDD; every new or recurrent episode will
count separately in the Eligible Population.

D. ELECTRONIC HEALTH RECORDS SPECIFICATION
Denominator
All consumer visits for those consumers aged 18 years and older with a diagnosis of
major depressive disorder

Adult Major Depressive Disorder (MDD): Suicide Risk Assessment (SRA-A)

Denominator Logic
•

Initial Consumer Population =
o AND: “Patient Characteristic Birthdate: birth date” >= 17 year(s) starts
before start of “Measurement Period”
o

AND: “Diagnosis, Active: Major Depressive Disorder-Active” starts
during


OR: “Occurrence A of Encounter, Performed: Psych Visit –
Diagnostic Evaluation”



OR: "Occurrence A of Encounter, Performed: Psych Visit Psychotherapy"



OR: "Occurrence A of Encounter, Performed: Emergency
Department Visit"



OR: "Occurrence A of Encounter, Performed: Office Visit"”



OR: “Occurrence A of Encounter, Performed: Outpatient
Consultation”



OR: “Occurrence A of Encounter, Performed: Psychoanalysis”



OR: “Occurrence A of Encounter, Performed: Face-to-Face
Interaction”



during “Measurement Period”

AND:




OR:
-

AND: “Occurrence A of Diagnosis, Active: Major Depressive
Disorder-Active” starts before or during “Occurrence A of
Encounter, Performed: Psych Visit – Diagnostic Evaluation”

AND: “Occurrence A of Encounter, Performed: Psych Visit –
Diagnostic Evaluation” during “Measurement Period”

AND NOT: “Occurrence A of Diagnosis, Active: Major
Depressive Disorder-Active” ends before start of “Occurrence
A of Encounter, Performed: Psych Visit – Diagnostic
Evaluation”

OR:
-

AND: “Occurrence A of Diagnosis, Active: Major Depressive
Disorder-Active” starts before or during “Occurrence A of
Encounter, Performed: Psych Visit – Psychotherapy”

AND: “Occurrence A of Encounter, Performed: Psych Visit –
Psychotherapy” during “Measurement Period”
86

Adult Major Depressive Disorder (MDD): Suicide Risk Assessment (SRA-A)



AND NOT: “Occurrence A of Diagnosis, Active: Major
Depressive Disorder-Active” ends before start of “Occurrence
A of Encounter, Performed: Psych Visit – Psychotherapy”

OR:
-

AND: “Occurrence A of Diagnosis, Active: Major Depressive
Disorder-Active” starts before or during “Occurrence A of
Encounter, Performed: Emergency Department Visit “

AND: “Occurrence A of Encounter, Performed: Emergency
Department Visit “ during “Measurement Period”

AND NOT: “Occurrence A of Diagnosis, Active: Major
Depressive Disorder-Active” ends before start of “Occurrence
A of Encounter, Performed: Emergency Department Visit “

OR:
-

AND: “Occurrence A of Diagnosis, Active: Major Depressive
Disorder-Active” starts before or during “Occurrence A of
Encounter, Performed: Office Visit”

AND: “Occurrence A of Encounter, Performed: Office Visit”
during “Measurement Period”

AND NOT: “Occurrence A of Diagnosis, Active: Major
Depressive Disorder-Active” ends before start of “Occurrence
A of Encounter, Performed: Office Visit”

OR:
-

AND: “Occurrence A of Diagnosis, Active: Major Depressive
Disorder-Active” starts before or during “Occurrence A of
Encounter, Performed: Outpatient Consultation”

AND: “Occurrence A of Encounter, Performed: Outpatient
Consultation” during “Measurement Period”

AND NOT: “Occurrence A of Diagnosis, Active: Major
Depressive Disorder-Active” ends before start of “Occurrence
A of Encounter, Performed: Outpatient Consultation”

OR:
-

AND: “Occurrence A of Diagnosis, Active: Major Depressive
Disorder-Active” starts before or during “Occurrence A of
Encounter, Performed: Psychoanalysis”

AND: “Occurrence A of Encounter, Performed:
Psychoanalysis” during “Measurement Period”

Adult Major Depressive Disorder (MDD): Suicide Risk Assessment (SRA-A)



AND NOT: “Occurrence A of Diagnosis, Active: Major
Depressive Disorder-Active” ends before start of “Occurrence
A of Encounter, Performed: Psychoanalysis”

OR:
-

AND: Occurrence A of Diagnosis, Active: Major Depressive
Disorder-Active" starts before or during "Occurrence A of
Encounter, Performed: Face-to-Face Interaction"

AND: "Occurrence A of Encounter, Performed: Face-to-Face
Interaction" during "Measurement Period"

AND NOT: "Occurrence A of Diagnosis, Active: Major
Depressive Disorder-Active" ends before start of "Occurrence
A of Encounter, Performed: Face-to-Face Interaction"

•

Denominator =
o AND: “Initial Consumer Population”
Numerator
The number of consumer visits with a suicide risk assessment completed during the visit
in which a new diagnosis or recurrent episode was identified.
Numerator Guidance
It is expected that a suicide risk assessment will be completed at the visit during which a
new diagnosis is made or at the visit during which a recurrent episode is first identified
(i.e., at the initial evaluation). This measure is an episode-of-care measure and should be
reported for each instance of a new or recurrent episode of MDD; every new or recurrent
episode will count separately in the Initial Consumer Population.
Use of a standardized tool or instrument to assess suicide risk will meet numerator
performance. Standardized tools can be mapped to the concept "Intervention, Performed:
Suicide Risk Assessment” included in the numerator logic below.
The measure description outlined in the header for this measure states, ‘consumers aged
18 years and older’ while the logic statement states, ‘>= 17 year(s) starts before start of
“Measurement Period.”’ The logic statement, as written, captures consumers who turn
18 years old during the measurement period so that these patients are included in the
measure. To ensure all consumers with major depressive disorder (MDD) are assessed
for suicide risk, there are two clinical quality measures addressing suicide risk
assessment; CMS 177 covers children and adolescents aged 6 through 17, and CMS 161
covers the adult population aged 18 years and older.

Adult Major Depressive Disorder (MDD): Suicide Risk Assessment (SRA-A)

Numerator Logic
o

AND: “Intervention, Performed: Suicide Risk Assessment” during
 OR: “Occurrence A of Encounter, Performed: Psych Visit
Diagnostic Evaluation"


OR: "Occurrence A of Encounter, Performed: Psych Visit Psychotherapy"



OR: "Occurrence A of Encounter, Performed: Emergency
Department Visit "



OR: "Occurrence A of Encounter, Performed: Office Visit"



OR: "Occurrence A of Encounter, Performed: Outpatient
Consultation"



OR: "Occurrence A of Encounter, Performed: Psychoanalysis"



OR: "Occurrence A of Encounter, Performed: Face-to-Face
Interaction"

Exclusions
None
E. MEDICAL RECORDS SPECIFICATION
Denominator
The number of consumers in the eligible population (Section C)
Numerator
The number of consumers with a suicide risk assessment completed during the visit in
which a new diagnosis or recurrent episode was identified.
Exclusions
None
Example Calculation: See Appendix SRA-A.C.
F. ADDITIONAL NOTES
Both this measure and the source measure were specified at the provider level. Neither is
risk adjusted. This measure is modified from the source measure to provide a
specification consistent in format to other measures in this set of BHC measures. The
substance of the measure is unchanged.
Interpretation of score: Better quality = Higher score
89

Adult Major Depressive Disorder (MDD): Suicide Risk Assessment (SRA-A)

Data Criteria – Quality Data Model (QDM) Data Elements for the Electronic
Measure
•

"Diagnosis, Active: Major Depressive Disorder-Active" using "Major Depressive
Disorder-Active Grouping Value Set (2.16.840.1.113883.3.526.3.1491)"

•

"Encounter, Performed: Emergency Department Visit" using "Emergency
Department Visit Grouping Value Set
(2.16.840.1.113883.3.464.1003.101.12.1010)"

•

"Encounter, Performed: Face-to-Face Interaction" using "Face-to-Face Interaction
Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1048)"

•

"Encounter, Performed: Office Visit" using "Office Visit Grouping Value Set
(2.16.840.1.113883.3.464.1003.101.12.1001)"

•

"Encounter, Performed: Outpatient Consultation" using "Outpatient Consultation
Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1008)"

•

"Encounter, Performed: Psych Visit - Diagnostic Evaluation" using "Psych Visit Diagnostic Evaluation Grouping Value Set (2.16.840.1.113883.3.526.3.1492)"

•

"Encounter, Performed: Psych Visit - Psychotherapy" using "Psych Visit Psychotherapy Grouping Value Set (2.16.840.1.113883.3.526.3.1496)"

•

"Encounter, Performed: Psychoanalysis" using "Psychoanalysis Grouping Value
Set (2.16.840.1.113883.3.526.3.1141)"

•

"Intervention, Performed: Suicide Risk Assessment" using "Suicide Risk
Assessment Grouping Value Set (2.16.840.1.113883.3.526.3.1484)"

•

"Patient Characteristic Birthdate: birth date" using "birth date LOINC Value Set
(2.16.840.1.113883.3.560.100.4)"

Reporting Stratification
•

"Patient Characteristic Payer: Payer" using "Payer SOP Value Set
(2.16.840.1.114222.4.11.3591)"

Supplemental Data Elements
•
•
•

"Patient Characteristic Ethnicity: Ethnicity" using "Ethnicity CDCREC Value Set
(2.16.840.1.114222.4.11.837)"
"Patient Characteristic Race: Race" using "Race CDCREC Value Set
(2.16.840.1.114222.4.11.836)"
"Patient Characteristic Sex: ONC Administrative Sex" using "ONC
Administrative Sex Administrative Gender Value Set (2.16.840.1.113762.1.4.1)

Screening for Clinical Depression and Follow-Up Plan (CDF-BH)

Screening for Clinical Depression and Follow-Up Plan (CDF-BH)
Based on a measure stewarded by the
Centers for Medicare & Medicaid Services (NQF #0418)
A. DESCRIPTION
Percentage of consumers aged 12 and older screened for clinical depression on the date of
the encounter using an age-appropriate standardized depression screening tool, and if
positive, a follow-up plan is documented on the date of the positive screen
Data Collection Method: Hybrid
Guidance for Reporting:
•

This measure is stratified by whether the consumer is a Medicaid beneficiary,
eligible for both Medicare and Medicaid, and other. It also is stratified by age
group (ages 12 to 17, ages 18 to 64, and age 65 and older). For purposes of
determining whether a consumer is a Medicaid beneficiary or a dual Medicare and
Medicaid enrollee, use their insurance status on the date of the measured visit.

•

This measure uses administrative data and medical record review to calculate the
denominator exclusions for the measure. Providers may also choose to use
medical record review to identify numerator cases. Providers should indicate in
section E or F (Adherence to Measure Specifications or Additional Notes,
respectively) of the data-reporting template, deviations from the measure
specifications if they use the hybrid method to identify numerator cases.

•

The original specification for this measure included six G codes intended to
capture, for the numerator, whether individual providers reported on this measure.
For the purpose of BHC reporting, there are two G codes included in the
numerator to capture whether clinical depression screening was done and if the
screen was positive, whether a follow-up plan was documented.

•

The date of encounter and screening must occur on the same date of service; if a
consumer has more than one encounter during the measurement year, the
consumer should be counted in the numerator and denominator only once based
on the most recent encounter.
91

Screening for Clinical Depression and Follow-Up Plan (CDF-BH)

•

To the extent possible, include all paid, suspended, pending, and denied claims.

•

Refer to the specific data-reporting template for the reporting requirements
applicable to each measure and to the Appendices in Volume 2 of this manual.

Measurement Period: The measurement period for both the denominator and the
numerator is the measurement year (e.g., for CCBHCs, DY1 or DY2).
B. DEFINITIONS
TERM

DEFINITION
Proposed outline of treatment to be conducted as a result of clinical
depression screening. Follow-up for a positive depression screening
must include one (1) or more of the following:
•

Additional evaluation

•

Suicide risk assessment

•

Referral to a practitioner who is qualified to diagnose and treat
depression

•

Pharmacological interventions

•

Other interventions or follow-up for the diagnosis or treatment of
depression

Follow-up Plan

Provider Entity

Screening

The documented follow-up plan must be related to positive
depression screening, for example: “Patient referred for psychiatric
evaluation due to positive depression screening.”
The provider entity that is being measured (i.e., BHC)
Completion of a clinical or diagnostic tool used to identify people at
risk of developing or having a certain disease or condition, even in
the absence of symptoms.
Screening tests can predict the likelihood of someone having or
developing a particular disease or condition. This measure looks for
the screening being conducted in the practitioner’s office that is filing
the code.

Screening for Clinical Depression and Follow-Up Plan (CDF-BH)

TERM

Standardized
Tool

DEFINITION
An assessment tool that has been appropriately normalized and
validated for the population in which it is being utilized. The name
of the age-appropriate standardized depression screening tool utilized
must be documented in the medical record. Some depression
screening tools are: Patient Health Questionnaire (PHQ-9); Beck
Depression Inventory (BDI or BDI-II); Center for Epidemiologic
Studies Depression Scale (CES-D); Depression Scale (DEPS); Duke
Anxiety-Depression Scale (DADS); Geriatric Depression Scale
(GDS); Hopkins Symptom Checklist (HSCL); The Zung Self-Rating
Depression Scale (SDS), and Cornell Scale Screening (this screening
tool is used in situations where the consumer has cognitive
impairment and is administered through the caregiver), and PRIME
MD-PHQ2.

C. ELIGIBLE POPULATION
CRITERIA

Age

REQUIREMENTS
Consumers aged 12 years and older on date of encounter.
Report three age stratifications:
•

12–17 years

•

18–64 years

•

65 years and older

Follow the steps below to identify the eligible population:

Event/Diagnosis

Step 1
Identify consumers flagged as having been an outpatient visit at the
provider entity at least once during the measurement year according
to the codes (Current Procedural Terminology [CPT®] and
Healthcare Common Procedure Coding System [HCPCS])
identifying outpatient visits according to Table CDF-A in Appendix
CDF-BH.B.
Step 2
Identify consumers from step 1 who were aged 12 years and older on
the date of the encounter.

Screening for Clinical Depression and Follow-Up Plan (CDF-BH)

D. HYBRID SPECIFICATION
Denominator
The number of consumers in the eligible population (Section C) with an outpatient visit
during the measurement year (refer to Table CDF-A in Appendix CDF-BH.B).
Numerator
The number of consumers who were screened for clinical depression using a standardized
tool AND, if positive, a follow-up plan is documented on the date of the positive screen
using one of the codes in Table CDF-B in Appendix CDF-BH.B.
Note: Providers should indicate deviations from the measure specifications if they choose
to use the hybrid method to identify numerator cases.
Exclusions
Exclude consumers if one or more of the following conditions are documented in the
patient medical record:
•

Consumer has an active diagnosis of Depression or Bipolar Disorder (see Table
CDF-C in Appendix CDF-BH.B)

•

Consumer refuses to participate

•

Consumer is in an urgent or emergent situation where time is of the essence and
to delay treatment would jeopardize the consumer’s health status

•

Situations where the consumer’s functional capacity or motivation to improve
may impact the accuracy of results of nationally recognized standardized
depression assessment tools (for example, certain court-appointed cases or cases
of delirium).

In addition, use the codes in Table CDF-C in Appendix CDF-BH.B to identify G codes
indicating rationales for not screening or not providing follow-up.
Example Calculation: See Appendix CDF-BH.A.
E. ADDITIONAL NOTES
The source measure is designed for the Medicaid population and is not risk adjusted. The
source measure was specified and tested at the health plan level. This measure is
modified to require clinic-level reporting, and to be consistent in format with other
measures in this set of BHC measures, but is not tested at the clinic level.
Interpretation of score: Better quality = Higher score

Depression Remission at Twelve Months (DEP-REM-12)

Depression Remission at Twelve Months (DEP-REM-12)
Based on a measure stewarded by Minnesota Community Measurement (NQF #0710, PQRS
#370)
A. DESCRIPTION
Adult consumers 18 years of age or older with Major Depression or Dysthymia who
reached remission 12 months (± 30 days) after an index visit. This measure applies to
consumers with both newly diagnosed and existing Depression whose current PHQ-9
score indicates a need for treatment.
Data Collection Method: Medical Records
Guidance for Reporting:
•

This measure is stratified by whether the consumer is a Medicaid beneficiary,
eligible for both Medicare and Medicaid, and other.

•

This measure is to be reported once per reporting period for consumers seen
during the denominator identification measurement period with a diagnosis of
Depression and an initial PHQ-9 greater than nine.

•

These measures apply to consumers who are diagnosed with Major Depression or
Dysthymia; either newly diagnosed or existing.

•

Referenced Value Sets are available from the source measure steward’s website at
the Cycle A DDS Guides page on the MN Community Measurement.

•

Refer to the specific data-reporting template for the reporting requirements
applicable to each measure and to the Appendices in Volume 2 of this manual.

Measurement Period: The measurement period for the denominator is the measurement
year (e.g., for CCBHCs, DY1 or DY2), but it starts for each person at their individual
index date. The measurement period for the numerator runs from the index date for the
individual during the measurement year to the point 12 months after (± 30 days).

Depression Remission at Twelve Months (DEP-REM-12)

B. DEFINITIONS
TERM

DEFINITION
An index visit occurs when ALL of the following criteria
are met:
• A PHQ-9 result greater than nine
• An active diagnosis of Major Depression or
Dysthymia** (Major Depression or Dysthymia Value
Set)
• The patient is NOT in a prior index period

Index Date

Provider Entity

PHQ-9

Remission

Twelve Months

An index period begins with an index visit and is 13
months in duration.
**For behavioral health providers only: The diagnosis of
Major Depression or Dysthymia must be the primary
diagnosis.
Note: This distinction between behavioral health providers
and other providers is only meaningful for BHCs that
include non-behavioral health healthcare providers who
may screen for depression as a part of providing general
health care.
The provider entity that is being measured (i.e., BHC)
The Patient Health Questionnaire (PHQ-9) tool is a widely
accepted, standardized tool that is completed by the
consumer, ideally at each visit, and utilized by the provider
to monitor treatment progress. It is available in many
languages and was developed by Drs. Robert L. Spitzer,
Janet B.W. Williams, Kurt Kroenke, et al. It is available at
Patient Health Questionnaire (PHQ-9).
A PHQ-9 score of less than five
The point in time from the index date in the measurement
period that a patient meets the inclusion criteria (diagnosis
and elevated PHQ-9 > 9) extending out twelve months and
then allowing a grace period of thirty days prior to and
thirty days after this date. Any PHQ-9 less than five
obtained during this 60 day period is deemed remission at
12 months; values obtained prior to or after this period are
not counted as numerator compliant (remission).

Depression Remission at Twelve Months (DEP-REM-12)

C. ELIGIBLE POPULATION
CRITERIA
Age

Event/Diagnosis

REQUIREMENTS
Consumers 18 years of age or older at the index visit
Follow the steps below to identify the eligible population:
Step 1
Identify consumers seen at the provider entity at least once
during the measurement year.
Step 2
Identify consumers from step 1 who have a diagnosis of
Major Depression or Dysthymia during an outpatient
encounter during the measurement year (Major Depression
or Dysthymia Value Set).
Note: For behavioral health providers, the Depression or
dysthymia diagnosis codes must be listed as the primary
diagnosis. This excludes patients with other psychiatric
diagnoses with a secondary component of Depression. If
the provider is primary care, the diagnosis codes can be in
any position (this might occur if the patient was diagnosed
by a primary care provider and subsequently seen by the
BHC). This distinction between behavioral health providers
and other providers is only meaningful for BHCs that
include non-behavioral health healthcare providers who may
screen for depression as a part of providing general health
care.
Step 3
Identify consumers from step 2 who have an index date
PHQ-9 score greater than 9 documented during the twelvemonth denominator identification period (code G9511).
Step 4
Identify consumers from step 3 who are aged 18 years and
older at the index date.
Note: To be considered denominator eligible for this
measure, the consumer must have both the diagnosis of
Major Depression or Dysthymia and an index date PHQ-9
score greater than 9 documented at the same encounter
during the dates of denominator identification measurement
period.

Depression Remission at Twelve Months (DEP-REM-12)

D. MEDICAL RECORD SPECIFICATION
Denominator
The number of consumers in the eligible population (Section C)
Note: The measurement period for the denominator is the measurement year, but it starts
for each person at their individual index date.
Numerator
The number of consumers in the eligible population who achieved remission with a PHQ9 result less than 5, 12 months (± 30 days) after an index visit
Numerator Options: The options below indicate the coding possibilities related
to the numerator. The first, where performance is met, indicate situations where
the data point is included in the numerator. The second, where performance is not
met, means that the data point is excluded from the numerator.
Performance Met: Remission at twelve months as demonstrated by a
twelve month (+/-30 days) PHQ-9 score of less than 5 (G9509 or
equivalent record of score)
OR
Performance Not Met: Remission at twelve months not demonstrated by
a twelve month (+/-30 days) PHQ-9 score of less than five. Either PHQ-9
score was not assessed during the allowed time period or is greater than or
equal to 5 (G9510 or equivalent record of score)
Note: The measurement period for the numerator runs from the index date for the
individual during the measurement year to the point 12 months after (± 30 days).
Required Exclusions
The following exclusions must be applied to the eligible population:
•

Consumer had an active diagnosis of Bipolar Disorder (Bipolar Disorder Value
Set)

•

Consumer had an active diagnosis of Personality Disorder (Personality Disorder
Value Set)

For consumers with bipolar disorder or personality disorder diagnoses, those
diagnoses can be in any position (primary, secondary, etc.).
Optional Exclusions: The following exclusions are allowed to be applied to the eligible
population:
98

Depression Remission at Twelve Months (DEP-REM-12)

•

Consumer was a permanent nursing home resident at any time during the
measurement year

•

Consumer was in hospice or receiving palliative care at any time during the
measurement year

•

Consumer died prior to the end of the measurement year

Example Calculation
See Appendix DEP-REM-12.
E. ADDITIONAL NOTES
Both this measure and the source measure were specified at the provider level. Neither is
risk adjusted. This measure is modified from the source measure to provide a
specification consistent in format to other measures in this set of BHC measures. The
substance of the measure is unchanged.
Interpretation of score: Better quality = Higher score

TECHNICAL SPECIFICATIONS -- STATE-REPORTED
MEASURES

100

Housing Status (HOU)

Housing Status (HOU)
SAMHSA-Developed Metric
A. DESCRIPTION
Percentage of consumers in 10 categories of living situation
Data Collection Method: Uniform Reporting System (URS) data
Guidance for Reporting:
•

These data are reported in aggregate by the states as part of the URS and are
broken into 10 categories of living situations. As part of the URS, they are
reported in Table 15 of the URS Tables; for the Mental Health Block Grants, they
are reported in Table 19 of the MHBG Report Tables on the URS & CLD Forms
and Information page on NRI website. For purposes of this measure, the state
will report by provider entity.

•

For the purposes of this metric, the data should be collected at least twice during
the measurement year, including at admission (intake) and/or discharge where
relevant. When collected at a point other than admission or discharge, the living
situation should be the one reported at the last assessment of housing status during
the measurement period.

•

Refer to the specific data-reporting template for the reporting requirements
applicable to each measure and to the Appendices in Volume 2 of this manual.

Measurement Period: The measurement period is the measurement year, divided into
two equal parts.

101

Housing Status (HOU)

B. DEFINITIONS
TERM

Living Situation

DEFINITION
As used in the URS, living situation describes the type of
residence in which the consumer resided. The specific living
situations include:
•

Private Residence: Consumer lives in a house, apartment,
trailer, hotel, dorm, barrack, or Single Room Occupancy
(SRO).

•

Foster Home: Consumer resides in a Foster Home. A Foster
Home is a home that is licensed by a County or State
Department to provide foster care to children, adolescents,
and/or adults. This includes Therapeutic Foster Care
Facilities. Therapeutic Foster Care is a service that provides
treatment for troubled children within private homes of
trained families.

•

Residential Care: Consumer resides in a residential care
facility. This level of care may include a Group Home,
Therapeutic Group Home, Board and Care, Residential
Treatment, or Rehabilitation Center, or Agency-operated
residential care facilities.

•

Crisis Residence: Consumer resides in a residential (24
hours/day) stabilization program that delivers services for
acute symptom reduction and restores consumers to a precrisis level of functioning. These programs are time limited
for consumers until they achieve stabilization. Crisis
residences serve persons experiencing rapid or sudden
deterioration of social and personal conditions such that they
are clinically at risk of hospitalization but may be treated in
this alternative setting.

102

Housing Status (HOU)

TERM

Living Situation
(cont’d)

DEFINITION
• Children’s Residential Treatment Facility: Consumer resides
in a Children and Youth Residential Treatment Facility
(RTF). RTFs provide fully integrated mental health
treatment services to seriously emotionally disturbed
children and youth. RTFs are an organization, not licensed
as a psychiatric hospital, whose primary purpose is the
provision of individually planned programs of mental health
treatment services in conjunction with residential care for
children and youth. The services are provided in facilities
which are certified by state or federal agencies or through a
national accrediting agency.
•

Institutional Setting: Consumer resides in an institutional
care facility with care provided on a 24-hour 7 day a week
basis. This level of care may include a Skilled
Nursing/Intermediate Care Facility, Nursing Homes,
Institutes of Mental Disease (IMD), Inpatient Psychiatric
Hospital, Psychiatric Health Facility (PHF), Veterans Affairs
Hospital, or State Hospital.

•

Jail/ Correctional Facility: Consumer resides in a Jail and/or
Correctional facility with care provided on a 24-hour, 7 day a
week basis. This level of care may include a Jail,
Correctional Facility, Detention Centers, Prison, Youth
Authority Facility, Juvenile Hall, Boot Camp, or Boys
Ranch.

103

Housing Status (HOU)

TERM

Living Situation
(cont’d)

DEFINITION
• Homeless: A person should be counted in the “Homeless”
category if he/she was reported homeless at their most recent
(last) assessment during the reporting period (or at discharge
for patients discharged during the year). The “last”
Assessment could occur at Admission, Discharge, or at some
point during treatment. A person is considered homeless if
he/she lacks a fixed, regular, and adequate nighttime
residence and/or his/her primary nighttime residency is:
A) A supervised, publicly or privately operated shelter designed
to provide temporary living accommodations,
B) An institution that provides a temporary residence for
consumers intended to be institutionalized, or
C) A public or private place not designed for, or ordinarily used
as, a regular sleeping accommodation for human beings
(e.g., on the street).

Provider Entity
Uniform
Reporting System
(URS)

•

Other: Consumer resides in any other living situation not
expressly included above.

•

Unavailable: Information on a consumer’s residence is not
available.

The provider entity that is being measured (i.e., BHC)
The URS is used by SAMHSA to collect uniform reporting of
state-level data to describe the public mental health system and
the outcomes of that system’s programs.

C. ELIGIBLE POPULATION
CRITERIA
Age

REQUIREMENTS
Consumers of all ages

D. SPECIFICATION
The following specification details how the state should ask to receive the data on
measure of living situation from the provider entity:
Denominator
The number of consumers seen during each measurement period (Section C)
104

Housing Status (HOU)

Numerator
The number of consumers in each living situation based on their most recent assessment
or on the most recent available information on record during the measurement period.
For people with two or more living situations during the measurement period (one half
year), report only the last known living situation. The last assessment could occur at
admission, discharge, or at some point during treatment.second measurement period.
Note: The intention here is to continue reporting on the URS or MHBG tables as has
been done in the past. Hence, if a person is only seen in the first measurement period,
they will be excluded from the count in the second measurement period.
Example Calculation
See Appendix HOU to this metric for an example of how the state should require the data
be reported by the provider entity.
E. ADDITIONAL NOTES
For these data to be meaningful, the provider entity must actually assess the living
situation of each consumer at least twice a year.

105

Suicide Attempts (SU-A)

Suicide Attempts (SU-A)
SAMHSA-Developed Metric
A. DESCRIPTION
The percentage of consumers aged 12 years and older who attempted suicide during the
measurement year, where the suicide attempt resulted in injury requiring medical services
Data Collection Method: Administrative
Guidance for Reporting:
•

This metric is stratified by age (12–17 years, 18–64 years, 65 years and older) and
by whether the consumer is a Medicaid beneficiary, eligible for both Medicare
and Medicaid, and other.

•

Suicide attempts are defined here as those that are either fatal ones or non-fatal
ones that resulted in the use of medical services.

•

To the extent possible, include all paid, suspended, pending, and denied claims.

•

Refer to the specific data-reporting template for the reporting requirements
applicable to each measure and to the Appendices in Volume 2 of this manual.

Measurement Period: The measurement period for the denominator is the first 11
months of the measurement year. The measurement period for the numerator is the
measurement year.
B. DEFINITIONS
TERM

DEFINITION

Injury Requiring
Medical Services

Physical injury related to the suicide attempt for which
medical services were obtained

Provider Entity

The provider entity that is being measured (i.e., BHC)

Suicide Attempt

A self-directed, potentially injurious behavior with any
intent to die as a result of the behavior, whether the
person dies as a result or not

106

Suicide Attempts (SU-A)

C. ELIGIBLE POPULATION
CRITERIA

REQUIREMENTS
Consumers aged 12 years and older as of the first
encounter at the provider entity during the
measurement year
Report three age stratifications and a total rate:

Age

•

12–17 years

•

18–64 years

•

65 years and older

•

Benefits

Event/Diagnosis

Total (all age groups)
Medical
Follow the steps below to identify the eligible
population:
Step 1
Identify consumers flagged as having been seen at the
provider entity at least once during the first 11 months
of the measurement year.
Step 2
Identify consumers from step 1 aged 12 years and older
as of the first encounter at the provider entity during the
measurement year.

D. ADMINISTRATIVE SPECIFICATION
Denominator
The number of consumers in the eligible population (Section C)
Note: The measurement period for the denominator is the first 11 months of the
measurement year.
Numerator
The number of consumers in the eligible population who attempted suicide at least once
during the measurement year, where the suicide attempt resulted in injury
requiring medical services during the measurement year
An eligible suicide attempt must be evidenced by consumer receipt of medical
services in an outpatient, intensive outpatient, partial hospitalization, emergency

107

Suicide Attempts (SU-A)

department (ED), nonacute inpatient, or acute inpatient setting, with one of more
of the following:
•

International Classification of Diseases, Tenth Revision, Clinical
Modification (ICD-10-CM) ICD-10-CM Codes from Tables 1–3 of
Appendix SU-A

•

ICD-10-CM Suicidal Ideation Code R45851 and any ICD-10-CM
Indicating Physical Injury

•

ICD-10-CM Suicide Attempt Code T1491

Application of the ICD-10-CM codes referred to above should be taken as
evidence of injury requiring medical services.
Note: Only one suicide attempt per consumer should be counted towards the numerator.
Note: The measurement period for the numerator is the measurement year.
Exclusions
None.
E. ADDITIONAL NOTES
This measure is designed to require provider-level reporting but is not tested at the
provider level.
This measure has limitations. Complete accuracy depends on knowledge of consumer
intent and accurate coding that reflects suicidality. This measure also only captures
suicide attempts that result in billing for services and does not include some individuals
who die before receiving any medical services.
Interpretation of score: Better quality = Lower score. The goal is zero.

108

Patient Experience of Care Survey (PEC)

Patient Experience of Care Survey (PEC)
SAMHSA-Developed Metric
A. DESCRIPTION
Annual completion and submission of Mental Health Statistics Improvement Program
(MHSIP) Adult Consumer Experience of Care Survey, identifying results separately for
BHCs and comparison clinics and oversampling those clinics
Data Collection Method: MHSIP Survey
Guidance for Reporting:
•

Results of the MHSIP generally are not reported unless the survey is statewide
and the sample size is sufficient to be statistically meaningful, and states are
directed not to report results from only a few providers or one region. For
purposes of the CCBHC Demonstration Program, however, states will have
specific responsibilities. States are to continue sampling as they presently do,
using the same version of the MHSIP as they do at present. States, however, are
asked to make the following modifications:
o If not already doing so, modify procedures to allow reporting by CCBHC and
comparison clinics specifically.
o Oversample CCBHCs and comparison clinics in order to generate sufficient
sample size, specifically reaching out to 300 consumers per CCBHC and
comparison clinic.
o States will submit the results aggregated at the CCBHC and comparison clinic
level as part of CCBHC data reporting using Tables 11 and 11a of the URS
reporting template that is current at time of the survey and that may be found
at URS & CLD Forms and Information page on NRI website (Table 22A for
the Mental Health Block Grant), including required information on sampling
methodology and response rates. This report will be provided separately from
that already compiled by the state to allow analysis of only those data
pertinent to the Demonstration Program.

•

Refer to the specific data-reporting template for the reporting requirements
applicable to each measure and to the Appendices in Volume 2 of this manual.

109

Patient Experience of Care Survey (PEC)

Measurement Period: The measurement period for both the denominator and
numerator is the measurement year, with the survey to be performed as part of the state’s
existing survey.
B. DEFINITIONS
TERM

Adult Consumer
Experience of
Care Survey

Mental Health
Statistics
Improvement
Program
(MHSIP)
Provider Entity
Uniform
Reporting System
(URS)

DEFINITION
The Mental Health Statistics Improvement Program (MHSIP)
Adult Consumer Experience of Care Survey is used to collect
data on adult behavioral health consumer experience of care.
The official version and instructions are found at URS & CLD
Forms and Information page on NRI website. Some states have
customized this survey, and instructions on the site address that
circumstance.
The MHSIP Consumer Surveys measure concerns that are
important to consumers of publicly funded mental health
services in the areas of Access, Quality/Appropriateness,
Outcomes, Overall Satisfaction, and Participation in Treatment
Planning
The provider entity that is being measured (i.e., BHC)
The URS is used by SAMHSA to collect uniform reporting of
state-level data to describe the public mental health system and
the outcomes of that system’s programs

C. ELIGIBLE POPULATION
CRITERIA
Age

REQUIREMENTS
Consumers aged 18 years or older at the time of survey

D. SPECIFICATION
For purposes of the CCBHC Demonstration Program, results for CCBHCs and
comparison clinics should be submitted in a way that permits distinction between each
CCBHC and each comparison clinic, with oversampling of those provider entities.

110

Youth/Family Experience of Care Survey (Y/FEC)

Youth/Family Experience of Care Survey (Y/FEC)
SAMHSA-Developed Metric
A. DESCRIPTION
Annual completion and submission of Youth/Family Services Survey for Families (YSSF) Experience of Care Survey, identifying results separately for BHCs and comparison
clinics and oversampling those clinics
Data Collection Method: YSS-F Survey
Guidance for Reporting:
•

Results of the YSS-F generally are not reported unless the survey is statewide and
the sample size is sufficient to be statistically meaningful, and states are directed
not to report results from only a few providers or one region. For purposes of the
CCBHC Demonstration Program, however, states will have specific
responsibilities. States are to continue sampling as they presently do, using the
same version of the MHSIP as they do at present. States, however, are asked to
make the following modifications:
o If not already doing so, modify procedures to allow reporting by CCBHC and
comparison clinics specifically.
o Oversample CCBHCs and comparison clinics in order to generate sufficient
sample size, specifically reaching out to 300 consumers per CCBHC and
comparison clinic.

•

States will submit the results aggregated at the CCBHC and comparison clinic
level as part of CCBHC data reporting using Tables 11 and 11a of the URS
reporting template that is current at time of the survey and which may be found at
http://www.nri-inc.org/#!urs-forms--info/c1xvm (Table 22B for the Mental Health
Block Grant), including required information on sampling methodology and
response rates. This report will be provided separately from that already
compiled by the state to allow analysis of only those data pertinent to the
Demonstration Program.

•

Refer to the specific data-reporting template for the reporting requirements
applicable to each measure and to the Appendices in Volume 2 of this manual.

Measurement Period: The measurement period for both the denominator and numerator
is the measurement year.
111

Youth/Family Experience of Care Survey (Y/FEC)

B. DEFINITIONS
TERM

DEFINITION

YSS-F Experience
of Care Survey

The YSS-F Experience of Care Survey is used to collect data on
youth and family behavioral health consumer experience of care.
The official version and instructions are found at URS & CLD
Forms and Information page on NRI website.. Some states have
customized this survey, and the instructions on this site also
address that circumstance.
The provider entity that is being measured (i.e., BHC)
The URS is used by SAMHSA to collect uniform reporting of
state-level data to describe the public mental health system and
the outcomes of that system’s programs.

Provider Entity
Uniform
Reporting System
(URS)

C. ELIGIBLE POPULATION
CRITERIA
Age

REQUIREMENTS
Consumers aged 17 years or younger at the time of survey

D. SPECIFICATION
For purposes of the Demonstration Program, results for CCBHCs and comparison clinics
should be submitted in a way that permits distinction between each CCBHC and each
comparison clinic, with oversampling of those provider entities.

112

Follow-up After Emergency Department Visit for Mental Illness (FUM)
Please see NCQA Notice of Copyright and Disclaimers in front matter to this manual.

Follow-up After Emergency Department Visit for Mental Illness (FUM)
Based on measure stewarded by the
National Committee for Quality Assurance (Draft HEDIS 2017)
A. DESCRIPTION
The percentage of emergency department (ED) visits for consumers 6 years of age and
older with a primary diagnosis of mental illness, who had an outpatient visit, an intensive
outpatient encounter or a partial hospitalization for mental illness. Two rates are reported:
1. The percentage of ED visits for which the consumer received follow-up within
30 days of the ED visit.
2. The percentage of ED visits for which the consumer received follow-up within
7 days of the ED visit.
Data Collection Method: Administrative
Guidance for Reporting:
•

•

When initially required of the CCBHCs, the Follow-Up After Discharge from the
Emergency Department for Mental Health or Alcohol or Other Dependence (NQF
# 2605) was intended. Because that measure (which included two rates (30 and 7
day follow-up) for each of mental illness and AOD dependence) has not been
maintained and is being replaced with two measures for HEDIS 2017 use which
separate mental illness and AOD dependence with two rates each, the
specifications in this manual rely on the separate draft 2017 HEDIS measures.
This measure is stratified by whether the consumer is a Medicaid beneficiary,
eligible for both Medicare and Medicaid, and other. For purposes of determining
whether a consumer is a Medicaid beneficiary or a dual Medicare and Medicaid
enrollee, see Continuous Enrollment, Allowable Gap, and Anchor Date
requirements below in section C.
Referenced Value Sets may be found in the Healthcare Effectiveness Data and
Information Set (HEDIS) specifications Volume 2. Value Sets are available at
NCQA HEDIS 2016

113

Follow-up After Emergency Department Visit for Mental Illness (FUM)
Please see NCQA Notice of Copyright and Disclaimers in front matter to this manual.

•

Refer to the specific data-reporting template for the reporting requirements
applicable to each measure and to the Appendices in Volume 2 of this manual.

Measurement Period: The measurement period for the denominator is the measurement
year (e.g., for CCBHCs, DY1 or DY2) absent the last 30 days of the measurement year.
The measurement period for the numerator is the measurement year.
B. DEFINITIONS
TERM
Provider Entity

DEFINITION
The provider entity that is being measured (i.e., BHC)

C. ELIGIBLE POPULATION
CRITERIA
Age
Continuous Enrollment
Allowable Gap
Anchor Date
Benefits

REQUIREMENTS
Consumers aged 6 years and older as of the date of the
ED visit
Date of ED visit through 30 days after the ED visit
No gaps in enrollment
None
Medical and mental health

114

Follow-up After Emergency Department Visit for Mental Illness (FUM)
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CRITERIA

REQUIREMENTS
Follow the steps below to identify the eligible
population:
Step 1
Identify consumers flagged as having been seen at the
provider entity during the measurement year.
Step 2
Identify consumers from step 1 who were aged 6 years
and older as of the date of the ED visit.

Event/Diagnosis

Step 3
Identify consumers from step 2 who had an ED visit
(ED Value Set) with a primary diagnosis of mental
illness (Mental Illness Value Set) on or between the first
day of the measurement year and the last day of the
measurement year (less 30 days).
Note: The denominator for this measure is based on ED
visits, not on consumers. If a consumer has more than
one ED visit, include all ED visits between the first day
of the measurement year and the last day of the
measurement year (less 30 days).
Note: If a consumer has more than one ED visit in a
30-day period, include only the last ED visit in each 30day period.

D. ADMINISTRATIVE SPECIFICATION
Denominator
The number of ED visits by consumers in the eligible population (Section C)
Note: The measurement period for the denominator is the measurement year less the last
30 days of the measurement year.
Numerator
30-Day Follow-Up
An outpatient visit, intensive outpatient encounter or partial hospitalization, with any
practitioner, with a primary diagnosis of a mental health disorder within 30 days after the
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Follow-up After Emergency Department Visit for Mental Illness (FUM)
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ED visit. Include outpatient visits, intensive outpatient visits or partial hospitalizations
that occur on the date of the ED visit.
7-Day Follow-Up
An outpatient visit, intensive outpatient encounter or partial hospitalization, with any
practitioner, with a primary diagnosis of a mental health disorder within 7 days after the
ED visit. Include outpatient visits, intensive outpatient visits or partial hospitalizations
that occur on the date of the ED visit.
For both indicators, any of the following meet criteria for a follow-up visit:
•

A visit (FUH Stand Alone Visits Value Set) with a primary diagnosis of a
mental health disorder (Mental Health Diagnosis Value Set)

•

A visit (FUH Visits Group 1 Value Set and FUH POS Group 1 Value Set)
with a primary diagnosis of a mental health disorder (Mental Health
Diagnosis Value Set)

•

A visit (FUH Visits Group 2 Value Set and FUH POS Group 2 Value Set)
with a primary diagnosis of a mental health disorder (Mental Health
Diagnosis Value Set)

•

A visit to a behavioral healthcare facility (FUH RevCodes Group 1 Value Set)

•

A visit to a non-behavioral healthcare facility (FUH RevCodes Group 2 Value
Set) with a primary diagnosis of a mental health disorder (Mental Health
Diagnosis Value Set)

Follow-up After Emergency Department Visit for Mental Illness (FUM)
Please see NCQA Notice of Copyright and Disclaimers in front matter to this manual.

Note: These events are excluded from the measure because admission to the hospital or
transfer may prevent an outpatient follow-up visit from taking place.
Note: Organizations identify “transfers” using their own methods and confirm the acute
or nonacute inpatient care setting using the steps above.
E. ADDITIONAL NOTES
The source measure is designed for the Commercial, Medicaid, and Medicare population
and does not require risk adjustment. The source measure was specified and tested at the
health plan level. This measure is modified to require clinic-level reporting, and to be
consistent in format with other measures in this set of BHC measures, but is not tested at
the clinic level.
Interpretation of score: Better quality = Higher score

117

Follow-up After Emergency Department Visit for Alcohol and Other Drug Dependence (FUA)
Please see NCQA Notice of Copyright and Disclaimers in front matter to this manual.

Follow-up After Emergency Department Visit for Alcohol and Other Drug
Dependence (FUA)
Based on measure stewarded by the
National Committee for Quality Assurance (Draft HEDIS 2017)
A. DESCRIPTION
The percentage of emergency department (ED) visits for consumers 13 years of age and
older with a primary diagnosis of alcohol or other drug (AOD) dependence, who had an
outpatient visit, an intensive outpatient encounter or a partial hospitalization for AOD.
Two rates are reported:
1. The percentage of ED visits for which the consumer received follow-up within
30 days of the ED visit.
2. The percentage of ED visits for which the consumer received follow-up within
7 days of the ED visit.
Data Collection Method: Administrative
Guidance for Reporting:
•

•

This measure is stratified by whether the consumer is a Medicaid beneficiary,
eligible for both Medicare and Medicaid, and other. For purposes of determining
whether a consumer is a Medicaid beneficiary or a dual Medicare and Medicaid
enrollee, see Continuous Enrollment, Allowable Gap, and Anchor Date
requirements below in section C.

•

Referenced Value Sets may be found in the Healthcare Effectiveness Data and
Information Set (HEDIS) specifications Volume 2. Value Sets are available at
NCQA HEDIS 2016

118

Follow-up After Emergency Department Visit for Alcohol and Other Drug Dependence (FUA)
Please see NCQA Notice of Copyright and Disclaimers in front matter to this manual.

•

Refer to the specific data-reporting template for the reporting requirements
applicable to each measure and to the Appendices in Volume 2 of this manual.

DEFINITION
The provider entity that is being measured (i.e., BHC)

C. ELIGIBLE POPULATION
CRITERIA
Age
Continuous Enrollment
Allowable Gap
Anchor Date
Benefits

REQUIREMENTS
Consumers aged 13 years and older as of the date of the
ED visit
Date of ED visit through 30 days after the ED visit
No gaps in enrollment
None
Medical and chemical dependency
Note: Consumers with detoxification-only chemical
dependency benefits do not meet these criteria.

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Follow-up After Emergency Department Visit for Alcohol and Other Drug Dependence (FUA)
Please see NCQA Notice of Copyright and Disclaimers in front matter to this manual.

CRITERIA

Event/Diagnosis

Step 3
Identify consumers from step 2 who had an ED visit
(ED Value Set) with a primary diagnosis of AOD (AOD
Dependence Value Set) on or between the first day of
the measurement year and the last day of the
measurement year (less 30 days).
Note: The denominator for this measure is based on ED
visits, not on consumers. If a consumer has more than
one ED visit, include all ED visits between the first day
of the measurement year and the last day of the
measurement year (less 30 days).
Note: If a consumer has more than one ED visit in a
30-day period, include only the last ED visit in each 30day period.

D. ADMINISTRATIVE SPECIFICATION
Denominator
The number of ED visits by consumers in the eligible population (Section C)
Note: The measurement period for the denominator is the measurement year less the last
30 days of the measurement year.
Numerator
30-Day Follow-Up
An outpatient visit, intensive outpatient encounter or partial hospitalization, with any
practitioner, with a primary diagnosis of AOD within 30 days after the ED visit. Include
outpatient visits, intensive outpatient visits or partial hospitalizations that occur on the
date of the ED visit.
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Follow-up After Emergency Department Visit for Alcohol and Other Drug Dependence (FUA)
Please see NCQA Notice of Copyright and Disclaimers in front matter to this manual.

7-Day Follow-Up
An outpatient visit, intensive outpatient encounter or partial hospitalization, with any
practitioner, with a primary diagnosis of AOD within 7 days after the ED visit. Include
outpatient visits, intensive outpatient visits or partial hospitalizations that occur on the
date of the ED visit.
For both indicators, any of the following meet criteria for a follow-up visit:
•
•
•

IET Stand Alone Visits Value Set with a primary diagnosis of AOD (AOD
Dependence Value Set)
IET Visits Group 1 Value Set with IET POS Group 1 Value Set and a
primary diagnosis of AOD (AOD Dependence Value Set)
IET Visits Group 2 Value Set with IET POS Group 2 Value Set and a
primary diagnosis of AOD (AOD Dependence Value Set)

Note: Organizations may have different methods for billing intensive outpatient visits
and partial hospitalizations. Some methods may be comparable to outpatient billing, with
separate claims for each date of service; others may be comparable to inpatient billing,
with an admission date, a discharge date and units of service. Organizations whose billing
methods are comparable to inpatient billing may count each unit of service as an
individual visit. The unit of service must have occurred during the required period for the
rate (i.e., within 30 days after the ED visit or within 7 days after the ED visit).
Exclusions
ED visits followed by admission or direct transfer to an acute or nonacute inpatient care
setting within the 30-day follow-up period, regardless of primary diagnosis for the
admission. To identify admissions to an acute or nonacute inpatient care setting:
1. Identify all acute and nonacute inpatient stays (Inpatient Stay Value Set).
2. Identify the admission date for the stay.
Note: These events are excluded from the measure because admission to the hospital or
transfer may prevent an outpatient follow-up visit from taking place.
Note: Organizations identify “transfers” using their own methods and confirm the acute
or nonacute inpatient care setting using the steps above.
E. ADDITIONAL NOTES
The source measure is designed for the Commercial, Medicaid, and Medicare population
and does not require risk adjustment. The source measure was specified and tested at the
health plan level. This measure is modified to require clinic-level reporting, and to be
121

Follow-up After Emergency Department Visit for Alcohol and Other Drug Dependence (FUA)
Please see NCQA Notice of Copyright and Disclaimers in front matter to this manual.

consistent in format with other measures in this set of BHC measures, but is not tested at
the clinic level.
Interpretation of score: Better quality = Higher score

122

Plan All-Cause Readmissions Rate (PCR-BH)

Plan All-Cause Readmissions Rate (PCR-BH)
Based on a measure stewarded by the
National Committee for Quality Assurance (NQF #1768, HEDIS 2016)
A. DESCRIPTION
For consumers age 18 and older, the number of acute inpatient stays during the
measurement year that were followed by an unplanned acute readmission for any
diagnosis within 30 days. Data are reported in the following three categories:
•

Count of Index Hospital Stays (IHS) (denominator)

•

Count of 30-Day Readmissions (numerator)

•

Readmission Rate

Data Collection Method: Administrative
Guidance for Reporting:
•

This measure is stratified by age (aged 18 to 64 years, aged 65 years and older)
and by whether the consumer is a Medicaid beneficiary, eligible for both
Medicare and Medicaid, and other. For purposes of determining whether a
consumer is a Medicaid beneficiary or a dual Medicare and Medicaid enrollee,
see Continuous Enrollment, Allowable Gap, and Anchor Date requirements below
in section C.

•

This measure requires risk adjustment. However, there are no standardized risk
adjustment tables for Medicaid. Therefore, it is suggested that states report
unadjusted rates for this measure (Appendix PCR-BH, Columns 1, 2, and 3 in
Tables PCR-A and PCR-B) until a standardized risk adjustor is made available.

•

Referenced Value Sets may be found in the BHC Value Set Directory.

•

Include paid claims only.

•

Refer to the specific data-reporting template for the reporting requirements
applicable to each measure and to the Appendices in Volume 2 of this manual.

Measurement Period: The measurement period for the denominator is measured from
the discharge date and encompasses the measurement year (e.g., for CCBHCs, DY1 or
DY2) less the last 30 days. The measurement period for the numerator is the
measurement year.

123

Plan All-Cause Readmissions Rate (PCR-BH)

B. DEFINITIONS
TERM
Classification
Period
Index
Admission Date
Index Discharge
Date
Index Hospital
Stay (IHS)
Index
Readmission
Date
Index
Readmission
Stay
Planned
Hospital Stay
Provider Entity

DEFINITION
365 days prior to and including an Index Discharge Date
The IHS admission date
The IHS discharge date. The index discharge date must occur during
the measurement year less the last 30 days.
An acute inpatient stay with a discharge occur during the
measurement year less the last 30 days. Exclude stays that meet the
exclusion criteria in the denominator section
The admission date associated with the Index Readmission Stay
An acute inpatient stay for any diagnosis with an admission date
within 30 days of a previous Index Discharge Date
A hospital stay is considered planned if it meets criteria as described
in step 6 (required exclusions) of the Eligible Population
The provider entity that is being measured (i.e., BHC)

C. ELIGIBLE POPULATION
CRITERIA

REQUIREMENTS
Consumers aged 18 and older as of Index Discharge Date. Report
two age stratifications:

Age

•

Aged 18 to 64 years

•

Continuous
Enrollment
Allowable Gap
Anchor Date
Benefits

Aged 65 years and older
365 days prior to the Index Discharge Date through 30 days after the
Index Discharge Date
No more than one gap in enrollment of up to 45 days during the 365
days prior to the Index Discharge Date and no gap during the 30 days
following the Index Discharge Date.
Index Discharge Date
Medical

124

Plan All-Cause Readmissions Rate (PCR-BH)

CRITERIA

REQUIREMENTS
Follow the steps below to identify the eligible population:
Step 1
Identify consumers flagged as having been seen at the provider entity
at least once during the measurement year.
Step 2
Identify consumers from step 1 who were aged 18 years and older as
of the Index Discharge Date.
Step 3
Identify consumers from step 2 who experience an acute inpatient
discharge during the measurement year less the last 30 days.
To identify acute inpatient discharges:
1. Identify all acute and nonacute inpatient stays (Inpatient Stay
Value Set)
2. Exclude nonacute inpatient stays (Nonacute Inpatient Stay
Value Set
3. Identify the discharge date for the stay

Event/Diagnosis

Note: The measure includes acute discharges from any type of
facility (including behavioral healthcare facilities).
Note: Acute-to-Acute Transfers: Keep the original admission date as
the Index Admission Date, but use the transfer’s discharge date as the
Index Discharge Date. States must identify “direct transfers” using
their own methods and then confirm the acute inpatient care setting
using the process in step 3.
Step 4
From consumers identified in step 3, exclude hospital stays where the
Index Admission Date is the same as the Index Discharge Date.
Step 5
From consumers identified in step 4, exclude other hospital stays for
the following reasons:
• The consumer died during the stay
• A principal diagnosis of pregnancy (Pregnancy Value Set)
• A principal diagnosis of a condition originating in the
perinatal period (Perinatal Conditions Value Set)

125

Plan All-Cause Readmissions Rate (PCR-BH)

CRITERIA

REQUIREMENTS
Note: For hospital stays where there was an acute-to-acute transfer
(identified in step 3 (Note)), use both the original stay and the
transfer stay to identify exclusions in this step.
Step 6
For consumers identified in step 5, exclude planned readmissions as
identified below:
For all acute inpatient discharges identified using steps 1–5,
determine if there was a planned hospital stay within 30 days. To
identify planned hospital stays, identify all acute inpatient discharges
during the measurement year:

Event/Diagnosis
(cont'd)

Identify all acute and nonacute inpatient stays (Inpatient Stay
Value Set).

Exclude nonacute inpatient stays (Nonacute Inpatient Stay
Value Set).

Identify the admission date for the stay.

Exclude any hospital stay as an Index Hospital Stay if the
admission date of the first stay within 30 days meets any of
the following criteria:
• A principal diagnosis of maintenance chemotherapy
(Chemotherapy Value Set)
• A principal diagnosis of rehabilitation (Rehabilitation Value
Set)
• An organ transplant (Kidney Transplant Value Set, Bone
Marrow Transplant Value Set, Organ Transplant Other Than
Kidney Value Set)
• A potentially planned procedure (Potentially Planned
Procedure Value Set) without a principal acute diagnosis (Acute
Condition Value Set)

Note: For hospital stays where there was an acute-to-acute transfer
(identified in step 3 (Note)), use only the original stay to identify
planned hospital stays in this step (i.e., do not use diagnoses and
procedures from the transfer stay).
Example 1: For a consumer with the following acute inpatient stays,
exclude stay 1 as an Index Hospital Stay.

126

Plan All-Cause Readmissions Rate (PCR-BH)

CRITERIA

REQUIREMENTS
• Stay 1 (January 30–February 1 of the measurement year):
Acute inpatient discharge with a principal diagnosis of COPD
• Stay 2 (February 5–7 of the measurement year): Acute
inpatient discharge with a principal diagnosis of maintenance
chemotherapy
Example 2: For a consumer with the following acute inpatient stays,
exclude stays 2 and 3 as Index Hospital Stays in the following
scenario.
• Stay 1 (January 15–17 of the measurement year): Acute
inpatient discharge with a principal diagnosis of diabetes
• Stay 2 (January 30–February 1 of the measurement year):
Acute inpatient discharge with a principal diagnosis of COPD

Event/Diagnosis
(cont'd)

• Stay 3 (February 5–7 of the measurement year): Acute
inpatient discharge with an organ transplant
• Stay 4 (February 10–15 of the measurement year): Acute
inpatient discharge with a principal diagnosis of rehabilitation
Step 7
For consumers identified in step 6, calculate continuous enrollment.
Step 8
Assign each acute inpatient stay to an age category. Refer to Table
PCR-A and Table PCR-B in Appendix PCR-BH.
Note: The denominator for this measure is based on discharges, not
consumers. Include all acute inpatient discharges for consumers who
had one or more discharges on or between the first day of the
measurement year and the first day of the twelfth month of the
measurement year. The state should follow the steps above to identify
acute inpatient stays.

D. ADMINISTRATIVE SPECIFICATION
Denominator
The number of eligible discharges (Section C)

127

Plan All-Cause Readmissions Rate (PCR-BH)

Numerator
At least one acute readmission for any diagnosis within 30 days of the Index Discharge
Date.
Step 1
Identify all acute inpatient stays with an admission date on or between the second
day and the last day of the measurement year. To identify acute inpatient
admissions:
1. Identify all acute and nonacute inpatient stays (Inpatient Stay Value Set).
2. Exclude nonacute inpatient stays (Nonacute Inpatient Stay Value Set).
3. Identify the admission date for the stay.
Step 2
Acute-to-acute transfers: Keep the original admission date as the Index
Admission Date, but use the transfer’s discharge date as the Index Discharge
Date. States must identify “direct transfers” using their own methods and then
confirm the acute inpatient care setting using the steps above.
Step 3
Exclude acute inpatient hospital discharges with a principal diagnosis of
pregnancy (Pregnancy Value Set) or a principal diagnosis for a condition
originating in the perinatal period (Perinatal Conditions Value Set).
Step 4
For each IHS, determine if any of the acute inpatient stays had an admission date
within 30 days after the Index Discharge Date.
Reporting
Reporting: Denominator
Count the number of IHS and enter these values into the table in Appendix PCRBH.
Reporting: Numerator
Count the number of IHS with a readmission within 30 days and enter these
values into the table in Appendix PCR-BH.

128

Plan All-Cause Readmissions Rate (PCR-BH)

Reporting: Readmission Rate
This measure requires risk adjustment. However, there are no standardized risk
adjustment tables for Medicaid. Therefore, it is suggested that states report
unadjusted rates for this measure (Appendix PCR-BH, Columns 1, 2, and 3 in
Tables PCR-A and PCR-B) until a standardized risk adjustor is made available.
Note: Medicaid-specific risk adjustment tables are required to calculate columns
4, 5, and 6 in Tables PCR-A and PCR-B in Appendix PCR-BH.
E. ADDITIONAL NOTES
The source measure is designed for the Medicaid population and is not risk adjusted. The
source measure was specified and tested at the health plan level. This measure is
modified to require clinic-level reporting, and to be consistent in format with other
measures in this set of BHC measures, but is not tested at the clinic level.
Interpretation of score: Better quality = Higher score

129

Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic
Medications (SSD)
Please see NCQA Notice of Copyright and Disclaimers in front matter to this manual.

Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who
Are Using Antipsychotic Medications (SSD)
Based on a measure stewarded by the
National Committee for Quality Assurance (NQF #1932, HEDIS 2016)
A. DESCRIPTION
The percentage of consumers 18-64 years of age with schizophrenia or bipolar disorder,
who were dispensed an antipsychotic medication and had a diabetes screening test during
the measurement year
Data Collection Method: Administrative
Guidance for Reporting:
•

This measure is stratified by whether the consumer is a Medicaid beneficiary,
eligible for both Medicare and Medicaid, and other. For purposes of determining
whether a consumer is a Medicaid beneficiary or a dual Medicare and Medicaid
enrollee, see Continuous Enrollment, Allowable Gap, and Anchor Date
requirements below in section C.

•

Referenced Value Sets may be found in the Healthcare Effectiveness Data and
Information Set (HEDIS) specifications Volume 2. Value Sets are available at
NCQA HEDIS 2016

•

Refer to the specific data-reporting template for the reporting requirements
applicable to each measure and to the Appendices in Volume 2 of this manual.

Measurement Period: The measurement period for the denominator is the measurement
year and the year prior to the measurement year. The measurement period for the
numerator is the measurement year (e.g., for CCBHCs, DY1 or DY2).

130

Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic
Medications (SSD)
Please see NCQA Notice of Copyright and Disclaimers in front matter to this manual.

B. DEFINITIONS
TERM

DEFINITION

Antipsychotic
Medication
Dispensing
Events

A dispensed antipsychotic, as identified by claim/encounter data.
Antipsychotics are those identified on the National Committee for
Quality Assurance (NCQA) Healthcare Effectiveness Data and
Information Set (HEDIS) 2016 Final National Drug Code (NDC)
Lists webpage at HEDIS 2016 Final NDC Lists

Glucose Test

HbA1c Test
Provider Entity

A glucose test (Glucose Tests Value Set) performed during the
measurement year, as identified by claim/encounter or automated
laboratory data
An Hemoglobin A1c (HbA1c) test (HbA1c Tests Value Set)
performed during the measurement year, as identified by
claim/encounter or automated laboratory data
The provider entity that is being measured (i.e., BHC)

C. ELIGIBLE POPULATION
CRITERIA
Age
Continuous
Enrollment

Allowable Gap

Anchor Date
Benefits

REQUIREMENTS
Consumers aged 18–64 years as of the end of the measurement year
The measurement year
No more than one gap in enrollment of up to 45 days during the
measurement year. To determine continuous enrollment consumer
for whom enrollment is verified monthly, the consumer may not have
more than a 1-month gap in coverage (i.e., a consumer whose
coverage lapses for 2 months [60 days] is not considered
continuously enrolled).
The last day of the measurement year
Medical and pharmacy

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Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic
Medications (SSD)
Please see NCQA Notice of Copyright and Disclaimers in front matter to this manual.

CRITERIA

Event/Diagnosis

1. At least one acute inpatient encounter, with any diagnosis of
schizophrenia or bipolar disorder. Any of the following code
combinations meet criteria:
•

BH Stand Alone Acute Inpatient Value Set with
Schizophrenia Value Set

•

BH Stand Alone Acute Inpatient Value Set with Bipolar
Disorder Value Set

•

BH Stand Alone Acute Inpatient Value Set with Other
Bipolar Disorder Value Set

•

BH Acute Inpatient Value Set with BH Acute Inpatient
POS Value Set and Schizophrenia Value Set

•

BH Acute Inpatient Value Set with BH Acute Inpatient
POS Value Set and Bipolar Disorder Value Set

•

BH Acute Inpatient Value Set with BH Acute Inpatient
POS Value Set and Other Bipolar Disorder Value Set
OR

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Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic
Medications (SSD)
Please see NCQA Notice of Copyright and Disclaimers in front matter to this manual.

CRITERIA

REQUIREMENTS
2. At least two visits in an outpatient, intensive outpatient
(IOP), partial hospitalization (PH), emergency department
(ED), or nonacute inpatient setting, on different dates of
service, with any diagnosis of schizophrenia. Any two of the
following code combinations meet criteria:
• BH Stand Alone Outpatient/PH/IOP Value Set with
Schizophrenia Value Set
•

BH Outpatient/PH/IOP Value Set with BH
Outpatient/PH/IOP POS Value Set and Schizophrenia
Value Set

•

ED Value Set with Schizophrenia Value Set

•

BH ED Value Set with BH ED POS Value Set and
Schizophrenia Value Set

•

BH Stand Alone Nonacute Inpatient Value Set with
Schizophrenia Value Set

•

BH Nonacute Inpatient Value Set with BH Nonacute
Inpatient POS Value Set and Schizophrenia Value Set

Event/Diagnosis
(cont’d)

OR
3. At least two visits in an outpatient, intensive outpatient
(IOP), partial hospitalization (PH), ED, or nonacute inpatient
setting, on different dates of service, with any diagnosis of
bipolar disorder. Any two of the following code
combinations meet criteria:
•

BH Stand Alone Outpatient/PH/IOP Value Set with
Bipolar Disorder Value Set

•

BH Stand Alone Outpatient/PH/IOP Value Set with Other
Bipolar Disorder Value Set

•

BH Outpatient/PH/IOP Value Set with BH
Outpatient/PH/IOP POS Value Set and Bipolar Disorder
Value Set

•

BH Outpatient/PH/IOP Value Set with BH
Outpatient/PH/IOP POS Value Set and Other Bipolar
Disorder Value Set

133

Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic
Medications (SSD)
Please see NCQA Notice of Copyright and Disclaimers in front matter to this manual.

CRITERIA

Event/Diagnosis
(cont’d)

REQUIREMENTS
• ED Value Set with Bipolar Disorder Value Set
• ED Value Set with Other Bipolar Disorder Value Set
•

BH ED Value Set with BH ED POS Value Set and
Bipolar Disorder Value Set

•

BH ED Value Set with BH ED POS Value Set and Other
Bipolar Disorder Value Set

•

BH Stand Alone Nonacute Inpatient Value Set with
Bipolar Disorder Value Set

•

BH Stand Alone Nonacute Inpatient Value Set with Other
Bipolar Disorder Value Set

•

BH Nonacute Inpatient Value Set with BH Nonacute
Inpatient POS Value Set and Bipolar Disorder Value Set

•

BH Nonacute Inpatient Value Set with BH Nonacute
Inpatient POS Value Set and Other Bipolar Disorder
Value Set

Step 4
Identify and exclude consumers from step 3 who met any of the
following criteria:
1. Exclude consumers with diabetes. There are two ways to identify
consumers with diabetes: by claim/encounter data and by
pharmacy data. The reporting entity must use both methods to
identify consumers with diabetes, but a consumer need only be
identified by one method to be excluded from the measure.
Consumers may be identified as having diabetes during the
measurement year or the year prior to the measurement year.
- Claim/encounter data. Consumers who met any of the
following criteria during the measurement year or the year
prior to the measurement year (count services that occur over
both years)

134

Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic
Medications (SSD)
Please see NCQA Notice of Copyright and Disclaimers in front matter to this manual.

CRITERIA

REQUIREMENTS
• At least two outpatient visits (Outpatient Value Set),
observation visits (Observation Value Set), ED visits (ED
Value Set), or nonacute inpatient encounters (Nonacute
Inpatient Value Set) on different dates of service, with a
diagnosis of diabetes (Diabetes Value Set). Visit type
need not be the same for the two visits.
•

At least one acute inpatient encounter (Acute Inpatient
Value Set) with a diagnosis of diabetes (Diabetes Value
Set)

Event/Diagnosis
(cont’d)

2. Pharmacy data. Consumers who were dispensed insulin or oral
hypoglycemics/ antihyperglycemics during the measurement year
or year prior to the measurement year on an ambulatory basis
(See Table CDC-A on the NCQA HEDIS 2015 Final National
Drug Code (NDC) Lists webpage at: HEDIS 2016 Final NDC
Lists).
3. Consumers who had no antipsychotic medications dispensed
during the measurement year. There are two ways to identify
dispensing events: by claim/encounter data and by pharmacy
data. The reporting entity must use both methods to identify
dispensing events, but an event need only be identified by one
method to be counted.
-

Claim/encounter data. An antipsychotic medication (LongActing Injections Value Set)

Pharmacy data. Dispensed an antipsychotic medication on an
ambulatory basis. (See Table SSD-D on the NCQA website at
HEDIS 2016 Final NDC Lists for a current list of
antipsychotic medications).

Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic
Medications (SSD)
Please see NCQA Notice of Copyright and Disclaimers in front matter to this manual.

Numerator
The number of consumers who had one or more diabetes screenings (a glucose test
[Glucose Tests Value Set] or an HbA1c [HbA1c Tests Value Set]) performed during the
measurement year, as identified by claim/encounter or automated laboratory data
Note: The measurement period for the numerator is the measurement year.
Exclusions
See Step 4 in Section C above.
E. ADDITIONAL NOTES
The source measure is designed for the Medicaid population and is not risk adjusted. The
source measure was specified and tested at the health plan level. This measure is
modified to require clinic-level reporting, and to be consistent in format with other
measures in this set of BHC measures, but is not tested at the clinic level.
Interpretation of score: Better quality = Higher score

136

Diabetes Care For People With Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control (>9.0%)
(SMI-PC)
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Diabetes Care For People With Serious Mental Illness: Hemoglobin A1c
(HbA1c) Poor Control (>9.0%) (SMI-PC)
Based on a measure stewarded by the
National Committee for Quality Assurance (NQF #2607)
A. DESCRIPTION
The percentage of consumers 18–75 years of age with a serious mental illness and
diabetes (type 1 and type 2) whose most recent Hemoglobin A1c (HbA1c) level during
the measurement year is >9.0%
Data Collection Method: Administrative
Guidance for Reporting:


The source measure is adapted from an existing health plan measure used in a
variety of reporting programs for the general population (NQF #0059:
Comprehensive Diabetes Care: Hemoglobin A1c [HbA1c] Control >9.0%).
NQF #0059 is derived in turn from the Healthcare Effectiveness Data and
Information Set (HEDIS) Comprehensive Diabetes Care (CDC) measure.



This measure is stratified by whether the consumer is a Medicaid beneficiary,
eligible for both Medicare and Medicaid, and other. For purposes of
determining whether a consumer is a Medicaid beneficiary or a dual Medicare
and Medicaid enrollee, see Continuous Enrollment, Allowable Gap, and
Anchor Date requirements below in section C.



Referenced Value Sets may be found on the SAMHSA website.



Refer to the specific data-reporting template for the reporting requirements
applicable to each measure and to the Appendices in Volume 2 of this manual.

DEFINITION
Diabetes includes both type 1 and type 2 diabetes.
Hemoglobin A1c
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Diabetes Care For People With Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control (>9.0%)
(SMI-PC)
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TERM
Provider Entity
Serious Mental
Illness

DEFINITION
The provider entity that is being measured (i.e., BHC)
For purposes of this measure, Serious Mental Illness includes
schizophrenia, bipolar I disorder, or major depression.

C. ELIGIBLE POPULATION
CRITERIA
Age
Continuous
Enrollment

Allowable Gap

Anchor Date
Benefits

REQUIREMENTS
Consumers aged 18–75 years as of the end of the measurement
year
The measurement year and the year prior to the measurement year
No more than one gap in enrollment of up to 45 days during the
measurement year. To determine continuous enrollment for a
consumer for whom enrollment is verified monthly, the consumer
may not have more than a 1-month gap in coverage (i.e., a
consumer whose coverage lapses for 2 months [60 days] is not
considered continuously enrolled).
The last day of the measurement year
Medical

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Diabetes Care For People With Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control (>9.0%)
(SMI-PC)
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CRITERIA

REQUIREMENTS
Follow the steps below to identify the eligible population:
Step 1
Identify consumers flagged as having been seen at the provider
entity at least once during the measurement year.
Step 2
Identify consumers from step 1 who were aged 18–75 years as of
the end of the measurement year.
Step 3
Identify consumers from step 2 with a diagnosis of serious mental
illness. Consumers are identified as having serious mental illness
if they met at least one of the following criteria during the
measurement year:

Event/Diagnosis

1. At least one acute inpatient claim/encounter with any
diagnosis of schizophrenia, bipolar I disorder, or major
depression using any of the following code combinations:
•

BH Stand Alone Acute Inpatient Value Set with
Schizophrenia Value Set

•

BH Stand Alone Acute Inpatient Value Set with Bipolar
Disorder Value Set

•

BH Stand Alone Acute Inpatient Value Set with Major
Depression Value Set

•

BH Acute Inpatient Value Set with BH Acute Inpatient
POS Value Set and Schizophrenia Value Set

•

BH Acute Inpatient Value Set with BH Acute Inpatient
POS Value Set and Bipolar Disorder Value Set

•

BH Acute Inpatient Value Set with BH Acute Inpatient
POS Value Set and Major Depression Value Set
OR

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Diabetes Care For People With Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control (>9.0%)
(SMI-PC)
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CRITERIA

Event/Diagnosis
(con’t)

REQUIREMENTS
2. At least two visits in an outpatient, intensive outpatient (IOP),
partial hospitalization (PH), emergency department (ED), or
nonacute inpatient setting, on different dates of service, with
any diagnosis of schizophrenia. Any two of the following
code combinations meet criteria:
•

BH Stand Alone Outpatient/PH/IOP Value Set with
Schizophrenia Value Set

•

BH Outpatient/PH/IOP Value Set with BH
Outpatient/PH/IOP POS Value Set and Schizophrenia
Value Set

•

ED Value Set with Schizophrenia Value Set

•

BH ED Value Set with BH ED POS Value Set and
Schizophrenia Value Set

•

BH Stand Alone Nonacute Inpatient Value Set with
Schizophrenia Value Set

•

BH Nonacute Inpatient Value Set with BH Nonacute
Inpatient POS Value Set and Schizophrenia Value Set
OR

3. At least two visits in an outpatient, IOP, PH, ED, or nonacute
inpatient setting on different dates of service with a diagnosis
of bipolar I disorder. Any two of the following code
combinations meet criteria:
•

BH Stand Alone Outpatient/PH/IOP Value Set with
Bipolar Disorder Value Set

•

BH Outpatient/PH/IOP Value Set with BH
Outpatient/PH/IOP POS Value Set and Bipolar Disorder
Value Set

•

ED Value Set with Bipolar Disorder Value Set

•

BH ED Value Set with BH ED POS Value Set and Bipolar
Disorder Value Set

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Diabetes Care For People With Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control (>9.0%)
(SMI-PC)
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CRITERIA

REQUIREMENTS
• BH Stand Alone Nonacute Inpatient Value Set with
Bipolar Disorder Value Set
•

BH Nonacute Inpatient Value Set with BH Nonacute
Inpatient POS Value Set and Bipolar Disorder Value Set

Step 4
Identify consumers from step 3 with diabetes (Diabetes Value Set)
during the measurement year or the year prior to the measurement
year, using the following data:
1. Claim/encounter data: Had a diagnosis of diabetes during the
measurement year or the year prior to the measurement year on
claims for either of the following types of encounters:
•

Event/Diagnosis
(cont’d)

At least two outpatient visits (Outpatient Value Set),
observation visits (Observation Value Set), emergency
department (ED) visits (ED Value Set), or nonacute
inpatient encounters (Nonacute Inpatient Value Set) on
different dates of service with a diagnosis of diabetes
(Diabetes Value Set). Visit type need not be the same for
the two visits.
OR

•

At least one acute inpatient encounter (Acute Inpatient
Value Set) with a diagnosis of diabetes (Diabetes Value
Set)

OR
2. Pharmacy data: Were dispensed insulin or hypoglycemics/
antihyperglycemics on an ambulatory basis during the
measurement year or the year prior to the measurement year.
For prescriptions that can be used to identify consumers with
diabetes, refer to Table CDC-A on the NCQA HEDIS 2016
Final National Drug Code (NDC) Lists webpage at: HEDIS
2016 Final NDC Lists).
Note: The reporter must use both methods to identify the eligible
population, but a consumer only needs to be identified by one
method to be included in the measure.

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Diabetes Care For People With Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control (>9.0%)
(SMI-PC)
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D. ADMINISTRATIVE SPECIFICATION
Denominator
The number of consumers in the eligible population (Section C)
Note: The measurement period for the denominator is the measurement year and the year
prior to the measurement year.
Numerator
The number of consumers whose most recent HbA1c level is greater than 9.0% (poor
control) during the measurement year
Numerator Options: Either an Administrative or Medical Records data
source may be used.
Administrative:
Use codes (HbA1c Tests Value Set) to identify the most recent HbA1c test during
the measurement year. The patient is numerator compliant if the most recent
HbA1c level is >9.0% or is missing a result, or if an HbA1c test was not done
during the measurement year. The patient is not numerator compliant if the result
for the most recent HbA1c test during the measurement year is ≤9.0%.
Organizations that use Current Procedural Terminology (CPT ® ) Category II
codes to identify numerator compliance for this indicator must search for all codes
in the following value sets and use the most recent code during the measurement
year to evaluate whether the patient is numerator compliant.
Value Set

Numerator Compliance

HbA1c Level Less Than 7.0 Value Set

Not compliant

HbA1c Level 7.0–9.0 Value Set

Not compliant

HbA1c Level Greater Than 9.0 Value
Set

Compliant

Medical Records:
At a minimum, documentation in the medical record must include a note
indicating the date when the HbA1c test was performed and the result. The patient
is numerator compliant if the result for the most recent HbA1c level during the
measurement year is >9.0% or is missing, or if an HbA1c test was not done
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Diabetes Care For People With Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control (>9.0%)
(SMI-PC)
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during the measurement year. The patient is not numerator compliant if the most
recent HbA1c level during the measurement year is ≤9.0%.
Ranges and thresholds do not meet criteria for this indicator. A distinct numeric
result is required for numerator compliance.
Note: This numerator represents a reversal of the pattern for most measures, where
compliance would be a positive outcome and better quality would be associated with a
higher score. In this measure, HbA1c levels >9.0% (poor control) and failure to perform
the test or report the score are considered numerator compliant because they reflect a
failure to control, test, or report this outcome.
Note: The measurement period for the numerator is the measurement year.
Exclusions: Consumers who do not have a diagnosis of diabetes (Diabetes Value Set), in
any setting, during the measurement year or year prior to the measurement year and who
meet either of the following criteria:
•

A diagnosis of polycystic ovaries (Polycystic Ovaries Value Set), in any
setting, any time during the consumer’s history through the end of the
measurement year
OR

•

A diagnosis of gestational diabetes or steroid-induced diabetes (Diabetes
Exclusions Value Set), in any setting, during the measurement year or the year
prior to the measurement year.

E. ADDITIONAL NOTES
The source measure is designed for the Medicaid population and is not risk adjusted. The
source measure was specified and tested at the health plan level. This measure is
modified to require clinic-level reporting, and to be consistent in format with other
measures in this set of BHC measures, but is not tested at the clinic level.
Interpretation of score: Better quality = Lower score

143

Metabolic Monitoring for Children and Adolescents on Antipsychotics (AP)
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Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM)
Based on a measure stewarded by the
National Committee for Quality Assurance (HEDIS 2016)
A. DESCRIPTION
The percentage of children and adolescents aged 1–17 years who had two or more
antipsychotic prescriptions and had metabolic testing
Data Collection Method: Administrative
Guidance for Reporting:
•

This measure is stratified by whether the consumer is a Medicaid beneficiary,
eligible for both Medicare and Medicaid, and other. The total denominator
also is stratified by age (1-5, 6-11, 12-17, and total). For purposes of
determining whether a consumer is a Medicaid beneficiary or a dual Medicare
and Medicaid enrollee, see Continuous Enrollment, Allowable Gap, and
Anchor Date requirements below in section C.

•

Referenced Value Sets may be found in the Healthcare Effectiveness Data
and Information Set (HEDIS) specifications Volume 2. Value Sets are
available at NCQA HEDIS 2016.

•

Refer to the specific data-reporting template for the reporting requirements
applicable to each measure and to the Appendices in Volume 2 of this manual.

Measurement Period: The measurement period is the measurement year for both the
denominator and numerator.
B. DEFINITIONS
TERM
Antipsychotic
Medication
Dispensing
Events
Cholesterol Test
Other Than
LDL

DEFINITION
A dispensed antipsychotic, as identified by claim/encounter data.
Antipsychotics are those identified on the National Committee for
Quality Assurance (NCQA) Healthcare Effectiveness Data and
Information Set (HEDIS) 2016 Final National Drug Code
(NDC) Lists webpage at HEDIS 2016 Final NDC Lists.
A cholesterol test other than LDL (Cholesterol Tests Other Than
LDL Value Set) performed during the measurement year, as
identified by claim/encounter or automated laboratory data

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Metabolic Monitoring for Children and Adolescents on Antipsychotics (AP)
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TERM
Glucose Test

HbA1c Test

LDL-C Test
Provider Entity

DEFINITION
A glucose test (Glucose Tests Value Set) performed during the
measurement year, as identified by claim/encounter or automated
laboratory data
An Hemoglobin A1c (HbA1c) test (HbA1c Tests Value Set)
performed during the measurement year, as identified by
claim/encounter or automated laboratory data
A low-density lipoprotein cholesterol (LDL-C) test (LDL-C Tests
Value Set) performed during the measurement year, as identified
by claim/encounter or automated laboratory data
The provider entity that is being measured (i.e., BHC)

C. ELIGIBLE POPULATION
CRITERIA

Age

Continuous
Enrollment
Allowable Gap
Anchor Date
Benefits

REQUIREMENTS
Consumers aged 1–17 years as of the end of the measurement
year. Report three age stratifications and a total rate:
•

1–5 years

•

6–11 years

•

12–17 years

•

Total (the sum of the age stratifications)

The measurement year
No more than one gap in enrollment of up to 45 days during the
measurement year
The last day of the measurement year
Medical and pharmacy

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Metabolic Monitoring for Children and Adolescents on Antipsychotics (AP)
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CRITERIA

REQUIREMENTS
Follow the steps below to identify the eligible population:
Step 1
Identify consumers flagged as having been seen at the provider
entity at least once during the measurement year.

Event/Diagnosis

Step 2
Identify consumers from step 1 aged 1–17 years as of the end of
the measurement year.
Step 3
Identify consumers from step 2 who had at least two
antipsychotic medication dispensing events of the same or
different medications, on different dates of service during the
measurement year (See Table APM-A on the NCQA website for
the current list of antipsychotic medications (HEDIS 2016 Final
NDC Lists )).

D. ADMINISTRATIVE SPECIFICATION
Denominator
The number of consumers in the eligible population (Section C)
Numerator
The number of consumers in the eligible population who met both of the following
during the measurement year:
•

At least one test for blood glucose (Glucose Tests Value Set) or HbA1c (HbA1c
Tests Value Set)

•

At least one test for LDL-C (LDL-C Tests Value Set) or cholesterol (Cholesterol
Tests Other Than LDL Value Set)

Exclusions
None
E. ADDITIONAL NOTES
The source measure is designed for the Medicaid and Commercial populations and is not
risk adjusted. The source measure was specified and tested at the health plan level. This
measure is modified to require clinic-level reporting, and to be consistent in format with
other measures in this set of BHC measures, but is not tested at the clinic level.
Interpretation of score: Better quality = Higher score
146

Cardiovascular Monitoring for People With Cardiovascular Disease and Schizophrenia (SMC)
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Cardiovascular Monitoring for People With Cardiovascular Disease and
Schizophrenia (SMC)
Based on measure stewarded by the
National Committee for Quality Assurance (NQF #1933, HEDIS 2016)
A. DESCRIPTION
The percentage of consumers 18–64 years of age with schizophrenia and cardiovascular
disease, who had an LDL-C test during the measurement year
Data Collection Method: Administrative
Guidance for Reporting:
•

This measure is stratified by whether the consumer is a Medicaid beneficiary,
eligible for both Medicare and Medicaid, and other. For purposes of determining
whether a consumer is a Medicaid beneficiary or a dual Medicare and Medicaid
enrollee, see Continuous Enrollment, Allowable Gap, and Anchor Date
requirements below in section C.

•

See 2016 Healthcare Effectiveness Data and Information Set (HEDIS) Value
Sets referred to in the specification for relevant codes. Referenced Value Sets
may be found in the National Committee for Quality Assurance (NCQA) HEDIS
specifications Volume 2. Value Sets are available at NCQA HEDIS 2016.

•

Refer to the specific data-reporting template for the reporting requirements
applicable to each measure and to the Appendices in Volume 2 of this manual.

Measurement Period: For the denominator, the measurement period is the measurement
year and the prior year. The measurement period for the numerator is the measurement
year.
B. DEFINITIONS
TERM
AMI
CABG
IVD

DEFINITION
Acute Myocardial Infarction
Coronary Artery Bypass Graft
Ischemic Vascular Disease

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Cardiovascular Monitoring for People With Cardiovascular Disease and Schizophrenia (SMC)
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TERM

LDL-C Test

DEFINITION
An LDL-C test (LDL-C Tests Value Set) performed during the
measurement year, as identified by claim/encounter or automated
laboratory data

PCI
Provider Entity

The reporting entity may use a calculated or direct LDL.
Percutaneous Coronary Intervention
The provider entity that is being measured (i.e., BHC)

C. ELIGIBLE POPULATION
CRITERIA
Age
Continuous
Enrollment

Allowable Gap

Anchor Date
Benefits

REQUIREMENTS
Consumers aged 18–64 years as of the end of the measurement
year
The measurement year and the year prior to the measurement year
No more than one gap in enrollment of up to 45 days during each
year of continuous enrollment. To determine continuous
enrollment for a consumer for whom enrollment is verified
monthly, the consumer may not have more than a 1-month gap in
coverage (i.e., a consumer whose coverage lapses for 2 months
[60 days] is not considered continuously enrolled).
The last day of the measurement year
Medical

148

Cardiovascular Monitoring for People With Cardiovascular Disease and Schizophrenia (SMC)
Please see NCQA Notice of Copyright and Disclaimers in front matter to this manual.

CRITERIA

REQUIREMENTS
Follow the steps below to identify the eligible population:
Step 1
Identify consumers flagged as having been seen at the provider
entity at least once during the measurement year.
Step 2
Identify consumers from step 1 aged 18–64 years as of the end of
the measurement year.
Step 3
Identify consumers from step 2 with schizophrenia as those who
met at least one of the following criteria during the measurement
year:
1. At least one acute inpatient encounter with any diagnosis
of schizophrenia. Either of the following code
combinations meets criteria:

Event/Diagnosis

– BH Stand Alone Acute Inpatient Value Set with
Schizophrenia Value Set
– BH Acute Inpatient Value Set with BH Acute Inpatient
POS Value Set and Schizophrenia Value Set
OR
2. At least two visits in an outpatient, intensive outpatient
(IOP), partial hospitalization (PH), emergency department
(ED), or nonacute inpatient setting, on different dates of
service, with any diagnosis of schizophrenia. Any two of
the following code combinations meet criteria:
– BH Stand Alone Outpatient/PH/IOP Value Set with
Schizophrenia Value Set
– BH Outpatient/PH/IOP Value Set with BH
Outpatient/PH/IOP POS Value Set and Schizophrenia
Value Set
– ED Value Set with Schizophrenia Value Set
– BH ED Value Set with BH ED POS Value Set and
Schizophrenia Value Set

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Cardiovascular Monitoring for People With Cardiovascular Disease and Schizophrenia (SMC)
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CRITERIA

REQUIREMENTS
– BH Stand Alone Nonacute Inpatient Value Set with
Schizophrenia Value Set
– BH Nonacute Inpatient Value Set with BH Nonacute
Inpatient POS Value Set and Schizophrenia Value Set
Step 4
Identify consumers from step 3 who also have cardiovascular
disease. Consumers are identified as having cardiovascular
disease in two ways: by event (AMI, CABG, or PCI) or by
diagnosis (AMI). The reporting entity must use both methods to
identify the eligible population, but a consumer need only be
identified by one to be included in the measure.
1. Event: Any of the following during the year prior to the
measurement year meet criteria:
- AMI. Discharged from an inpatient setting with an AMI
(AMI Value Set). To identify discharges:

Event/Diagnosis
(cont’d)

a. Identify all acute and nonacute inpatient stays
(Inpatient Stay Value Set).
b. Identify the discharge date for the stay.
- CABG. Discharged from an inpatient setting with a
CABG (CABG Value Set). To identify discharges:
a. Identify all acute and nonacute inpatient stays
(Inpatient Stay Value Set).
b. Identify the discharge date for the stay.
- PCI. Consumers who had PCI (PCI Value Set) in any
setting (e.g., inpatient, outpatient, ED).
OR
2. Diagnosis: Identify consumers with IVD as those who met
at least either of the following criteria during both the
measurement year and the year prior to the measurement
year. The criteria need not be the same across both years.
- At least one outpatient visit (Outpatient Value Set) with a
diagnosis of IVD (IVD Value Set)
- At least one acute inpatient encounter (Acute Inpatient
Value Set) with a diagnosis of IVD (IVD Value Set).

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Cardiovascular Monitoring for People With Cardiovascular Disease and Schizophrenia (SMC)
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D. ADMINISTRATIVE SPECIFICATION
Denominator
The number of consumers in the eligible population (Section C)
Note: For the denominator, the measurement period is the measurement year and the
prior year.
Numerator
The number of consumers with an LDL-C test (LDL-C Tests Value Set) performed
during the measurement year, as identified by claim/encounter or automated laboratory
data.
Note: The measurement period for the numerator is the measurement year.
Exclusions
None
E. ADDITIONAL NOTES
The source measure is designed for the Medicaid population and is not risk adjusted. The
source measure was specified and tested at the health plan level. This measure is
modified to require clinic-level reporting, and to be consistent in format with other
measures in this set of BHC measures, but is not tested at the clinic level.
Interpretation of score: Better quality = Higher score

151

Adherence to Mood Stabilizers for Individuals with Bipolar I Disorder (AMS-BD)

Adherence to Mood Stabilizers for Individuals with Bipolar I Disorder
(AMS-BD)
Based on a measure stewarded by the
Centers for Medicare & Medicaid Services (NQF #1880)
A. DESCRIPTION
The percentage of consumers at least 18 years of age as of the beginning of the
measurement period with Bipolar I Disorder who had at least two prescription drug
claims for mood stabilizer medications and had a Proportion of Days Covered (PDC) of
at least 0.8 for mood stabilizer medications during the measurement period (12
consecutive months)
Data Collection Method: Administrative
Guidance for Reporting:
•

This measure is stratified by whether the consumer is a Medicaid beneficiary,
eligible for both Medicare and Medicaid, and other. For purposes of determining
whether a consumer is a Medicaid beneficiary or a dual Medicare and Medicaid
enrollee, see Continuous Enrollment, Allowable Gap, and Anchor Date
requirements below in section C.

•

To the extent possible, include all paid, suspended, pending, and denied claims.

•

Refer to the specific data-reporting template for the reporting requirements
applicable to each measure and to the Appendices in Volume 2 of this manual.

Measurement Period: The measurement period for the denominator and the numerator
is the measurement year.
B. DEFINITIONS
TERM
Bipolar I Disorder
Mood Stabilizer
Medication

DEFINITION
A diagnosis of Bipolar I Disorder is indicated by the presence of
any of the codes listed in Table 1 of Appendix AMS-BD.
A list of medications that may be treated as mood stabilizers for
purposes of this specification are listed in Tables 3 and 4 of
Appendix AMS-BD.

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Adherence to Mood Stabilizers for Individuals with Bipolar I Disorder (AMS-BD)

TERM

DEFINITION
The PDC is a measure of adherence to prescribed medications.
Calculate the PDC for each individual in the eligible population
(i.e., the measure’s denominator) according to the following
methods:
1. Determine the individual’s medication therapy period,
defined as the index prescription date through the end of the
measurement period, or death, whichever comes first. The
index date is the service date (fill date) of the first
prescription drug claim for a mood stabilizer medication in
the measurement period.
2. Within the medication therapy period, count the days the
individual was covered by at least one drug in the mood
stabilizer medication class based on the prescription drug
claim service date and days of supply.

Proportion of
Days Covered
(PDC)

a. Sort and de-duplicate claims for mood stabilizers by
beneficiary ID, service date, generic name, and descending
days’ supply. If prescriptions for the same drug (generic
name) are dispensed on the same date of service for an
individual, keep the dispensing with the largest days’ supply.
b. Calculate the number of days covered by mood stabilizer
therapy per individual:
i. For prescription drug claims with a days’ supply
that extends beyond the end of the measurement
period, count only the days for which the drug was
available to the individual during the measurement
period.
ii. If claims for the same drug (generic name)
overlap, then adjust the last prescription start date to
be the day after the previous fill has ended.
iii. If claims for different drugs (different generic
names) overlap, do not adjust the prescription start
date.

153

Adherence to Mood Stabilizers for Individuals with Bipolar I Disorder (AMS-BD)

TERM

Proportion of
Days Covered
(PDC)

Provider Entity

DEFINITION
3. Calculate the PDC for each individual. Divide the number of
covered days found in step 2 by the number of days in the
individual’s medication therapy period found in step 1.
Note: An example of SAS code for steps 1-3 was adapted
from Pharmacy Quality Alliance (PQA) and is also available
at SAS Global Forum 2007.
The provider entity that is being measured (i.e., BHC)

C. ELIGIBLE POPULATION
CRITERIA
Age
Continuous
Enrollment

REQUIREMENTS
Consumers aged 18 years or older at the beginning of the
measurement year
The measurement year
No more than one gap in enrollment of up to 31 days during the
measurement year.
To determine continuous enrollment for a consumer for whom
enrollment is verified monthly, the member may not have more
than a 1-month gap in coverage.
To determine continuous enrollment for a consumer, the
consumer must be:

Allowable Gap

1. Continuously enrolled in Part D with no more than a 1-month
gap in enrollment during the measurement year,
2. Continuously enrolled in Part A and Part B with no more than
a 1-month gap in Part A enrollment and no more than a 1-month
gap in Part B enrollment during the measurement year,
AND

Anchor Date
Benefits

3. No more than 1 month of HMO (Health Maintenance
Organization) enrollment during the measurement year.
The last day of the measurement year
Medical and pharmacy

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Adherence to Mood Stabilizers for Individuals with Bipolar I Disorder (AMS-BD)

CRITERIA

REQUIREMENTS
Follow the steps below to identify the eligible population:
Step 1
Identify consumers flagged as having been seen at the provider
entity at least once during the measurement year.
Step 2
Identify consumers from step 1 who were aged 18 years or older
at the beginning of the measurement year.
Step 3
Identify consumers from step 2 who are identified by having a
diagnosis of Bipolar I Disorder (see Appendix AMS-BD, Table
1) within the inpatient or outpatient claims data during the
measurement year. Individuals must have:

Event/Diagnosis

1. At least two encounters with a diagnosis of Bipolar I
Disorder with different dates of service in an outpatient
setting (Appendix AMS-BD, Table 2.1), emergency
department (ED) setting (Appendix AMS-BD, Table 2.2), or
nonacute inpatient setting (Appendix AMS-BD, Table 2.3)
during the measurement period.
OR
2. At least one encounter with a diagnosis of Bipolar I Disorder
in an acute inpatient setting (Appendix AMS-BD, Table 2.4)
during the measurement period.
Step 4
Identify consumers from step 3 who had at least two prescription
drug claims for mood stabilizer medications (Appendix AMSBD, Tables 3 and 4) on different dates of service during the
measurement period.

D. ADMINISTRATIVE SPECIFICATION
Denominator
The number of consumers in the eligible population (Section C)
Numerator
The number of consumers with Bipolar I Disorder who had at least two prescription drug
claims for mood stabilizer medications and a PDC of at least 0.8 for mood stabilizer
medications. To calculate the numerator, first calculate the PDC for each individual in the
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Adherence to Mood Stabilizers for Individuals with Bipolar I Disorder (AMS-BD)

denominator and then determine the number of those individuals who have a PDC of at least
0.8.
Exclusions
None
E. ADDITIONAL NOTES
The source measure is designed for the Medicare population and is not risk adjusted. The
source measure was specified and tested at the state and other levels, including specifications
at the provider group level from which this measure is drawn. This measure is modified
from the source measure, however, to provide a specification consistent in format to other
measures in this set of BHC measures.
Interpretation of score: Better quality = Higher score

156

Adherence to Antipsychotic Medications for Individuals with Schizophrenia (SAA-BH)

Adherence to Antipsychotic Medications for Individuals with Schizophrenia
(SAA-BH)
Based on a measure stewarded by the
Centers for Medicare and Medicaid Services (HEDIS 2016)
A. DESCRIPTION
Percentage of consumers ages 19 to 64 during the measurement year with schizophrenia
who were dispensed and remained on an antipsychotic medication for at least 80 percent
of their treatment period
Data Collection Method: Administrative
Guidance for Reporting:
•

This measure is stratified by whether the consumer is a Medicaid beneficiary,
eligible for both Medicare and Medicaid, and other. For purposes of determining
whether a consumer is a Medicaid beneficiary or a dual Medicare and Medicaid
enrollee, see Continuous Enrollment, Allowable Gap, and Anchor Date
requirements below in section C.

•

Referenced Value Sets may be found in the BHC Value Set Directory.

•

Table SAA-A (Appendix SAA-BH) provides a list of antipsychotics. The
National Committee for Quality Assurance’s (NCQA) National Drug Code
(NDC) current list of antipsychotic medications can be found at: NCQA HEDIS
2016.

•

To the extent possible, include all paid, suspended, pending, and denied claims.

•

Refer to the specific data-reporting template for the reporting requirements
applicable to each measure and to the Appendices in Volume 2 of this manual.

Measurement Period: For both the denominator and the numerator, the measurement
period is the measurement year.

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Adherence to Antipsychotic Medications for Individuals with Schizophrenia (SAA-BH)

B. DEFINITIONS
TERM

DEFINITION
Calculate number of days covered (for the numerator) for long-acting
injections using the days-supply specified for the medication in Table
Calculating
SAA-A (Appendix SAA-BH). For multiple J Codes or NDCs for the
Number of
same or different medications on the same day, use the medication
Days Covered
with the longest days’ supply. For multiple J Codes or NDCs for the
for Long-Acting
same or different medications on different days with overlapping
Injections
days’ supply, count each day within the treatment period only once
toward the numerator.
If multiple prescriptions for the same or different oral medications
are dispensed on the same day, calculate number of days covered by
an antipsychotic medication (for the numerator) using the
prescription with the longest days’ supply.

Calculating
Number of
Days Covered
for Oral
Medications

Intake Period
IPSD
Long-Acting
Injections
Dispensing
Event

If multiple prescriptions for different oral medications are dispensed
on different days, count each day within the treatment period only
once toward the numerator.
If multiple prescriptions for the same oral medication are dispensed
on different days, sum the days’ supply and use the total to calculate
the number of days covered by an antipsychotic medication (for the
numerator). For example, if three antipsychotic prescriptions for the
same oral medication are dispensed on different days, each with a 30day supply; sum the days’ supply for a total of 90 days covered by an
oral antipsychotic (even if there is overlap).
Use the drug ID provided on the NDC list to determine if the
prescriptions are the same or different.
The 12-month window starting 7 months prior to the measurement
year and ending at the end of the fourth month after the beginning of
the measurement year
Index Prescription Start Date: The earliest prescription dispensing
date for an antipsychotic medication during the measurement year
Injections count as one dispensing event. Multiple J codes or NDCs
for the same or different medication on the same day are counted as a
single dispensing event.

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Adherence to Antipsychotic Medications for Individuals with Schizophrenia (SAA-BH)

TERM
Oral
Medication
Dispensing
Event
PDC
Provider Entity
Treatment
Period

DEFINITION
One prescription of an amount lasting 30 days or less. To calculate
dispensing events for prescriptions longer than 30 days, divide the
days’ supply by 30 and round down to convert. For example, a 100day prescription is equal to three dispensing events.
Proportion of Days Covered: The number of days a consumer is
covered by at least one antipsychotic medication prescription, divided
by the number of days in the treatment period
The provider entity that is being measured (i.e., BHC)
The period of time beginning on the IPSD through the last day of the
measurement year

C. ELIGIBLE POPULATION
CRITERIA
Age
Continuous
Enrollment

Allowable Gap

Anchor Date
Benefits

REQUIREMENTS
Consumers aged 19 to 64 years as of the last day of the measurement
year
The measurement year
No more than one gap in enrollment of up to 45 days during the
measurement year. To determine continuous enrollment for a
consumer for whom enrollment is verified monthly, the consumer
may not have more than a 1-month gap in coverage (i.e., a consumer
whose coverage lapses for 2 months [60 days] is not considered
continuously enrolled).
The last day of the measurement year
Medical and pharmacy

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Adherence to Antipsychotic Medications for Individuals with Schizophrenia (SAA-BH)

CRITERIA

REQUIREMENTS
Follow the steps below to identify the eligible population:
Step 1
Identify consumers flagged as having been seen at the provider entity
at least once during the measurement year.
Step 2
Identify consumers from step 1 who were aged 19 to 64 years as of
the last day of the measurement year.
Step 3
Identify consumers from step 2 with schizophrenia if they met at
least one of the following criteria during the measurement year:
1. At least one acute inpatient encounter with any diagnosis of
schizophrenia. Either of the following code combinations
meets criteria:
2. BH Stand Alone Acute Inpatient Value Set with Schizophrenia
Value Set

Event/Diagnosis

3. BH Acute Inpatient Value Set with BH Acute Inpatient POS
Value Set and Schizophrenia Value Set
OR
4. At least two visits in an outpatient, intensive outpatient, partial
hospitalization, ED, or nonacute inpatient setting, on different
dates of service, with any diagnosis of schizophrenia. Any two of
the following code combinations meet criteria:
•

BH Stand Alone Outpatient/PH/IOP Value Set with
Schizophrenia Value Set

•

BH Outpatient/PH/IOP Value Set with BH
Outpatient/PH/IOP POS Value Set and Schizophrenia Value
Set

•

ED Value Set with Schizophrenia Value Set

•

BH ED Value Set with BH ED POS Value Set and
Schizophrenia Value Set

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Adherence to Antipsychotic Medications for Individuals with Schizophrenia (SAA-BH)

CRITERIA

REQUIREMENTS
• BH Stand Alone Nonacute Inpatient Value Set with
Schizophrenia Value Set
•

BH Nonacute Inpatient Value Set with BH Nonacute
Inpatient POS Value Set and Schizophrenia Value Set

Step 4
Required exclusions. From consumers in step 3, exclude those who
met at least one of the following during the measurement year:
1. A diagnosis of dementia (Dementia Value Set)
Event/Diagnosis
(cont'd)

2. Did not have at least two antipsychotic medication dispensing
events. There are two ways to identify dispensing events: by
claim/encounter data and by pharmacy data. The state must use
both methods to identify dispensing events, but an event need
only be identified by one method to be counted.
3. Claims/encounter data. An antipsychotic medication (LongActing Injections 14 Days Supply Value Set or Long-Acting
Injections 28 Days Supply Value Set)
4. Pharmacy data. Dispensed an antipsychotic medication (Table
SAA-A (Appendix SAA-BH)) on an ambulatory basis

D. ADMINISTRATIVE SPECIFICATION
Denominator
The number of consumers in the eligible population (Section C)
Numerator
The number of consumers who achieved a PDC of at least 80 percent for their
antipsychotic medications (Table SAA-A (Appendix SAA-BH); Long-Acting Injections
14 Days Supply Value Set; Long-Acting Injections 28 Days Supply Value Set) during the
measurement year.
Follow the steps below to identify numerator compliance:
Step 1
Identify the IPSD. The IPSD is the earliest dispensing event for any antipsychotic
medication (Table SAA-A (Appendix SAA-BH); Long-Acting Injections 14 Days Supply
Value Set; Long-Acting Injections 28 Days Supply Value Set) during the measurement
year.
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Adherence to Antipsychotic Medications for Individuals with Schizophrenia (SAA-BH)

Step 2
To determine the treatment period, calculate the number of days beginning on the IPSD
through the end of the measurement year.
Step 3
Count the days covered by at least one antipsychotic medication (Table SAA-A
(Appendix SAA-BH); Long-Acting Injections 14 Days Supply Value Set; Long-Acting
Injections 28 Days Supply Value Set) during the treatment period. To ensure that the
day’s supply does not exceed the treatment period, subtract any day’s supply that extends
beyond the last day of the measurement year.
Step 4
Calculate the consumer’s PDC using the following equation:
Total Days Covered by an Antipsychotic Medication in the Treatment Period (step 3)
divided by Total Days in Treatment Period (step 2)
Round to two decimal places, using the .5 rule (if the decimal is 0.5 or above round up to
the nearest whole number. If the decimal is 0.499999 or below round down to the nearest
whole number).
Step 5
Sum the number of consumers whose PDC is ≥80 percent for their treatment period.
Exclusions
Exclude those who met at least one of the following during the measurement year:
•

A diagnosis of dementia (Dementia Value Set)

•

Did not have at least two antipsychotic medication dispensing events. There are
two ways to identify dispensing events: by claim/encounter data and by pharmacy
data. The state must use both methods to identify dispensing events, but an event
need only be identified by one method to be counted.
o Claims/encounter data. An antipsychotic medication (Long-Acting
Injections 14 Days Supply Value Set or Long-Acting Injections 28 Days
Supply Value Set)
o Pharmacy data. Dispensed an antipsychotic medication (Table SAA-A
(Appendix SAA-BH)) on an ambulatory basis

E. ADDITIONAL NOTES
The source measure is designed for the Medicaid population and is not risk adjusted. The
source measure was specified and tested at the health plan level. This measure is
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Adherence to Antipsychotic Medications for Individuals with Schizophrenia (SAA-BH)

modified to require clinic-level reporting, and to be consistent in format with other
measures in this set of BHC measures, but is not tested at the clinic level.
Interpretation of score: Better quality = Higher score

163

Follow-Up After Hospitalization for Mental Illness (FUH-BH-A)
Please see NCQA Notice of Copyright and Disclaimers in front matter to this manual.

Follow-Up After Hospitalization for Mental Illness (FUH-BH-A)
Based on a measure stewarded by the
National Committee for Quality Assurance (NQF #0576, HEDIS 2016)
A. DESCRIPTION
The percentage of discharges for consumers age 21 and older who were hospitalized for
treatment of selected mental illness diagnoses and who had an outpatient visit, an
intensive outpatient encounter, or partial hospitalization with a mental health practitioner
Two rates are reported:
•

Percentage of discharges for which the consumer received follow-up within 30
days of discharge

•

Percentage of discharges for which the consumer received follow-up within 7
days of discharge

Data Collection Method: Administrative
Guidance for Reporting:
•

This measure is stratified by age (aged 21 to 64 years, aged 65 years and older)
and by whether the consumer is a Medicaid beneficiary, eligible for both
Medicare and Medicaid, and other. For purposes of determining whether a
consumer is a Medicaid beneficiary or a dual Medicare and Medicaid enrollee,
see Continuous Enrollment, Allowable Gap, and Anchor Date requirements below
in section C.

•

The denominator for this measure should be the same for the 30-day rate and the
7-day rate.

•

The 30-day follow-up rate should be greater than (or equal to) the 7-day followup rate

•

Referenced Value Sets may be found in the BHC Value Set Directory.

•

To the extent possible, include all paid, suspended, pending, and denied claims.

•

Refer to Appendix D for the definition of a mental health practitioner.

•

Refer to the specific data-reporting template for the reporting requirements
applicable to each measure and to the Appendices in Volume 2 of this manual.

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Follow-Up After Hospitalization for Mental Illness (FUH-BH-A)
Please see NCQA Notice of Copyright and Disclaimers in front matter to this manual.

Measurement Period: For both rates, the measurement period for the denominator is
measured from the discharge date and encompasses the measurement year (e.g., for
CCBHCs, DY1 or DY2) less the last 30 days. The measurement period for the numerator
for rate 1 is the discharge date through 7 days after the discharge date. The measurement
period for the numerator for rate 2 is the measurement year.
B. DEFINITIONS
TERM
Provider Entity

DEFINITION
The provider entity that is being measured (i.e., BHC)

C. ELIGIBLE POPULATION
CRITERIA

Age

Continuous
Enrollment
Allowable Gap
Anchor Date
Benefits

REQUIREMENTS
Consumers aged 21 and older as of the date of discharge. Report two
age stratifications (as applicable):
•

21–64 years

•

65 years and older

The date of discharge through 30 days after discharge
No gaps in enrollment
None
Medical and mental health (inpatient and outpatient)

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Follow-Up After Hospitalization for Mental Illness (FUH-BH-A)
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CRITERIA

REQUIREMENTS
Follow the steps below to identify the eligible population:
Step 1
Identify consumers flagged as having been seen at the provider entity
at least once during the measurement year.
Step 2
Identify consumers from step 1 who were aged 21 years and older as
of the date of discharge.
Step 3
Identify consumers from step 2 who experience an acute inpatient
discharge with a principal diagnosis of mental illness (Mental Illness
Value Set) during the measurement year less the last 30 days.

Event/Diagnosis

To identify acute inpatient discharges:
1. Identify all acute and nonacute inpatient stays (Inpatient Stay
Value Set).
2. Exclude nonacute inpatient stays (Nonacute Inpatient Stay
Value Set)
3. Identify the discharge date for the stay.
Note: Use only facility claims to identify discharges and diagnoses
for denominator events (including readmissions or direct transfers).
Do not use professional claims.
Note: The denominator for this measure is based on discharges, not
consumers. If consumers had more than one discharge, include all
discharges during the measurement year less the last 30 days.

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Follow-Up After Hospitalization for Mental Illness (FUH-BH-A)
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CRITERIA

Acute Facility
Readmission or
Direct Transfer

REQUIREMENTS
If the discharge is followed by readmission or direct transfer to an
acute inpatient care setting for a principal mental health diagnosis
(Mental Health Diagnosis Value Set) within the 30-day follow-up
period, count only the last discharge. Exclude both the initial
discharge and the readmission/direct transfer discharge if the last
discharge occurs during the last 30 days of the measurement year.
To identify readmissions to an acute inpatient care setting:
1. Identify all acute and nonacute inpatient stays (Inpatient Stay
Value Set).
2. Exclude nonacute inpatient stays (Nonacute Inpatient Stay
Value Set).
3. Identify the admission date for the stay.
States must identify “direct transfers” using their own methods and
then confirm the acute inpatient care setting using the steps above.

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Follow-Up After Hospitalization for Mental Illness (FUH-BH-A)
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CRITERIA

REQUIREMENTS
Exclude discharges followed by readmission or direct transfer to a
nonacute inpatient care setting within the 30-day follow-up period,
regardless of principal diagnosis for the readmission. To identify
readmissions to a nonacute inpatient care setting:
1. Identify all acute and nonacute inpatient stays (Inpatient Stay
Value Set).
2. Confirm the stay was for nonacute care based on the presence
of a nonacute code (Nonacute Inpatient Stay Value Set) on
the claim.
3. Identify the admission date for the stay.

Exclusions

Exclude discharges followed by readmission or direct transfer to an
acute inpatient care setting within the 30-day follow-up period if the
principal diagnosis was for non-mental health (any principal
diagnosis code other than those included in the Mental Health
Diagnosis Value Set). To identify readmissions to an acute inpatient
care setting:
1. Identify all acute and nonacute inpatient stays (Inpatient Stay
Value Set).
2. Exclude nonacute inpatient stays (Nonacute Inpatient Stay
Value Set).
3. Identify the admission date for the stay.
Note: States must identify “direct transfers” using their own methods
and then confirm the acute inpatient care setting using the steps
above.
Note: These discharges are excluded from the measure because
rehospitalization or transfer may prevent an outpatient follow-up visit
from taking place.

D. ADMINISTRATIVE SPECIFICATION
Denominator
The number of eligible discharges for the eligible population (Section C)
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Follow-Up After Hospitalization for Mental Illness (FUH-BH-A)
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Note: For the denominator, the measurement period is measured from the discharge date
and encompasses the measurement year less the last 30 days.
Numerators
Rate 1: 30-Day Follow-Up
An outpatient visit, intensive outpatient visit, or partial hospitalization with a mental
health practitioner within 30 days after discharge. Include outpatient visits, intensive
outpatient visits, or partial hospitalizations that occur on the date of discharge.
Rate 2: 7-Day Follow-Up
An outpatient visit, intensive outpatient visit, or partial hospitalization with a mental
health practitioner within 7 days after discharge include outpatient visits, intensive
outpatient visits, or partial hospitalizations that occur on the date of discharge.
For both indicators, any of the following meet criteria for a follow-up visit:


A visit (FUH Stand Alone Visits Value Set) with a mental health practitioner



A visit (FUH Visits Group 1 Value Set and FUH POS Group 1 Value Set) with a
mental health practitioner



A visit (FUH Visits Group 2 Value Set and FUH POS Group 2 Value Set) with a
mental health practitioner



A visit in a behavioral healthcare facility (FUH RevCodes Group 1 Value Set)



A visit in a non-behavioral healthcare facility (FUH RevCodes Group 2 Value Set)
with a mental health practitioner



A visit in a non-behavioral healthcare facility (FUH RevCodes Group 2 Value Set)
with a diagnosis of mental illness (Mental Illness Value Set)



Transitional care management services (TCM 7 Day Value Set) where the date of
service on the claim is 29 days after the date the eligible population
event/diagnosis date of discharge

The following meets criteria for only the 30-Day Follow-Up indicator:


Transitional care management services (TCM 14 Day Value Set) where the date of
service on the claim is 29 days after the event/diagnosis date of discharge

Note: Transitional care management is a 30-day period that begins on the date of
discharge and continues for the next 29 days. The date of service on the claim is within
29 days after discharge and not the date of the face-to-face visit.

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Follow-Up After Hospitalization for Mental Illness (FUH-BH-A)
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Note: The measurement period for the numerator for rate 1 is the discharge date
through 7 days after the discharge date. The measurement period for the numerator for
rate 2 is the measurement year.
E. ADDITIONAL NOTES
There may be different methods for billing intensive outpatient visits and partial
hospitalizations. Some methods may be comparable to outpatient billing, with separate
claims for each date of service; others may be comparable to inpatient billing, with an
admission date, a discharge date, and units of service. Where billing methods are
comparable to inpatient billing, each unit of service may be counted as an individual visit.
The unit of service must have occurred during the period specified (e.g., within 30 days
after discharge or within 7 days after discharge).
The source measure is designed for the Medicaid population and is not risk adjusted. The
source measure was specified and tested at the health plan level. This measure is
modified to require clinic-level reporting, and to be consistent in format with other
measures in this set of BHC measures, but is not tested at the clinic level.
Interpretation of score: Better quality = Higher score

170

Follow-Up after Hospitalization for Mental Illness (FUH-BH-C)
Please see NCQA Notice of Copyright and Disclaimers in front matter to this manual.

Follow-Up after Hospitalization for Mental Illness (FUH-BH-C)
Based on a measure stewarded by the
National Committee for Quality Assurance (NQF #0576, HEDIS 2016
A. DESCRIPTION
Percentage of discharges for children and adolescents ages 6-20 who were hospitalized
for treatment of selected mental illness diagnoses and who had an outpatient visit, an
intensive outpatient encounter, or partial hospitalization with a mental health practitioner.
Two rates are reported:
•

Percentage of discharges for which children received follow-up within 30 days of
discharge

•

Percentage of discharges for which children received follow-up within 7 days of
discharge

Data Collection Method: Administrative
Guidance for Reporting:
•

This measure is stratified by whether the consumer is a Medicaid beneficiary,
eligible for both Medicare and Medicaid, and other. For purposes of determining
whether a consumer is a Medicaid beneficiary or a dual Medicare and Medicaid
enrollee, see Continuous Enrollment, Allowable Gap, and Anchor Date
requirements below in section C.

•

Follow the detailed specifications to (1) include the appropriate discharge when
the patient was transferred directly or readmitted to an acute or non-acute care
facility for a mental health diagnosis, and (2) exclude discharges in which the
patient was transferred directly or readmitted to an acute or non-acute care facility
for a non-mental health diagnosis.

•

The denominator for this measure should be the same for the 30-day rate and the
7-day rate.

•

The 30-day follow-up rate should be greater than (or equal to) the 7-day followup rate.

•

Referenced Value Sets may be found in the BHC Value Set Directory.

•

To the extent possible, include all paid, suspended, pending, and denied claims.

•

Refer to Appendix D for the definition of a mental health practitioner.
171

Follow-Up after Hospitalization for Mental Illness (FUH-BH-C)
Please see NCQA Notice of Copyright and Disclaimers in front matter to this manual.

•

Refer to the specific data-reporting template for the reporting requirements
applicable to each measure and to the Appendices in Volume 2 of this manual.

DEFINITION
The provider entity that is being measured (i.e., BHC)

C. ELIGIBLE POPULATION
CRITERIA

REQUIREMENTS

Age
Continuous
Enrollment
Allowable Gap
Anchor Date
Benefits

Consumers aged 6–20 years as of the date of discharge
The date of discharge through 30 days after discharge
No gaps in enrollment
None
Medical and mental health (inpatient and outpatient)

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Follow-Up after Hospitalization for Mental Illness (FUH-BH-C)
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CRITERIA

Event/Diagnosis

Step 3
Identify consumers from step 2 who experience an acute inpatient
discharge with a principal diagnosis of mental illness (Mental Illness
Value Set) during the measurement year less the last 30 days.
To identify acute inpatient discharges:
1. Identify all acute and nonacute inpatient stays (Inpatient Stay
Value Set).
2. Exclude nonacute inpatient stays (Nonacute Inpatient Stay
Value Set)
3. Identify the discharge date for the stay.
Note: Use only facility claims to identify discharges and diagnoses
for denominator events (including readmissions or direct transfers).
Do not use professional claims.
Note: The denominator for this measure is based on discharges, not
children. If children have more than one discharge, include all
discharges during the measurement year less the last 30 days.

173

Follow-Up after Hospitalization for Mental Illness (FUH-BH-C)
Please see NCQA Notice of Copyright and Disclaimers in front matter to this manual.

CRITERIA

Acute Facility
Readmission or
Direct Transfer

To identify readmissions to an acute inpatient care setting:
1. Identify all acute and nonacute inpatient stays (Inpatient Stay
Value Set).
2. Exclude nonacute inpatient stays (Nonacute Inpatient Stay
Value Set).
3. Identify the admission date for the stay.
States must identify “direct transfers” using their own methods and
then confirm the acute inpatient care setting using the steps above.

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Follow-Up after Hospitalization for Mental Illness (FUH-BH-C)
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CRITERIA

Exclusions

Identify all acute and nonacute inpatient stays (Inpatient Stay
Value Set).

Confirm the stay was for nonacute care based on the presence
of a nonacute code (Nonacute Inpatient Stay Value Set) on
the claim.

Identify the admission date for the stay.

Identify all acute and nonacute inpatient stays (Inpatient Stay
Value Set).

Exclude nonacute inpatient stays (Nonacute Inpatient Stay
Value Set).

Identify the admission date for the stay.

Note: States must identify “direct transfers” using their own methods
and then confirm the acute inpatient care setting using the steps
above.
Note: These discharges are excluded from the measure because
rehospitalization or transfer may prevent an outpatient follow-up visit
from taking place.
D. ADMINISTRATIVE SPECIFICATION
Denominator
The number of eligible discharges for the eligible population (Section C)

175

Follow-Up after Hospitalization for Mental Illness (FUH-BH-C)
Please see NCQA Notice of Copyright and Disclaimers in front matter to this manual.

Note: For the denominator, the measurement period is measured from the discharge date
and encompasses the measurement year less the last 30 days.
Numerators
Rate 1: 30-Day Follow-Up
An outpatient visit, intensive outpatient visit, or partial hospitalization with a mental
health practitioner within 30 days after discharge. Include outpatient visits, intensive
outpatient visits, or partial hospitalizations that occur on the date of discharge.
Rate 2: 7-Day Follow-Up
An outpatient visit, intensive outpatient visit, or partial hospitalization with a mental
health practitioner within 7 days after discharge. Include outpatient visits, intensive
outpatient visits, or partial hospitalizations that occur on the date of discharge.
For both indicators, any of the following meet criteria:
•

A visit (FUH Stand Alone Visits Value Set) with a mental health practitioner

•

A visit (FUH Visits Group 1 Value Set and FUH POS Group 1 Value Set) with a
mental health practitioner

•

A visit (FUH Visits Group 2 Value Set and FUH POS Group 2 Value Set) with a
mental health practitioner

•

A visit in a behavioral healthcare facility (FUH RevCodes Group 1 Value Set)

•

A visit in a non-behavioral healthcare facility (FUH RevCodes Group 2 Value Set)
with a mental health practitioner

•

A visit in a non-behavioral healthcare facility (FUH RevCodes Group 2 Value Set)
with a diagnosis of mental illness (Mental Illness Value Set)

•

Transitional care management services (TCM 7 Day Value Set) where the date of
service on the claim is 29 days after the date the eligible population
event/diagnosis date of discharge

The following meets criteria for only the 30-Day Follow-Up indicator:
•

Transitional care management services (TCM 14 Day Value Set) where the date of
service on the claim is 29 days after the event/diagnosis date of discharge

Follow-Up after Hospitalization for Mental Illness (FUH-BH-C)
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177

Follow-Up Care for Children Prescribed Attention-Deficit Hyperactivity Disorder (ADHD) Medication
(ADD-BH)
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Follow-Up Care for Children Prescribed Attention-Deficit Hyperactivity
Disorder (ADHD) Medication (ADD-BH)
Based on a measure stewarded by the
National Committee for Quality Assurance (NQF #0108)
A. DESCRIPTION
Percentage of children newly prescribed attention-deficit/hyperactivity disorder (ADHD)
medication who had at least three follow-up care visits within a 10-month period, one of
which was within 30 days of when the first ADHD medication was dispensed. Two rates
are reported.
Initiation Phase: Percentage of children ages 6 to 12 as of the Index Prescription Start
Date (IPSD) with an ambulatory prescription dispensed for ADHD medication, who had
one follow-up visit with practitioner with prescribing authority during the 30-day
Initiation Phase.
Continuation and Maintenance (C&M) Phase: Percentage of children ages 6 to 12 as of
the IPSD with an ambulatory prescription dispensed for ADHD medication who
remained on the medication for at least 210 days and who, in addition to the visit in the
Initiation Phase, had at least two follow-up visits with a practitioner within 270 days (9
months) after the Initiation Phase ended.

Data Collection Method: Administrative
Guidance for Reporting:
•

This measure is stratified by whether the consumer is a Medicaid beneficiary,
eligible for both Medicare and Medicaid, and other. For purposes of determining
whether a consumer is a Medicaid beneficiary or a dual Medicare and Medicaid
enrollee, see Continuous Enrollment, Allowable Gap, and Anchor Date
requirements below in section C.

•

Children who switch between Medicaid and CHIP and whom the state cannot
identify as continuously enrolled between the Rate 1 and Rate 2 continuous
enrollment periods should only be included in Rate 1 (initiation phase).

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Follow-Up Care for Children Prescribed Attention-Deficit Hyperactivity Disorder (ADHD) Medication
(ADD-BH)
Please see NCQA Notice of Copyright and Disclaimers in front matter to this manual.

•

Many of the ADHD medications are also used in the treatment of narcolepsy. In
order to have a precise ADHD measure, children with narcolepsy should be
removed from the denominator of both indicators.

•

Referenced Value Sets may be found in the BHC Value Set Directory.

•

Table ADD.A (Appendix ADD-BH) provides a list of ADHD medications.
NCQA’s National Drug Code (NDC) current list of ADHD medications can be
found at: NCQA HEDIS 2016.

•

To the extent possible, include all paid, suspended, pending, and denied claims.

•

Refer to Appendix D for the definition of a prescribing practitioner.

•

Refer to the specific data-reporting template for the reporting requirements
applicable to each measure and to the Appendices in Volume 2 of this manual.

Measurement Period:
For the denominator, two measurement periods are used:
•

Index prescription start date (IPSD): 10 months before the measurement year
begins to 2 months after the measurement year begins

•

Negative medication history review: The time period between 120 days before the
IPSD measurement period begins and 120 days before the IPSD measurement
period ends

For the numerator, two measurement periods are used:
•

Initiation Phase: The time period between 30 days after the IPSD measurement
period begins and 30 days after the IPSD measurement period ends

•

Continuation and Maintenance Phase: The time period between 300 days after the
IPSD measurement period begins and 300 days after the IPSD measurement
period ends

B. DEFINITIONS
TERM
Continuous
Medication
Treatment
C&M Phase
Initiation Phase

DEFINITION
The number of medication treatment days during the 10-month
follow-up period must be ≥210 days (i.e., 300 treatment days – 90
gap days)
The 300 days following the IPSD (10 months)
The 30 days following the IPSD

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Follow-Up Care for Children Prescribed Attention-Deficit Hyperactivity Disorder (ADHD) Medication
(ADD-BH)
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TERM

DEFINITION
The 12-month window starting 10 months before the measurement
Intake Period
year begins to 2 months after the measurement year begins
Index Prescription Start Date. The earliest prescription dispensing
date for an ADHD medication where the date is in the Intake Period
IPSD
and there is a Negative Medication History.
A period of 120 days (4 months) prior to the IPSD when the child
Negative
had no ADHD medications dispensed for either new or refill
Medication
prescriptions
History
The child must have a 120-day (4-month) Negative Medication
New Episode
History on or before the IPSD.
Provider Entity The provider entity that is being measured (i.e., BHC)
The actual number of calendar days covered with prescriptions within
Treatment Days the specified 300-day measurement interval (e.g., a prescription of a
(Covered Days) 90 days’ supply dispensed on the 220th day will have 80 days
counted in the 300-day interval)
C. ELIGIBLE POPULATION
Eligible Population: Rate 1 - Initiation Phase
CRITERIA
Age
Continuous
Enrollment
Allowable Gap
Anchor Date
Benefits

REQUIREMENTS
Consumers aged 6 years as of 10 months before the measurement
year begins to age 12 as of 2 months after the measurement year
begins
Initiation Phase: Children must be continuously enrolled for 120 days
(4 months) prior to the IPSD through 30 days (1 month) after the
IPSD.
None
None
Medical and pharmacy

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Follow-Up Care for Children Prescribed Attention-Deficit Hyperactivity Disorder (ADHD) Medication
(ADD-BH)
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CRITERIA

REQUIREMENTS
Follow the steps below to identify the eligible population:
Step 1
Identify all children in the specified age range who were dispensed an
ADHD medication (Table ADD.A (Appendix ADD-BH)) during the
12-month Intake Period.
Step 2
Test for Negative Medication History. For each child identified in
step 1, test each ADHD prescription for a Negative Medication
History. The IPSD is the dispensing date of the earliest ADHD
prescription in the Intake Period with a Negative Medication History.

Event/Diagnosis

Step 3
Calculate continuous enrollment. For children in step 2, identify
those who are continuously enrolled for 120 days (4 months) prior to
the IPSD through 30 days after the IPSD.
Step 4
For children in step 3, exclude those who had an acute inpatient
encounter for mental health or chemical dependency during the 30
days after the IPSD. Any of the following meet criteria:
1. An acute inpatient encounter (Acute Inpatient Value Set) with a
principal mental health diagnosis (Mental Health Diagnosis Value
Set)
OR
2. An acute inpatient encounter (Acute Inpatient Value Set) with a
principal diagnosis of chemical dependency (Chemical
Dependency Value Set)

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Follow-Up Care for Children Prescribed Attention-Deficit Hyperactivity Disorder (ADHD) Medication
(ADD-BH)
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Eligible Population: Rate 2 - Continuation and Maintenance Phase
CRITERIA
Age

Continuous
Enrollment

Allowable Gap

Anchor Date
Benefits

REQUIREMENTS
Consumers aged 6 years as of 10 months before the measurement
year begins to age 12 years as of 2 months after the measurement
year begins
Children must be continuously enrolled for 120 days (4 months) prior
to the IPSD and 300 days (10 months) after the IPSD.
Children who switch between Medicaid and CHIP and whom the
state cannot identify as continuously enrolled between the Rate 1 and
Rate 2 continuous enrollment periods should only be included in Rate
1.
One 45-day gap in enrollment between 31 days and 300 days (10
months) after the IPSD. To determine continuous enrollment for a
consumer for whom enrollment is verified monthly, the child may not
have more than a 1-month gap in coverage (i.e., a child whose
coverage lapses for 2 months [60 days] is not considered
continuously enrolled).
None.
Medical and pharmacy

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Follow-Up Care for Children Prescribed Attention-Deficit Hyperactivity Disorder (ADHD) Medication
(ADD-BH)
Please see NCQA Notice of Copyright and Disclaimers in front matter to this manual.

CRITERIA

REQUIREMENTS
Follow the steps below to identify the eligible population:
Step 1
Identify all children that meet the eligible population criteria for Rate
1—Initiation Phase.
Step 2
Calculate continuous enrollment. For children in step 1, identify
those who are continuously enrolled from 120 days (4 months) prior
to the IPSD and 300 days (10 months) after the IPSD.
Step 3
Calculate the continuous medication treatment. Using the children in
step 2, determine if the child filled a sufficient number of
prescriptions to provide continuous treatment for at least 210 days
out of the 300-day period after the IPSD. The definition of
“continuous medication treatment” allows gaps in medication
treatment, up to a total of 90 days during the 300-day (10-month)
period. (This period spans the Initiation Phase [1 month] and the
C&M Phase [9 months].)

Event/Diagnosis

Note: Gaps can include either washout period gaps to change
medication or treatment gaps to refill the same medication.
Note: Regardless of the number of gaps, the total gap days may be no
more than 90. Count any combination of gaps (e.g., one washout gap
of 14 days and numerous weekend drug holidays).
Step 4
Of the children in step 3, exclude those who had an acute inpatient
encounter for mental health or chemical dependency during the 300
days (10 months) after the IPSD. Any of the following meet
criteria:
A. An acute inpatient encounter (Acute Inpatient Value Set) with a
principal mental health diagnosis (Mental Health Diagnosis Value
Set)
OR
B. An acute inpatient encounter (Acute Inpatient Value Set) with a
principal diagnosis of chemical dependency (Chemical
Dependency Value Set)
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Follow-Up Care for Children Prescribed Attention-Deficit Hyperactivity Disorder (ADHD) Medication
(ADD-BH)
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D. ADMINISTRATIVE SPECIFICATION
Denominator
The number of consumers in the eligible population (Section C) for Rate 1 and Rate 2,
respectively
Note: The measurement period for the IPSD is the time period 10 months before the
measurement year begins to 2 months after the measurement year begins. The
measurement period for the negative medication history review is the time period
between 120 days before the IPSD measurement period begins and 120 days before the
IPSD measurement period ends.
Numerator
Rate 1 - Initiation Phase
An outpatient, intensive outpatient, or partial hospitalization follow-up visit with a
practitioner with prescribing authority, within 30 days after the IPSD. Any of the
following code combinations billed by a practitioner with prescribing authority meet
the criteria:
•

ADD Stand Alone Visits Value Set

•

ADD Visits Group 1 Value Set with ADD POS Group 1 Value Set

•

ADD Visits Group 2 Value Set with ADD POS Group 2 Value Set

Note: Do not count a visit on the IPSD as the Initiation Phase visit.
Note: For the Initiation Phase numerator, the measurement period is the time period
between 30 days after the IPSD measurement period begins and 30 days after the IPSD
measurement period ends.
Rate 2 - Continuation and Maintenance
Identify all children that meet the following criteria:
•

Numerator compliant for Rate 1 Initiation Phase, and

•

At least two follow-up visits with any practitioner, from 31–300 days (9 months)
after the IPSD.

One of the two visits (during days 31–300) may be a telephone visit (Telephone Visits
Value Set) with any practitioner. Any of the following code combinations identify
follow-up visits:

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Follow-Up Care for Children Prescribed Attention-Deficit Hyperactivity Disorder (ADHD) Medication
(ADD-BH)
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•

ADD Stand Alone Visits Value Set

•

ADD Visits Group 1 Value Set with ADD POS Group 1 Value Set

•

ADD Visits Group 2 Value Set with ADD POS Group 2 Value Set

•

Telephone Visits Value Set

Note: For the Continuation and Maintenance Phase numerator, the measurement period is
the time period between 300 days after the IPSD measurement period begins and 300
days after the IPSD measurement period ends.
Exclusions (optional)
Exclude from the denominator for both rates, children with a diagnosis of narcolepsy
(Narcolepsy Value Set) any time during their history through the last day of the
measurement year.
Note: For the denominator, two measurement periods are used:
•

Index prescription start date (IPSD): 10 months before the measurement year
begins to 2 months after the measurement year begins

•

Negative medication history review: The time period covering 120 days prior to
the IPSD measurement period (beginning 120 days before the IPSD measurement
period begins and ending 120 days before the IPSD measurement period ends)

E. ADDITIONAL NOTES
For children who have multiple overlapping prescriptions, count the overlap days once
toward the days’ supply (whether the overlap is for the same drug or for a different drug).
There may be different methods for billing intensive outpatient encounters and partial
hospitalizations. Some methods may be comparable to outpatient billing, with separate
claims for each date of service; others may be comparable to inpatient billing, with an
admission date, a discharge date and units of service. Where billing methods are
comparable to inpatient billing, each unit of service may be counted as an individual visit.
The unit of service must have occurred during the time frame required for the rate (e.g.,
within 30 days after or from 31–300 days after the IPSD).
The source measure is designed for the Medicaid population and is not risk adjusted. The
source measure was specified and tested at the health plan level. This measure is
modified to require clinic-level reporting, and to be consistent in format with other
measures in this set of BHC measures, but is not tested at the clinic level.
Interpretation of score: Better quality = Higher score
185

Antidepressant Medication Management (AMM-BH)
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Antidepressant Medication Management (AMM-BH)
Based on a measure stewarded by the
National Committee for Quality Assurance (NQF #0105, HEDIS 2016)

A. DESCRIPTION
The percentage of consumers age 18 and older who were treated with antidepressant
medication, had a diagnosis of major depression, and who remained on an antidepressant
medication treatment. Two rates are reported:
•

Effective Acute Phase Treatment. Percentage of consumers who remained on an
antidepressant medication for at least 84 days (12 weeks)

•

Effective Continuation Phase Treatment. Percentage of consumers who remained on
an antidepressant medication for at least 180 days (6 months)

Data Collection Method: Administrative
Guidance for Reporting:
•

This measure is stratified by whether the consumer is a Medicaid beneficiary,
eligible for both Medicare and Medicaid, and other. It also is stratified by age.
States should calculate and report the two rates listed above for ages 18 to 64 and
age 65 and older. For purposes of determining whether a consumer is a Medicaid
beneficiary or a dual Medicare and Medicaid enrollee, see Continuous
Enrollment, Allowable Gap, and Anchor Date requirements below in section C.

•

Referenced Value Sets may be found in the BHC Value Set Directory.

•

Table AMM-C (Appendix AMM-BH) provides a list of antidepressant
medications. The National Committee for Quality Assurance’s (NCQA)
National Drug Code (NDC) current list of ADHD medications can be found at:
NCQA HEDIS 2016

•

To the extent possible, include all paid, suspended, pending, and denied claims.

•

Refer to the specific data-reporting template for the reporting requirements
applicable to each measure and to the Appendices in Volume 2 of this manual.

186

Antidepressant Medication Management (AMM-BH)
Please see NCQA Notice of Copyright and Disclaimers in front matter to this manual.

Measurement Period:
For the denominator, two measurement periods are used:
Index prescription start date (IPSD): The time period between 7 months before the
measurement year begins and 4 months after the measurement year begins
Negative medication history review: The time period between 105 days before the
IPSD measurement period begins and 105 days before the IPSD measurement
period ends
For the numerator, two measurement periods are used:
Acute Phase: The time period between 114 days after the IPSD measurement
period begins and 114 days after the IPSD measurement period ends
Continuation Phase: The time period between 231 days after the IPSD
measurement period begins and 231 days after the IPSD measurement period ends
B. DEFINITIONS
TERM

DEFINITION
The 12-month window starting 7 months prior to the measurement
year and ending at the end of the fourth months after the beginning of
Intake Period
the measurement year
Index Prescription Start Date: The earliest prescription dispensing
IPSD
date for an antidepressant medication during the Intake Period
A period of 105 days prior to the IPSD when the consumer had no
Negative
pharmacy claims for either new or refill prescriptions for an
Medication
antidepressant medication.
History
Provider Entity The provider entity that is being measured (i.e., BHC)
The actual number of calendar days covered with prescriptions within
the specified 180-day (6-month) measurement interval. For Effective
Treatment Days Continuation Phase Treatment, a prescription of 90 days (3 months)
supply dispensed on the 151st day will have 80 days counted in the
231-day interval.

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Antidepressant Medication Management (AMM-BH)
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C. ELIGIBLE POPULATION
CRITERIA

REQUIREMENTS
Consumers aged 18 and older as of the end of the fourth month of the
measurement year. Report two age stratifications:

Age

•

Continuous
Enrollment

Allowable Gap

Anchor Date
Benefits

Ages 18 - 64

• Ages 65+
105 days (3 months) prior to the IPSD through 231 days after the
IPSD
No more than one gap in enrollment of up to 45 days during the
continuous enrollment period. To determine continuous enrollment
for a consumer for whom enrollment is verified monthly, the
consumer may not have more than a 1-month gap in coverage (i.e., a
consumer whose coverage lapses for 2 months [60 days] is not
considered continuously enrolled).
IPSD
Medical and pharmacy

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Antidepressant Medication Management (AMM-BH)
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CRITERIA

REQUIREMENTS
Follow the steps below to identify the eligible population:
Step 1
Identify consumers flagged as having been seen at the provider entity
at least once during the measurement year.
Step 2
Identify consumers from step 1 who were aged 18 years and older as
of the end of the fourth month of the measurement year.
Step 3
Determine the IPSD. For consumers identified in step 2, identify the
date of the earliest dispensing event for an antidepressant medication
(Table AMM-C (Appendix AMM-BH)) during the Intake Period.

Event/Diagnosis

Step 4
Required exclusion. For consumers identified in step 3, exclude those
who did not have a diagnosis of major depression in an inpatient,
outpatient, ED, intensive outpatient, or partial hospitalization setting
during the 121 day period from 60 days prior to the IPSD, through
the IPSD and the 60 days after the IPSD. Consumers who meet any
of the following criteria remain in the eligible population:
•

An outpatient visit, intensive outpatient encounter or partial
hospitalization with any diagnosis of major depression. Either of
the following code combinations meets criteria:
o AMM Stand Alone Visits Value Set with Major Depression
Value Set
o AMM Visits Value Set with AMM POS Value Set and
Major Depression Value Set

•

An ED visit (ED Value Set) with any diagnosis of Major
Depression (Major Depression Value Set)

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Antidepressant Medication Management (AMM-BH)
Please see NCQA Notice of Copyright and Disclaimers in front matter to this manual.

CRITERIA

REQUIREMENTS
• An acute or nonacute inpatient discharge with any diagnosis of
Major Depression (Major Depression Value Set). To identify
acute and nonacute inpatient discharges:
o Identify all acute and nonacute inpatient stays (Inpatient
Stay Value Set)
o Identify the discharge date for the stay.

Event/Diagnosis
(cont’d)

Note: For a direct transfer, use the discharge date from the last
discharge.
Step 5
Test for Negative Medication History. For consumers identified in
step 4, exclude those who filled a prescription for an antidepressant
medication 105 days prior to the IPSD.
Step 6
Calculate continuous enrollment. For consumers identified in step 5,
identify those that are continuously enrolled for 105 days prior to the
IPSD to 231 days after the IPSD.

D. ADMINISTRATIVE SPECIFICATION
Denominator
The number of consumers in the eligible population (Section C)
Note: For the denominator, two measurement periods are used:
a. Index prescription start date (IPSD): The time period between 7 months before the
measurement year begins and 4 months after the measurement year begins
b. Negative medication history review: The time period between 105 days before the
IPSD measurement period begins and 105 days before the IPSD measurement
period ends
Numerator
Rate 1 - Effective Acute Phase Treatment
At least 84 days (12 weeks) of continuous treatment with antidepressant medication
(Table AMM-C (Appendix AMM-BH)) beginning on the IPSD through 114 days after
the IPSD (115 total days) Continuous treatment allows gaps in medication treatment up
to a total of 30 days during the 115-day period. Gaps can include either washout period
gaps to change medication or treatment gaps to refill the same medication.
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Antidepressant Medication Management (AMM-BH)
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Regardless of the number of gaps, there may be no more than 30 gap days. Count any
combination of gaps (e.g., two washout gaps of 15 days each, or two washout gaps of 10
days each and one treatment gap of 10 days).
Note: For the Acute Phase Treatment rate, the measurement period is the time period
between 114 days after the IPSD measurement period begins and 114 days after the IPSD
measurement period ends.
Rate 2 - Effective Continuation Phase Treatment
At least 180 days (6 months) of continuous treatment with antidepressant medication
(Table AMM-C (Appendix AMM-BH)) beginning on the IPSD through 231 days after
the IPSD (232 total days). Continuous treatment allows gaps in medication treatment up
to a total of 51 days during the 232-day period. Gaps can include either washout period
gaps to change medication or treatment gaps to refill the same medication.
Regardless of the number of gaps, there may be no more than 51 gap days. Count any
combination of gaps (e.g., two washout gaps, each of 25 days, or two washout gaps of 10
days each and one treatment gap of 10 days).
Note: For the Continuation Phase Treatment rate, the measurement period is the time
period between 231 days after the IPSD measurement period begins and 231 days after
the IPSD measurement period ends.
E. ADDITIONAL NOTES
There may be different methods for billing intensive outpatient encounters and partial
hospitalizations. Some methods may be comparable to outpatient billing, with separate
claims for each date of service; others may be comparable to inpatient billing, with an
admission date, a discharge date, and units of service. Where billing methods are
comparable to inpatient billing, each unit of service may be counted as an individual visit.
The unit of service must have occurred during the period specified.
The source measure is designed for the Medicaid population and is not risk adjusted. The
source measure was specified and tested at the health plan level. This measure is
modified to require clinic-level reporting, and to be consistent in format with other
measures in this set of BHC measures, but is not tested at the clinic level.
Interpretation of score: Better quality = Higher score

191

Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (IET-BH)
Please see NCQA Notice of Copyright and Disclaimers in front matter to this manual.

Initiation and Engagement of Alcohol and Other Drug Dependence Treatment
(IET-BH)
Based on a measure stewarded by the
National Committee for Quality Assurance (NQF #0004, HEDIS 2016)
A. DESCRIPTION
Percentage of consumers age 13 and older with a new episode of alcohol or other drug
(AOD) dependence who received the following:
•

Initiated treatment through an inpatient AOD admission, outpatient visit, intensive
outpatient encounter, or partial hospitalization within 14 days of the diagnosis

•

Initiated treatment and who had two or more additional services with a diagnosis
of AOD within 30 days of the initiation visit

Data Collection Method: Administrative
Guidance for Reporting:
•

Two rates are reported: initiation of AOD treatment and engagement of AOD
treatment.

•

This measure is stratified by age (aged 13 to 17 years, aged 18 to 64 years, aged
65 years and older) and by whether the consumer is a Medicaid beneficiary,
eligible for both Medicare and Medicaid, and other. For purposes of determining
whether a consumer is a Medicaid beneficiary or a dual Medicare and Medicaid
enrollee, see Continuous Enrollment, Allowable Gap, and Anchor Date
requirements below in section C.

•

Referenced Value Sets may be found in the BHC Value Set Directory.

•

To the extent possible, include all paid, suspended, pending, and denied claims.

•

Refer to the specific data-reporting template for the reporting requirements
applicable to each measure and to the Appendices in Volume 2 of this manual.

Measurement Period:
For the denominator, two measurement periods are used:
•

The Index Episode Start Date (IESD) measurement period is the first 10
months and 15 days of the measurement year.

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Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (IET-BH)
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•

The Negative Diagnosis History Review measurement period looks back 60
days prior to the IESD. It begins 60 days prior to the measurement year and
ends 60 days prior to the last possible date of the IESD during the
measurement year.

For the numerator, two measurement periods are used:
•

The measurement period for Initiation of AOD Treatment covers the 13 days
following the IESD. It begins on the 1st day of the first month and ends 13
days after the measurement period for the IESD ends.

•

The measurement period for Engagement of AOD Treatment covers the 29
days following Initiation of AOD Treatment. It begins on the 2nd day of the
first month and ends 29 days after the measurement period for Initiation of
AOD Treatment ends.

B. DEFINITIONS
TERM
Intake Period

Index Episode

DEFINITION
The first 10 months and 15 days of the measurement year. The Intake
Period is used to capture new episodes of AOD.
The earliest inpatient, intensive outpatient, partial hospitalization,
outpatient, detoxification, or emergency department (ED) visit during
the Intake Period with a diagnosis of AOD.
For ED visits that result in an inpatient stay, the inpatient stay is the
Index Episode.
Index Episode Start Date (IESD). The earliest date of service for an
inpatient, intensive outpatient, partial hospitalization, outpatient,
detoxification, or ED encounter during the Intake Period with a
diagnosis of AOD.

IESD

For an outpatient, intensive outpatient, partial hospitalization,
detoxification, or ED visit (not resulting in an inpatient stay), the IESD
is the date of service.
For an inpatient (acute or nonacute) event, the IESD is the date of
discharge.
For an ED visit that results in an inpatient event, the IESD is the date
of the inpatient discharge.
For direct transfers, the IESD is the discharge date from the last
admission.

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Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (IET-BH)
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TERM

Negative
Diagnosis
History

Provider Entity

DEFINITION
A period of 60 days (2 months) before the IESD when the consumer
had no claims/encounters with a diagnosis of AOD dependence.
For an inpatient event, use the admission date to determine the
Negative Diagnosis History.
For ED visits that result in an inpatient stay, use the ED date of service
to determine the Negative Diagnosis History.
For direct transfers, use the first admission to determine the Negative
Diagnosis History.
The provider entity that is being measured (i.e., BHC)

C. ELIGIBLE POPULATION
CRITERIA

Age

Continuous
Enrollment
Allowable Gap
Anchor Date
Benefits

REQUIREMENTS
Consumers ages 13 years and older as of the last day of the
measurement year. Report three age stratifications:
• Ages 13 to 17
• Ages 18 to 64
• Ages 65+
60 days (2 months) prior to the IESD through 44 days after the IESD
(105 total days)
None
None
Medical and chemical dependency (inpatient and outpatient)
Note: Medicaid enrollees with detoxification-only chemical
dependency benefits do not meet these criteria.

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Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (IET-BH)
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CRITERIA

REQUIREMENTS
Follow the steps below to identify the eligible population:
Step 1
Identify the Index Episode. Identify all consumers in the specified age
range who during the Intake Period had one of the following:
1. An outpatient visit, intensive outpatient visit, or partial
hospitalization with a diagnosis of AOD. Any of the following
code combinations meet criteria:

Event/Diagnosis

•

IET Stand Alone Visits Value Set with AOD Dependence
Value Set

•

IET Visits Group 1 Value Set with IET Place of Services
(POS) Group 1 Value Set and AOD Dependence Value Set

•

IET Visits Group 2 Value Set with IET POS Group 2 Value
Set and AOD Dependence Value Set

2. A detoxification visit (Detoxification Value Set)
3. An ED visit (ED Value Set) with a diagnosis of AOD (AOD
Dependence Value Set)
OR
4. An acute or nonacute inpatient discharge with either an AOD
diagnosis (AOD Dependence Value Set) or an AOD procedure
code (AOD Procedures Value Set). To identify acute and
nonacute inpatient discharges:
•

Identify all acute and nonacute inpatient stays (Inpatient
Stay Value Set).

•

Identify the discharge date for the stay.

Note: For consumers with more than one episode of AOD, use the first
episode.

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Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (IET-BH)
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CRITERIA

REQUIREMENTS
Note: For consumers whose first episode was an ED visit that resulted
in an inpatient stay, use the inpatient discharge.
Select the IESD.

Event/Diagnosis
(cont’d)

Step 2
For consumers from step 1, test for Negative Diagnosis History.
Exclude consumers who had a claim/encounter with a diagnosis of
AOD (AOD Dependence Value Set) during the 60 days (2 months)
before the IESD.
Note: For an inpatient IESD, use the admission date to determine the
60-day Negative Diagnosis History period.
Note: For an ED visit that results in an inpatient stay, use the ED date
of service to determine the 60-day Negative Diagnosis History period.
Step 3
For consumers from step 2, calculate continuous enrollment.
Consumers must be continuously enrolled for 60 days (2 months)
before the IESD through 44 days after the IESD (105 total days), with
no gaps.

D. ADMINISTRATIVE SPECIFICATION
Denominator
The number of consumers in the eligible population (Section C)
Note: For the denominator, two measurement periods are used:
•

The Index Episode Start Date (IESD) is the first 10 months and 15 days of the
measurement year.

•

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Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (IET-BH)
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Numerator
Rate 1: Initiation of AOD Treatment
Initiation of AOD treatment through an inpatient admission, outpatient visit, intensive
outpatient encounter, or partial hospitalization within 14 days of diagnosis.
If the Index Episode was an inpatient discharge, the inpatient stay is considered
initiation of treatment and the consumer is compliant.
If the Index Episode was an outpatient, intensive outpatient, partial
hospitalization, detoxification, or ED visit, the consumer must have an inpatient
admission, outpatient visit, intensive outpatient encounter, or partial
hospitalization, with a diagnosis of AOD, on the IESD or in the 13 days after the
IESD (14 total days). If the IESD and the initiation visit occur on the same day,
they must be with different providers in order to count. Any of the following
code combinations meet criteria:
1. An acute or nonacute inpatient admission with a diagnosis of AOD (AOD
Dependence Value Set). To identify acute and nonacute inpatient admissions:
a. Identify all acute and nonacute inpatient stays (Inpatient Stay Value
Set).
b. Identify the admission date for the stay.
2. IET Stand Alone Visits Value Set with AOD Dependence Value Set
3. IET Visits Group 1 Value Set with IET POS Group 1 Value Set and AOD
Dependence Value Set
OR
4. IET Visits Group 2 Value Set with IET POS Group 2 Value Set and AOD
Dependence Value Set
Note: Do not count events that include inpatient detoxification or detoxification
codes (Detoxification Value Set) when identifying initiation of treatment.
Note: For the Initiation numerator, the measurement period covers the 13 days
following the IESD. It begins on the 1st day of the first month and ends 13 days
after the measurement period for the IESD ends.

197

Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (IET-BH)
Please see NCQA Notice of Copyright and Disclaimers in front matter to this manual.

Rate 2: Engagement of AOD Treatment
Initiation of treatment with two or more additional services with a diagnosis of
AOD within 30 days of the initiation visit
Identify all consumers who meet the following criteria:
•

Numerator compliant for Rate 1 and

•

Two or more inpatient admissions, outpatient visits, intensive outpatient visits,
or partial hospitalizations with any AOD diagnosis, beginning on the day after
the initiation encounter through 29 days after the initiation event (29 total
days). Multiple engagement visits may occur on the same day, but they must
be with different providers in order to count. Any of the following code
combinations meet criteria:

1. An acute or nonacute inpatient admission with a diagnosis of AOD (AOD
Dependence Value Set). To identify acute and nonacute inpatient admissions:
a. Identify all acute and nonacute inpatient stays (Inpatient Stay Value
Set).
b. Identify the admission date for the stay.
2. IET Stand Alone Visits Value Set with AOD Dependence Value Set
3. IET Visits Group 1 Value Set with IET POS Group 1 Value Set and AOD
Dependence Value Set
OR
4. IET Visits Group 2 Value Set with IET POS Group 2 Value Set and AOD
Dependence Value Set
Note: For consumers who initiated treatment via an inpatient admission, the 29day period for the two engagement visits begins the day after discharge.
Note: Do not count events that include inpatient detoxification or detoxification
codes (Detoxification Value Set) when identifying the engagement of AOD
treatment.
Note: The time frame for engagement, which includes the initiation event, is 30
total days.
Note: For the Engagement numerator, the measurement period covers the 29 days
following Initiation of AOD Treatment. It begins on the 2nd day of the first
month and ends 29 days after the measurement period for Initiation.
198

Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (IET-BH)
Please see NCQA Notice of Copyright and Disclaimers in front matter to this manual.

Exclusions
Exclude consumers from the denominator for both rates if the initiation of treatment
event is an inpatient stay with a discharge date after the 11th month of the measurement
year.
E. ADDITIONAL NOTES
The source measure is designed for the Medicaid population and is not risk adjusted. The
source measure was specified and tested at the health plan level. This measure is
modified to require clinic-level reporting, and to be consistent in format with other
measures in this set of BHC measures, but is not tested at the clinic level.
There may be different methods for billing intensive outpatient encounters and partial
hospitalizations. Some methods may be comparable to outpatient billing, with separate
claims for each date of service; others may be comparable to inpatient billing, with an
admission date, a discharge date, and units of service. Where billing methods are
comparable to inpatient billing, each unit of service may be counted as an individual visit.
The unit of service must have occurred during the required time frame for the rate.
Interpretation of score: Better quality = Higher score

199

File Type	application/pdf
File Title	Metrics and Quality Measures for Behavioral Health Clinics, Technical Specifications and Resource Manual
Subject	Quality Measures, CCBHCs, Behavioral Health Clinics, Specifications
Author	Substance Abuse and Mental Health Services Administration
File Modified	2016-04-26
File Created	2016-04-11