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pdfSection 1115 Serious Mental Illness
and Serious Emotional Disturbance
Demonstrations Monitoring Metrics
Technical Specifications
Version 1
October 11, 2019
Section 1115 Serious Mental Illness and Serious Emotional Disturbance Demonstrations
Monitoring Metrics Technical Specifications
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timely and accurate review of states’ monitoring report submissions of Medicaid Section 1115 Severe Mental Illness
and Severe Emotional Disturbance Demonstrations, and also support consistency in monitoring and evaluation,
increase in reporting accuracy, and reduction in timeframes required for monitoring and evaluation. Under the
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1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
MATHEMATICA
CONTENTS
ACRONYMS ................................................................................................................................................ vii
ACKNOWLEDGEMENTS .............................................................................................................................xi
I.
BACKGROUND AND INTRODUCTION .......................................................................................... 1
A. Overview of 1115 SMI/SED demonstration monitoring metrics ................................................ 1
B. Reporting 1115 SMI/SED demonstration monitoring metrics defined by CMS ......................... 8
C. Using technical specifications.................................................................................................. 13
II.
METRIC SPECIFICATIONS .......................................................................................................... 15
APPENDIX A ESTABLISHED MEASURES AND MEASURE SETS REFERENCED IN
TECHNICAL SPECIFICATIONS .................................................................................. A.1
APPENDIX B VALUE SETS REFERENCED IN METRIC SPECIFICATIONS ......................................... B.1
APPENDIX C HOW TO USE SUPPORTING MEASURE SPECIFICATIONS, VALUE SETS,
AND CODE LISTS TO CALCULATE METRICS ..........................................................C.1
APPENDIX D TECHNICAL SPECIFICATIONS FOR ESTABLISHED QUALITY MEASURES
ADAPTED FROM FFY 2019 ADULT CORE SET MEASURE
SPECIFICATIONS ........................................................................................................D.1
APPENDIX E STANDARDIZED DEFINITION OF SMI ............................................................................ E.1
APPENDIX F ALOS STANDARD DEVIATIONS ...................................................................................... F.1
TABLES
1
Summary of 111SMI/SED monitoring metrics ................................................................................. 1
2
Overview of section 1115 SMI/SED demonstration monitoring metrics, by
measurement domain ...................................................................................................................... 4
3
Example of alignment between demonstration years and measurement periods ......................... 10
4
Reporting in quarterly and annual monitoring reports .................................................................... 11
5
Table shell for the metrics’ technical specifications ....................................................................... 13
A.1
Established measures and measure sets referenced in metric specifications ............................. A.3
B.1
HEDIS and other value sets referenced in metric specifications .................................................. B.3
C.1
How to use supporting measure specifications, value sets and code lists to
calculate metrics ...........................................................................................................................C.3
D.1
Measurement Period for Denominators and Numerators for the 1115 SMI/SED
Monitoring Metrics Adapted from FFY 2019 Child and Adult Core Set Measures .......................D.4
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METRICS
Metric #1: SUD Screening of Beneficiaries Admitted to Psychiatric Hospitals or Residential
Treatment Settings (SUB-2) ........................................................................................................................ 15
Metric #2: Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics
(APP-CH) .................................................................................................................................................... 16
Metric #3 All-Cause Emergency Department (ED) Utilization Rate for Medicaid Beneficiaries who
may Benefit From Integrated Physical and Behavioral Health Care (PMH-20) .......................................... 17
Metric #4: 30-Day All-Cause Unplanned Readmission Following Psychiatric Hospitalization in an
Inpatient Psychiatric Facility (IPF) ............................................................................................................... 18
Metric #5: Medication Reconciliation Upon Admission ............................................................................... 20
Metric #6: Medication Continuation Following Inpatient Psychiatric Discharge .......................................... 21
Metric #7: Follow-up After Hospitalization for Mental Illness: Ages 6-17 (FUH-CH) .................................. 22
Metric #8: Follow-up After Hospitalization for Mental Illness: Age 18 and Older (FUH-AD) ....................... 23
Metric #9: Follow-up After Emergency Department Visit for Alcohol and Other Drug Abuse
Dependence (FUA-AD) ............................................................................................................................... 24
Metric #10: Follow-up After Emergency Department Visit for Mental Illness (FUM-AD) ............................ 25
Metric #11: Suicide or Overdose Death Within 7 and 30 Days of Discharge From an Inpatient
Facility or Residential Treatment for Mental Health Among Individuals With SMI or SED (count) ............. 26
Metric #12: Suicide or Overdose Death Within 7 and 30 Days of Discharge From an Inpatient
Facility or Residential Treatment for Mental Health Among Individuals With SMI or SED (rate) ............... 29
Metric #13: Mental Health Services Utilization - Inpatient ......................................................................... 32
Metric #14: Mental Health Services Utilization - Intensive Outpatient and Partial Hospitalization ............ 33
Metric #15: Mental Health Services Utilization - Outpatient ........................................................................ 35
Metric #16: Mental Health Services Utilization - ED ................................................................................... 37
Metric #17: Mental Health Services Utilization - Telehealth ....................................................................... 38
Metric #18: Mental Health Services Utilization– Any Services ................................................................... 39
Metric #19a: Average Length of Stay in IMDs ............................................................................................ 41
Metric #19b: Average Length of Stay in IMDs (IMDs receiving FFP only) ................................................ 44
Metric #20: Beneficiaries With SMI/SED Treated in an IMD for Mental Health .......................................... 47
Metric #21: Count of Beneficiaries With SMI/SED (monthly) ...................................................................... 49
Metric #22: Count of Beneficiaries With SMI/SED (annually) ..................................................................... 50
Metric #23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c (HbA1c)
Poor Control (>9.0%) (HPCMI-AD) ............................................................................................................. 51
Metric #24: Screening for Depression and Follow-Up Plan: Age 18 and Older (CDF-AD)......................... 52
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Metric #25: Screening for Depression and Follow-Up Plan: Ages 12–17 (CDF-CH) ................................. 53
Metric #26: Access to Preventive/Ambulatory Health Services for Medicaid Beneficiaries With
SMI .............................................................................................................................................................. 54
Metric #27: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or
Alcohol or Other Drug Dependence ............................................................................................................ 55
Metric #28: Alcohol Screening and Follow-up for People with Serious Mental Illness ............................... 56
Metric #29: Metabolic Monitoring for Children and Adolescents on Antipsychotics ................................... 57
Metric #30: Follow-Up Care for Adult Medicaid Beneficiaries Who are Newly Prescribed an
Antipsychotic Medication............................................................................................................................. 58
Metric #31: Use of Multiple Concurrent Antipsychotics in Children and Adolescents (APC-CH) ............... 59
Metric #32: Total Costs Associated with Mental Health Services Among Beneficiaries with
SMI/SED – Not Inpatient or Residential ...................................................................................................... 60
Metric #33: Total Costs Associated with Mental Health Services Among Beneficiaries with
SMI/SED –Inpatient or Residential ............................................................................................................. 63
Metric #34: Per Capita Costs Associated With Mental Health Services Among Beneficiaries with
SMI/SED - Not Inpatient or Residential ...................................................................................................... 65
Metric #35: Per Capita Costs Associated With Mental Health Services Among Beneficiaries with
SMI/SED - Inpatient or Residential ............................................................................................................ 66
Metric #36: Grievances Related to services for SMI/SED .......................................................................... 67
Metric #37: Appeals Related to Services for SMI/SED ............................................................................... 68
Metric #38: Critical Incidents Related to Services for SMI/SED ................................................................. 69
Metric #39: Total Costs Associated With Treatment for Mental Health in an IMD Among
Beneficiaries with SMI/SED ........................................................................................................................ 70
Metric #40: Per Capita Costs Associated With Treatment for Mental Health in an IMD Among
Beneficiaries With SMI/SED........................................................................................................................ 75
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ACRONYMS
AAP
Adults’ Access to Preventive/Ambulatory Health Services (measure)
AHRQ
Agency for Healthcare Research and Quality
ALOS
Average Length of Stay
AD
Adult Core Set
AMA
American Medical Association
AOD
Alcohol or Other Drug Dependence
APC
Use of Multiple Concurrent Antipsychotics in Children and Adolescents
(measure)
APM
Metabolic Monitoring for Children and Adolescents on Antipsychotics
(measure)
APP
Use of first-line psychosocial care for children and adolescents on
antipsychotics (measure)
BDI or BDI-II Beck Depression Inventory
BDI-PC
Beck Depression Inventory-Primary Care Version
BH
Behavioral Health
CCBHC
Certified Community Behavioral Health Clinics Demonstration
CCS
Clinical Classification Software
CDF
Screening for Depression and Follow-Up Plan
CES-D
Center for Epidemiologic Studies Depression Scale
CH
Child Core Set
CHIP
Children’s Health Insurance Program
CMCS
Center for Medicaid & CHIP Services
CMS
Centers for Medicare & Medicaid Services
CPT
Current Procedural Terminology
CSDD
Cornell Scale for Depression in Dementia
DADS
Duke Anxiety- Depression Scale
DEPS
Depression Scale
DNI
Do Not Intubate
DNR
Do Not Resuscitate
DO
Doctor of Osteopathy
DY
Demonstration Year
ED
Emergency Department
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EHR
Electronic Health Record
FFP
Federal Financial Participation
FFS
Fee for Service
FFY
Federal Fiscal Year
FUA
Follow-up After Emergency Department Visit for Alcohol and Other Drug
Abuse Dependence (measure)
FUH
Follow-Up After Hospitalization for Mental Illness (measure)
FUM
Follow-up After Emergency Department Visit for Mental Illness (measure)
GDS
Geriatric Depression Scale
HAM-D
Hamilton Rating Scale for Depression
HCPCS
Healthcare Common Procedure Coding System
HEDIS
Healthcare Effectiveness Data and Information Set
HPCMI
Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c
(HbA1c) Poor Control (>9.0%) (measure)
HWR
Hospital-Wide Readmission (HWR)
ICD
International Classification of Diseases
IET
Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence
Treatment (measure)
IMD
Institution for Mental Diseases
IOP/PH
Intensive Outpatient Care/Partial Hospitalization
IPF
Inpatient Psychiatric Facility
IPFQR
Inpatient Psychiatric Facility Quality Reporting Program
IPSD
Index Prescription Start Date
LDL
Low-Density Lipoprotein
LOINC
Logical Observation Identifiers Names and Codes
MCO
Managed Care Organization
MD
Doctor of Medicine
MDD
Major Depressive Disorder
MLD
Medication List Directory
MPT
Mental Health Utilization measure
MSIS
Medicaid Statistical Information System
NBCC
National Board for Certified Counselors
NCQA
National Committee for Quality Assurance
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NDC
National Drug Code
NEC
Not Elsewhere Classified
NQF
National Quality Forum
NPI
National Provider Identifier
PHQ-9
Patient Health Questionnaire
PMH-20
All-cause Emergency Department Utilization Rate for Medicaid Beneficiaries
Who May Benefit from Integrated Physical and Behavioral Health Care
(measure)
POS
Place of Service
PTA
Prior To Admission
QDWI
Qualified Disabled and Working Individuals
QI
Qualified Individuals
QID-SR
Quick Inventory of Depressive Symptomatology Self-Report
QMB
Qualified Medicare Beneficiary
RN
Registered Nurse
SAMHSA
Substance Abuse and Mental Health Services Administration
SED
Serious Emotional Disturbance
SLMB
Specified Low-Income Medicare Beneficiary
SMDL
State Medicaid Director Letter
SMI
Serious Mental Illness
SUB-2
Alcohol Use Brief Intervention Provided or Offered (measure)
SUD
Substance Use Disorder
TJC
The Joint Commission
T-MSIS
Transformed Medicaid Statistical Information System
UB
Uniform Bill Codes
VS
Value Set
WHO
World Health Organization
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1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
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ACKNOWLEDGEMENTS
For Proprietary Codes:
CPT® codes copyright 2018 American Medical Association (AMA). All rights reserved.
CPT is a trademark of the American Medical Association. No fee schedules, basic units, relative
values or related listings are included in CPT. The AMA assumes no liability for the data
contained herein. Applicable FARS/DFARS restrictions apply to government use.
The International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9CM) 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, 9th Revision, Procedure Coding System (ICD9-PCS) is published by the World Health Organization (WHO). ICD-9-PCS is an official Health
Insurance Portability and Accountability Act standard.
The International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10CM) is published by the World Health Organization (WHO). ICD-10-CM is an official Health
Insurance Portability and Accountability Act standard.
The International Classification of Diseases, 10th Revision, Procedure Coding System (ICD10-PCS) is published by the World Health Organization (WHO). ICD-10-PCS is an official
Health Insurance Portability and Accountability Act standard.
The American Hospital Association (AHA) holds a copyright to the Uniform Bill Codes
(“UB”). The UB Codes in the Child Core Set and Adult Core Set specifications are included with
the permission of the AHA. The UB Codes contained in the Child Core Set and Adult Core Set
specifications may be used by states, health plans, and other health care delivery organizations
for the purpose of calculating and reporting Child Core Set and Adult Core Set measure results
or using Child Core Set and Adult Core Set measure results for their internal quality
improvement purposes. All other uses of the UB Codes require a license from the AHA. Anyone
desiring to use the UB Codes in a commercial product to generate measure results, or for any
other commercial use, must obtain a commercial use license directly from the AHA. To inquire
about licensing, please contact [email protected].
For National Committee for Quality Assurance (NCQA) measures in the technical
specifications for 1115 SMI/SED demonstration monitoring metrics:
Content reproduced with permission from HEDIS 2016 and 2019 Volume 2: Technical
Specifications for Health plans by the National Committee for Quality Assurance (NCQA).
HEDIS® is a registered trademark of NCQA. HEDIS measures and specifications are not
clinical guidelines and do not establish a standard of medical care. Use of an NQCA measure
does not indicate endorsement of it. 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 or specifications.
Anyone desiring to use or reproduce the materials without modification for a non-commercial
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.
xi
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The measure specification methodology used by CMS is different from NCQA’s
methodology. NCQA has not validated the adjusted measure specifications but has granted CMS
permission to adjust. Calculated measure results, based on the adjusted HEDIS specifications,
may be called only “Uncertified, Unaudited HEDIS rates.”
Measures in the CMS 1115 SMI/SED Demonstration contain HEDIS Value Sets (VS)
developed by and included with the permission of the NCQA.
Limited proprietary coding is contained in the measure specifications and HEDIS VS for
convenience; users of the proprietary code sets should obtain all necessary licenses from the
owners of these code sets. NCQA disclaims all liability for use or accuracy of any coding
contained in the specifications and VS.
The American Medical Association holds a copyright to the CPT@ codes contained in the
measure specifications and VS.
The American Hospital Association holds a copyright to the Uniform Billing Codes ("UB")
contained in the measure specifications and VS. The UB Codes are included with the permission
of the AHA. Anyone desiring to use the UB Codes in a commercial product to calculate measure
results, or for any other commercial use, must obtain a commercial use license directly from the
AHA. To inquire about licensing, contact [email protected].
MEASURE RATE NOTICE
States must prominently display the following notice on any display of Measure rates:
The MPT, FUH-CH, FUH-AD, FUA-AD, FUM-AD, AAP, APM, and APC measures
(metrics #13, 14, 15, 16, 17, 18, 7, 8, 9, 10, 26, 29, 31) are Healthcare Effectiveness Data and
Information Set (“HEDIS®”) measures that are owned and copyrighted by the National
Committee for Quality Assurance (“NCQA”). 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 or specifications.
The measure specification methodology used by CMS is different from NCQA’s
methodology. NCQA has not validated the adjusted measure specifications but has granted CMS
permission to adjust. Calculated measure results, based on the adjusted HEDIS specifications,
may be called only “Uncertified, Unaudited HEDIS rates.”
Certain non-NCQA measures in the CMS 1115 Substance Use Disorder Demonstration
contain HEDIS Value Sets (VS) developed by and included with the permission of the NCQA.
Proprietary coding is contained in the VS. Users of the proprietary code sets should obtain all
necessary licenses from the owners of these code sets. NCQA disclaims all liability for use or
accuracy of the VS with the non-NCQA measures and any coding contained in the VS.
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For the Joint Commission measure in the technical specifications for 1115 SMI/SED
demonstration monitoring metrics:
The Specifications Manual for National Hospital Inpatient Quality Measures [Versions 5.5
and 5.6] is periodically updated by the Centers for Medicare & Medicaid Services and The Joint
Commission. Users of the Specifications Manual for National Quality Measures must update
their software and associated documentation based on the published manual production
timelines.
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1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
I.
MATHEMATICA
BACKGROUND AND INTRODUCTION
This document provides instructions on how to calculate and report monitoring metrics for
states with section 1115 demonstrations that focus on serious mental illness (SMI) and serious
emotional disturbance (SED).1
Center for Medicaid and Chip Services (CMCS) selected SMI/SED demonstration
monitoring metrics with input from subject matter experts and members of the state technical
advisory group for Medicaid monitoring and evaluation. These metrics consist of (1) established
quality measures endorsed by NQF or included in other Medicaid Quality Measures measure
sets2 and (2) CMS-constructed implementation performance metrics to track the goals and
milestones presented in the State Medicaid Directors Letter dated November 13, 2018 (SMDL
#18-011). The implementation performance metrics often refer to definitions included in
established quality measures, but they did not go through the measure endorsement process and
are intended only for monitoring progress of SMI/SED demonstrations.
A. Overview of 1115 SMI/SED demonstration monitoring metrics
There are 40 metrics representing several demonstration milestones (Table 1).
Table 1. Summary of 1115 SMI/SED monitoring metrics
Demonstration milestonesa
Number of metricsb
Milestone 1: Ensuring Quality of Care in Psychiatric Hospitals and Residential Settings
2
Milestone 2: Improving Care Coordination and Transitions to Community-Based Care
10
Milestone 3: Increasing Access to Continuum of Care including Crisis Stabilization
Services
8
Milestone 4: Earlier Identification and Engagement in Treatment including through
Increased Integration
11
Other SMI/SED Metrics
9
Total
a
40
Milestones included in this table are from the State Medicaid Director Letter #18-011.
metric is listed under a primary milestone above. However, some metrics may address multiple milestones.
b Each
This set of metrics will be updated annually. As part of the annual update, metrics may be
removed, or added as new metrics are tested, endorsed, or selected for use.
Table 2 lists 1115 SMI/SED demonstration monitoring metrics by demonstration milestone
and provides key reporting parameters, including the measurement period and population groups
for each metric. The following reporting instructions apply to all metrics:
1
See the acronyms list on page vii for definitions of all acronyms in this document.
2
The 2019 Child Core Set and Adult Core Set.
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1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
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•
Measurement period. This parameter identifies the measurement period (the data collection
time frame) for each metric. Measurement periods may be month, quarter, or year. Section B
provides detailed guidance and reporting instructions for measurement period.
•
Reporting level. This parameter identifies the groups for which the metric should be
reported. SMI/SED demonstrations can operate at multiple levels: statewide; within a given
geographic area, such as a county; or within a model of care, such as an accountable care
organization. Model of care refers to the delivery system used to implement the
demonstration. For example, if demonstration services are provided by managed care
organizations (MCOs) for some beneficiaries and Medicaid fee-for-service (FFS) for others,
then the state could report metrics separately for each MCO and the fee-for-service
population. In addition, states may operate more than one SMI/SED program within a
demonstration, each providing different services for different beneficiaries. States must
report all metrics for the SMI/SED demonstration population overall. If a state includes
multiple programs that it runs separately by geographic area or model of care, states may
report metrics separately for each area or model. Under those circumstances, reporting
measures at the state level could obscure important differences across programs.
•
Demonstration population. The SMI/SED demonstration population is defined as any
beneficiary with a SMI/SED diagnosis in the measurement period and/or in the 12 months
before the measurement period. Any beneficiary with an IMD stay for SMI would also be
captured in this population.
•
Subpopulations. Some subpopulations have unique treatment needs with respect to
SMI/SED. When instructed by metric specifications, states should calculate and report
metrics for each stratification within subgroups. These subgroups are as follows:
-
Standardized definition of SMI. We refer to the National Committee for Quality
Assurance (NCQA) definition of SMI as the standardized definition of SMI3. NCQA
defines individuals with SMI as those who meet at least one of the following criteria
within the measurement period: (1) at least one acute inpatient claim/encounter with any
diagnosis of schizophrenia, bipolar I disorder, or major depression, 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, 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. See Table B.1 for applicable value sets and Appendix E for details.
-
State-specific definition of SMI. States may have their own distinct definition of SMI and
report according to the definition they provide in their monitoring protocols, specifically
within the document: 1115 SMI Monitoring Workbook.xlsx on the “Protocol-SMI &
SED definitions” tab.
-
Age groups (children <16, transition-age youth, 16-24, adults 25–64, and older adults
65+). Determine beneficiary age status as of the first day of the measurement period.
3
CMS acknowledges that the NCQA definition is somewhat narrowly targeted to three conditions (schizophrenia,
bipolar I disorder, and major depression) and may not capture the full range of individuals with SMI targeted by
states. CMS is using the NCQA definition as method to gather relatively standardized data from states.
2
1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
•
MATHEMATICA
-
Dual–eligible status (Medicaid only or Medicare-Medicaid eligible). Determine dual
eligible status as of the first day of the measurement period. For reference, in T-MSIS,
dual eligible status is determined by the eligibility file data element, DUAL-ELIGIBLECODE.4
-
Eligible for Medicaid on the basis of disability (yes, no). Determine eligibility for
Medicaid on the basis of disability based on ever qualifying for this subpopulation
during the measurement period. For reference, in T-MSIS, eligibility based on disability
is determined by the eligibility file data element, ELIGIBILITY-GROUP.
-
Criminal justice status (criminally involved, not criminally involved). Determine
criminal justice status based on ever qualifying for this subpopulation during the
measurement period. There is no standard methodology across states for identifying
criminal justice status; states will need to identify a method for flagging criminal
involvement (such as by matching Medicaid beneficiaries to data from state law
enforcement agencies).
-
Co-occurring SUD. Determine co-occurring SUD for this subpopulation during the
measurement period. States can identify beneficiaries with co-occurring SUD by
identifying beneficiaries with a SUD diagnosis and a SUD-related service during the
measurement period and/or in the 11 months before the measurement period.
-
Co-occurring or physical health conditions. Determine co-occurring physical health
conditions for this subpopulation during the measurement period. States may use the
definitions and ICD-10 codes in the CMS Chronic Conditions Data Warehouse
(https://www.ccwdata.org/documents/10280/19139421/ccw-chronic-conditionalgorithms.pdf) to identify co-occurring physical health conditions.
Data source. This parameter identifies the likely data source(s) to be used to report each
metric. Data sources include claims data, medical and administrative records, provider
enrollment databases, and other state-specific databases.
4
The T-MSIS data dictionary can be accessed at https://www.medicaid.gov/medicaid/data-and-systems/macbis/
tmsis/index.html. Additional resources for reporting on dually eligible beneficiaries is available on Medicaid.gov.
See, for example, https://www.medicaid.gov/state-resource-center/innovation-accelerator-program/iapdownloads/functional-areas/integrated-medicare-medicaid-data.pdf, and https://www.medicaid.gov/state-resourcecenter/innovation-accelerator-program/iap-functional-areas/data-analytics/index.html
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Table 2. Overview of section 1115 SMI/SED demonstration monitoring metrics, by measurement domain
Reporting level
Metric name
1
2
3
4
5
6
7
8
9
10
11
Milestone 1A
SUD Screening of Beneficiaries
Admitted to Psychiatric Hospitals or
Residential Treatment Settings (SUB2)
Use of First-Line Psychosocial Care
for Children and Adolescents on
Antipsychotics (APP-CH)
Milestone 2 A
All-Cause Emergency Department
Utilization Rate for Medicaid
Beneficiaries who may Benefit From
Integrated Physical and Behavioral
Health Care (PMH-20)
30-Day All-Cause Unplanned
Readmission Following Psychiatric
Hospitalization in an Inpatient
Psychiatric Facility (IPF)
Medication Reconciliation Upon
Admission
Medication Continuation Following
Inpatient Psychiatric Discharge
Follow-up After Hospitalization for
Mental Illness: Ages 6-17 (FUH-CH)
Endorsement; Use in
other programs
Data
source
Required or
recommended
Demonstration
Model/
Area
Subpopulations
Measurement
Period
NQF #1663;
IPFQR
Medical record
review or claims
Recommended
X
X
None
Year
NQF #2801; Child Core
Set
Claims
Required
X
X
None
Year
Claims
Required
X
X
None
Year
Claims
Required
X
X
None
Year
Electronic/ paper
medical records
Claims
Recommended
X
X
None
Year
Required
X
X
None
Year
Claims
Required
X
X
None
Year
Claims
Required
X
X
None
Year
Claims
Required
X
X
None
Year
Claims
Required
X
X
None
Year
X
X
Age only
Year
Based on NQF #2860;
Medicare Inpatient
Psychiatric Facility
Quality Reporting
Program (IPFQR)
Based on NQF #3317
Based on NQF #3205
NQF #0576; IPFQR;
Child Core Set;
Scorecard
Follow-up After Hospitalization for
NQF #0576;
Mental Illness: Age 18 and Older
IPFQR; Adult Core Set;
(FUH-AD)
Scorecard
Follow-up After Emergency
NQF #2605; Adult Core
Department Visit for Alcohol and Other Set
Drug Abuse (FUA-AD)
Follow-Up After Emergency
NQF #2605; Adult Core
Department Visit for Mental Illness
Set
(FUM-AD)
Suicide or Overdose Death Within 7
None
and 30 Days of Discharge From an
Inpatient Facility or Residential
Treatment for Mental Health Among
Beneficiaries With SMI or SED (count)
State data on cause Recommended
of death, linked to
claims
4
1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
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Table 2 (continued)
Reporting level
Metric name
12
13
14
15
16
17
18
19a
19b
20
21
22
23
24
25
Suicide or Overdose Death Within 7
and 30 Days of Discharge From an
Inpatient Facility or Residential
Treatment for Mental Health Among
Beneficiaries With SMI or SED (rate)
Milestone 3 A
Mental Health Services Utilization Inpatient
Mental Health Services Utilization Intensive Outpatient and Partial
Hospitalization
Mental Health Services Utilization Outpatient
Mental Health Services Utilization ED
Mental Health Services Utilization Telehealth
Mental Health Services Utilization Any Services
Average Length of Stay in IMDs
Average Length of Stay in IMDs (IMDs
receiving FFP only)
Beneficiaries With SMI/SED Treated in
an IMD for Mental Health
Milestone 4 A
Count of Beneficiaries With SMI/SED
(monthly)
Count of Beneficiaries With SMI/SED
(annually)
Diabetes Care for Patients with
Serious Mental Illness: Hemoglobin
A1c (HbA1c) Poor Control (>9.0%)
(HPCMI-AD)
Screening for Depression and FollowUp Plan: Age 18 and Older (CDF-AD)
Screening for Depression and FollowUp Plan: Ages 12–17 (CDF-CH)
Endorsement; Use in
other programs
Data
source
Required or
recommended
Demonstration
Model/
Area
Subpopulations
Measurement
Period
None
State data on cause Recommended
of death, linked to
claims
X
X
Age only
Year
None
Claims
Required
X
X
X
Month
None
Claims
Required
X
X
X
Month
None
Claims
Required
X
X
X
Month
None
Claims
Required
X
X
X
Month
None
Claims
Required
X
X
X
Month
None
Claims
Required
X
X
X
Month
None
None
Claims
Claims
Required
Required
X
X
X
X
None
None
Year
Year
None
Claims
Required
X
X
None
Year
None
Claims
Required
X
X
X
Month
None
Claims
Required
X
X
X
Year
NQF #2607; Adult Core
Set
Claims, Medical
Records
Required
X
X
None
Year
NQF #0418/0418e;
Adult Core Set
CMS; NQF
#0418/0418e; Child
Core Set
Claims or electronic
medical records
Claims or electronic
medical records
Recommended
X
X
None
Year
Recommended
X
X
None
Year
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Table 2 (continued)
Reporting level
Metric name
26
27
28
29
30
31
32
33
34
35
36
37
Access to Preventive/Ambulatory
Health Services for Medicaid
Beneficiaries With SMI
Tobacco Use Screening and Followup for People with Serious Mental
Illness or Alcohol or Other Drug
Dependence
Alcohol Screening and Follow-up for
People with Serious Mental Illness
Metabolic Monitoring for Children and
Adolescents on Antipsychotics
Follow-Up Care for Adult Medicaid
Beneficiaries Who are Newly
Prescribed an Antipsychotic
Medication
Use of Multiple Concurrent
Antipsychotics in Children and
Adolescents (APC-CH)
Other SMI/SED metrics
Total Costs Associated With Mental
Health Services Among Beneficiaries
With SMI/SED - Not Inpatient or
Residential
Total Costs Associated With Mental
Health Services Among Beneficiaries
With SMI/SED - Inpatient or
Residential
Per Capita Costs Associated With
Mental Health Services Among
Beneficiaries With SMI/SED - Not
Inpatient or Residential
Per Capita Costs Associated With
Mental Health Services Among
Beneficiaries With SMI/SED - Inpatient
or Residential
Grievances Related to Services for
SMI/SED
Appeals Related to Services for
SMI/SED
Endorsement; Use in
other programs
Data
source
Required or
recommended
Demonstration
Model/
Area
Subpopulations
Measurement
Period
None
Claims
Required
X
X
None
Year
NQF #2600
Claims
Recommended
X
X
None
Year
NQF #2599
Claims
Recommended
X
X
None
Year
Certified Community
Behavioral Health
Clinics Demonstration
(CCBHC)
NQF #3313
Claims
Required
X
X
None
Year
Claims
Required
X
X
None
Year
Child Core Set
Claims
Required
X
X
None
Year
None
Claims
Required
X
X
None
Year
None
Claims
Required
X
X
None
Year
None
Claims
Required
X
X
None
Year
None
Claims
Required
X
X
None
Year
None
Administrative
records
Administrative
records
Required
X
X
None
Quarter
Required
X
X
None
Quarter
None
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Table 2 (continued)
Reporting level
Metric name
38
39
40
A
Endorsement; Use in
other programs
Critical Incidents Related to Services None
for SMI/SED
Total Costs Associated With
None
Treatment for Mental Health in an IMD
Among Beneficiaries With SMI/SED
Per Capita Costs Associated With
None
Treatment for Mental Health in an IMD
Among Beneficiaries With SMI/SED
Data
source
Required or
recommended
Demonstration
Model/
Area
Subpopulations
Measurement
Period
Administrative
records
Claims
Required
X
X
None
Quarter
Required
X
X
None
Year
Claims
Required
X
X
None
Year
Milestones included in this table are from the State Medicaid Director Letter #18-011.
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1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
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B. Reporting 1115 SMI/SED demonstration monitoring metrics defined by
CMS
This section provides reporting guidance applicable to 1115 SMI/SED demonstration
monitoring metrics. The technical specifications for calculating each metric can be found in
Chapter II.
Technical assistance. To help states collect, report, and use the 1115 SMI/SED
demonstration monitoring metrics, CMS offers technical assistance. Please submit technical
assistance requests to: [email protected]. When you contact this
mailbox, please copy your CMS project officer on the message.
Metric type. This document describes three types of 1115 SMI/SED demonstration metrics:
•
CMS constructed metrics. Many of the metrics for the 1115 SMI/SED demonstration
were constructed by CMS. The technical specifications for these metrics are included in
this document. Many of these metrics reference HEDIS 2019 value sets or other lists
that contain complete sets of codes used to identify a treatment service or diagnosis.
When referenced, use these value sets to calculate a metric. Established value sets are
available to states upon request by contacting
[email protected].
•
Established quality measures. Some metrics are established quality measures available
from the Medicaid and CHIP Child Core Set, the Medicaid Adult Core Set, NQF, or the
measure steward.5 To help states calculate these metrics, this document references the
original measure specifications and associated value sets, which are available upon
request by contacting [email protected].
•
State-identified metrics. In addition to the metrics provided by CMS, a state can propose
metrics specific to its demonstration. These metrics are referred to as “state-identified
metrics” within this document.
Measurement period. When reporting 1115 SMI/SED demonstration monitoring metrics,
use the following guidance for determining the measurement periods.
•
For metrics where the measurement period is a month, the first measurement period is
the first month of the demonstration. For example, if the demonstration started on March
1, the first month is March 1 through March 31. The second month is April 1 through
April 30.
•
For metrics where the measurement period is a quarter, the first quarter of the
demonstration spans the first three months of the demonstration. For example, if the
demonstration started on March 1, the first quarter is March 1 through May 31.
•
For the CMS-constructed metrics where the measurement period is a year, the first
measurement period is the first year of the demonstration. For example, if the
5
Metrics that are established quality measures include: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 23, 24, 25, 26, 27, 28, 29, 30, and
31.
8
1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
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demonstration started on March 1, 2019 the measurement period is March 1, 2019
through February 29, 2020.
•
For metrics that are established quality measures, the first annual measurement period is
the first calendar year of the demonstration. For example, if the demonstration started on
March 1, 2019, the first calendar year is January 1, 2019 through December 31, 2019, to
align with the measurement period for these measures in other quality reporting
programs.
Baseline period. The baseline period is the first measurement period.
•
For metrics where the measurement period is a month or a quarter, as well as CMSconstructed and state-identified metrics where the measurement period is a year, the
baseline year will be the first SMI/SED demonstration year (DY). For example, for a
demonstration that started on March 1, 2019, the baseline year is March 1, 2019 through
February 29, 2020.
-
•
For states where the first SMI/SED DY (DY1) is less than 12 months, the state
should report the 12 months preceding the end of SMI/SED DY1 as its baseline
reporting period (including months before the start of the demonstration). For
example, if the state has a 10-month SMI/SED DY1 starting March 1, 2019 and
ending December 31, 2019, the baseline year is January 1, 2019 through December
31, 2019.
For metrics that are established quality measures, the calendar year in which the
demonstration started will become the baseline year. For example, for a demonstration
that started on March 1, 2019, the baseline year for established quality measures would
be January 1, 2019 through Dec 31, 2019.
-
For established quality measures calculated over a 2-year period, the baseline is the
calendar year in which the demonstration started and the prior year. For each
subsequent report period shift the period for the denominator forward one year.
-
For states where the SMI/SED DY1 is less than 12 months, the state should use the
last day of SMI/SED DY1 to identify the appropriate calendar year for reporting. If
the last day of SMI/SED DY1 is December 31, that same calendar year will be the
baseline year for established quality measures. Otherwise, the baseline year will be
the prior calendar year. For example, if a state has a 10-month SMI/SED DY1
starting on January 1, 2020 and ending on October 31, 2020, calendar year 2019
would be the baseline period.
•
For states with SMI/SED demonstrations that begin in the middle of a month, the state
should start its baseline period on the first date of the month. This applies to all baseline
periods (month, quarter, and year). For example, if a state’s SMI/SED demonstration
began on March 15, the state’s first measurement month is March 1 through March 31.
The second month is April 1 through April 30.
•
For states with a demonstration start date that falls after the demonstration approval date,
the baseline year begins on the demonstration start date.
Please confirm the measurement and baseline periods for your state with your project officer.
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1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
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Table 3 below illustrates these guidelines, using the demonstration start date of March 1,
2019 as an example.
Table 3. Example of alignment between demonstration years and measurement periods
Measurement Period
Month
•
Start
Date
Demonstration
Start Date:
March 1, 2019
Measurement
Baseline
year
End
Date
Quarter
Start
Date
Year
End
Date
Measurement
Year 3
End
Date
Mar 1
Apr 1
May 1
June 1
Feb 1
Mar 31
Apr 30
May 31
June 30
Feb 29
Mar 1
June 1
Sep 1
Dec 1
May 31
Aug 31
Nov 30
Feb 29
Month as defined in
the Baseline year
row
Quarter as defined in
the Baseline year row
Measurement
Year 4
Mar 1,
2019
Start
Date
End
Date
Established quality
measures
CMS-constructed and state-identified metrics
Measurement
Year 1
Measurement
Year 2
Start
Date
Feb 29,
2020
Jan 1,
2019
Dec 31,
2019
Mar 1,
2020
Feb 28,
2021
Jan 1,
2020
Dec 31,
2020
Mar 1,
2021
Feb 28,
2022
Jan 1,
2021
Dec 31,
2021
Mar 1,
2022
Feb 28,
2023
Jan 1,
2022
Dec 31,
2022
Mar 1,
2023
Feb 29,
2024
Jan 1,
2023
Dec 31,
2023
Metric calculation and reporting. States should report data to CMS in accordance with the
schedule and format agreed upon in the approved monitoring protocol. Because of the dynamic
nature of Medicaid data, metrics should be produced at the same time in each measurement
period throughout the demonstration. This applies even if data are not shared with CMS until a
later date. For example, if a state submits data quarterly, the submission should contain three
monthly values for each monthly metric, each produced at the same time relative to its
measurement period.
Guidelines for including metrics and narrative information in monitoring reports are as
follows:
•
Each quarterly report should contain (1) narrative information on implementation for the
most recent demonstration quarter, (2) grievances and appeals metrics, and qualitative
information on referrals into treatment for the most recent demonstration quarter, and (3) all
other monthly and quarterly metrics for the prior quarter (which allows at least 90 days for
claims run-out and other considerations for data completeness).
•
To allow for adequate time to implement annual specification updates from measure
stewards, annual metrics that are established quality measures should be reported:
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1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
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o For states with demonstration years (DYs) that end March 31 through November
30: in the annual report
o For states with demonstration years that end January 31 or February 28: in the
first quarterly report of the next demonstration year
o For states with demonstration years that end December 31: in the second quarterly
report of the next demonstration year
•
All other annual metrics should be reported in the first quarterly report of the following
demonstration year, rather than in the annual report. This allows at least 90 days for claims
run-out and other considerations for data completeness.
Table 4 illustrates these guidelines, which apply to both CMS-constructed and stateidentified metrics.
Table 4. Reporting in quarterly and annual monitoring reports
Report name:
Report due date:
Measurement periods,
by reporting category
Narrative information on
implementation
Grievances and appeals
and qualitative
information on referral
into treatment
Other monthly and
quarterly metrics
DY1 Q1
report
DY1 Q2
report
DY1 Q3
report
DY1 Q4
(annual)
report
DY2 Q1
report
DY2 Q2
report
Due 60
days after
quarter
ends
Due 60
days after
quarter
ends
Due 60
days after
quarter
ends
Due 90
days after
quarter
ends
Due 60
days after
quarter
ends
Due 60 days
after quarter
ends
DY1 Q1
DY1 Q2
DY1 Q3
DY1 Q4
DY2 Q1
DY2 Q2
DY1 Q1
DY1 Q2
DY1 Q3
DY1 Q4
DY2 Q1
DY2 Q2
NA
DY1 Q1
DY1 Q2
DY1 Q3
DY1 Q4
DY4 Q1
States with
DYs ending
3/31 –
11/30: DY1
(Q1-Q4)
NA
States with
DYs ending
on 1/31 or
2/28: DY1
(Q1-Q4)
DY1
Annual metrics that are
established quality
measures*
NA
NA
NA
Other annual metrics
NA
NA
NA
States with
DYs ending
on 12/31:
DY1 (Q1-Q4)
NA
DY = Demonstration year
NA = not applicable (information not expected to be included in report)
Note: The state is expected to submit retrospective metrics data in the state’s second monitoring report submission
after monitoring protocol approval
* Metrics that are established quality measures should be calculated for the calendar year. All other metrics should be
calculated for the SMI/SED demonstration year.
Manual version. For measurement periods in calendar year 2019, states should use version
1 of this manual (dated October 11, 2019). The technical specifications manual will be updated
annually in May to provide current specifications and value sets.
General guidance. When reporting 1115 SMI/SED demonstration monitoring metrics,
please follow these guidelines for all metrics:
11
1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
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•
Supporting measure specifications, value sets, and code lists. Many monitoring metrics
reference value sets, code lists, or full specifications for established quality measures. See
Appendix C for instructions on how to access and use these supporting materials to calculate
monitoring metrics.
•
Eligible population. The eligible population for each metrics will vary based on whether the
metric is a CMS-constructed metric or an established quality measure.
-
For CMS-defined quarterly and annual metrics, beneficiaries with full benefits enrolled
in Medicaid for at least one month (30 consecutive days) during the measurement period
are eligible for inclusion in metric calculations. Beneficiaries enrolled for any amount of
time during the measurement period should be included in calculations for monthly
metrics. Beneficiaries with partial benefits are only eligible for inclusion in metric
calculations (using the same enrollment criteria as beneficiaries with full benefits) if they
are eligible to receive the services described in the metric numerator. Any additional
eligibility criteria are presented in metric specifications in Chapter II.
o The metrics should include full benefit enrollees including individuals entitled to the
full scope of Medicaid benefits, enrolled in an alternative benchmark-equivalent
plan, eligible for only pregnancy-related services, or otherwise eligible for full
coverage of Medicaid SMI/SED treatment services.
o The metrics should exclude beneficiaries who are:
▪
only entitled to restricted benefits based on alien status;
▪
only entitled to restricted benefits based on Medicare dual-eligibility status
including QMB, SLMB, QDWI and QI;
▪
have a first source of payment other than Medicaid or Medicare for SMI/SED
services (for example private insurance or eligibility for Medicaid only after
spenddown);
▪
only eligible for family planning services; or
▪
inmates in a facility by operation of criminal law
o The exclusion criteria should only apply to the metric measurement period and not to
the look back period for CMS-constructed measures. That is, beneficiaries who
would not meet the inclusion criteria during a look back period, but who meet the
criteria during the measurement period, should still be included.
•
-
For established quality measures in the Medicaid Child and Adult Sets, refer to the
technical specifications included in Appendix D. For other established quality measures,
refer to the original measure specifications, provided separately by CMS.
•
Claim type. For monitoring metrics defined by CMS, use only paid claims to identify
whether a treatment service was provided to Medicaid beneficiaries. For established
quality measures, follow guidance from the measure steward. For example, some HEDIS
measures use paid, suspended, pending and denied claims.
State-specific codes. States may use state-specific diagnosis, procedure, or other types of
codes. When applicable, states should supplement the codes referenced in metric
specifications with state-specific codes that are not included in the value sets. State-specific
12
1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
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codes must be for services specific to mental health treatment. These modifications should
be noted as part of the state’s metrics submission, as described in the Monitoring Report
Template Instructions.
C. Using technical specifications
Table 5 defines the elements included in specifications for metrics in Chapter II. The
description column explains each metric element.
Table 5. Table shell for the metrics’ technical specifications
Metric #: Metric Name
Metric element
Description
Measure
sets/endorsements
Describes whether the metric is included in other Medicaid Quality Measures measure
sets (such as Core Set) and is endorsed by NQF. When applicable, this element also
names the measure steward.
Description
Brief measure description.
Numerator
When the metric is a rate, this element describes the numerator in the rate equation.
When the metric is a count, this element describes the counted variable.
This element is not used in metrics that reference established quality measures.
Denominator/
Population of interest
When the metric is a rate, this element describes the denominator in the rate equation.
When the metric is a count, this element describes the population of interest.
This element is not used in metrics that reference established quality measures.
Metric calculation
When the metric is a rate, this element provides instructions for calculating the metric.
This element is not used when the metric is a count.
Additional guidance
Any additional guidance required to report this metric.
Measurement period
(Metric type)
Measurement period describes whether the measurement period is a month, quarter, or
year. Metric type describes whether the metric is CMS-constructed or an established
quality measure.
Reporting category
Reporting category describes the category associated with reporting guidelines for
including metrics in monitoring reports (see Table 4 above). Categories include
grievances and appeals and qualitative information on referral into treatment, other
monthly and quarterly metrics, annual metrics that are established quality measures, and
other annual metrics
Reporting level
Describes the groups for which to report the metric.
Subpopulations
Describes population subgroups that states must report separately.
Relationship to other
metrics
Describes components of a metric that are used in other 1115 SMI/SED demonstration
metrics.
Data source
Describes the likely data source(s) used to report this metric.
Claim type
Describes the types of claims to include when calculating the metric.
13
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II. METRIC SPECIFICATIONS
Metric #1: SUD Screening of Beneficiaries Admitted to Psychiatric Hospitals or Residential Treatment
Settings (SUB-2)
Metric element
Description
Measure
sets/endorsements
NQF #1663
Measure steward: The Joint Commission
Description
Two rates will be reported for this measure:
1. SUB-2: Patients who screened positive for unhealthy alcohol use who
received or refused a brief intervention during the hospital stay.
2. SUB-2a: Patients who received the brief intervention during the hospital stay.
Metric calculation
Calculation instructions are located in The Specifications Manual for National Hospital
Inpatient Quality Measures v5.6; see measure SUB-2, Alcohol Use Brief Intervention
Provided or Offered, and measure SUB-2a, Alcohol Use Brief Intervention. The
specification is located in “2l-SUB2.pdf” and references ICD-10 codes in “Appendix A1.xls.” See also the Data Dictionary for the measure data elements in “1bAlphaDD.pdf”
Additional guidance
The Specifications Manual for National Hospital Inpatient Quality Measures v5.6 is
available at https://www.jointcommission.org/specifications_manual_for_national_
hospital_inpatient_quality_measures.aspx
Measurement period
(Metric type)
Year (Established quality measure)
Reporting category
Annual metrics that are established quality measures
Reporting level
Demonstration
Model
Subpopulations
None
Relationship to other
metrics
None
Data source
Medical record review or claims
Claim type
Not specified
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Metric #2: Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP-CH)
Metric element
Description
Measure
sets/endorsements
FFY 2019 Core Set of Child Health Care Quality Measures for Medicaid (Child Core
Set)
NQF #2801
Measure steward: NCQA
Description
Percentage of children and adolescents ages 1 to 17 who had a new prescription for
an antipsychotic medication and had documentation of psychosocial care as first-line
treatment.
Metric calculation
Instructions for calculating this metric can be found in Appendix D: Technical
Specifications for Established Quality Measures Adapted from FFY 2019 Child and
Adult Core Sets Measure Specifications
Additional guidance
None
Measurement period
(Metric type)
Year (Established quality measure)
Reporting category
Annual metrics that are established quality measures
Reporting level
Demonstration
Model
Subpopulations
None
Relationship to other
metrics
None
Data source
Claims
Claim type
Include paid, suspended, pending, and denied claims.
Note:
Measure specification shown applies to 2018 and is for illustrative purposes. The measure specification will
be updated in Spring 2020 for reporting on 2019.
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Metric #3 All-Cause Emergency Department (ED) Utilization Rate for Medicaid Beneficiaries who may
Benefit From Integrated Physical and Behavioral Health Care (PMH-20)
Metric element
Description
Measure
sets/endorsements
CMS
Description
Number of all-cause ED visits per 1,000 beneficiary months among adult Medicaid
beneficiaries age 18 and older who meet the eligibility criteria of beneficiaries with
SMI.
Calculation instructions are located in the full measure specification, which CMS will
provide separately. States should follow the instructions for the observed (i.e.,
unadjusted) measure rates.
Metric calculation
Additional guidance
The specifications and value sets for this measure are available to states upon
request by contacting [email protected].
Measurement period
(Metric type)
Year (Established quality measure)
Reporting category
Annual metrics that are established quality measures
Reporting level
Demonstration
Model
Subpopulations
None
Relationship to other
metrics
None
Data source
Claims
Claim type
Use only paid claims
Note:
Measure specification shown applies to 2018 and is for illustrative purposes. The measure specification will
be updated in Spring 2020 for reporting on 2019.
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Metric #4: 30-Day All-Cause Unplanned Readmission Following Psychiatric Hospitalization in an Inpatient
Psychiatric Facility (IPF)
Metric element
Description
Measure
sets/endorsem
ents
Medicare Inpatient Psychiatric Facility Quality Reporting Program (IPFQR) Based on NQF
#2860
Measure steward: CMS
The rate of unplanned, 30-day, readmission rate for demonstration beneficiaries with a primary
discharge diagnosis of a psychiatric disorder or dementia/Alzheimer’s disease. The
measurement period used to identify cases in the measure population is 12 months from
January 1 through December 31.
The count of 30-day readmissions. A readmission is defined as any admission, for any reason,
to an IPF or a short-stay acute care hospital (including CAHs) that occurs within 30 days after
the discharge date from an eligible index admission to an IPF, except those considered planned.
The measure uses the CMS 30-day Hospital-Wide Readmission (HWR) Measure Planned
Readmission Algorithm, Version 4.0.
Description
Numerator
Denominator
The count of index hospital admissions to IPFs
Metric
calculation
The measure population consists of eligible index admissions to IPFs. A readmission within 30days will also be eligible as an index admission, if it meets all other eligibility criteria. Patients
may have more than one index admission within the measurement period.
Step 1. Identify the Eligible population:
Identify beneficiaries who meet the following criteria:
•
Age 18 or older at admission
•
Discharged alive
•
Enrolled in Medicaid during the month of and at least one month after the index
admission
Step 2. Exclude beneficiaries who are:
•
Discharged against medical advice because the IPF may have limited opportunity to
complete treatment and prepare for discharge
•
With unreliable demographic and vital status data defined as the following:
o Age greater than 115 years
o Missing gender
o Discharge status of “dead” but with subsequent admissions
o Death date prior to admission date
o Death date within the admission and discharge dates but the discharge status
was not “dead”
•
With readmissions on the day of discharge or day following discharge because those
readmissions are likely transfers to another inpatient facility. The hospital that
discharges the patient to home or a non-acute care setting is accountable for
subsequent readmissions.
•
With readmissions two days following discharge because readmissions to the same IPF
within two days of discharge are combined into the same claim as the index admission
and do not appear as readmissions due to the interrupted stay billing policy. Therefore,
complete data on readmissions within two days of discharge are not available.
Step 3: Calculate the Denominator: count of index admissions with discharge dates between
January 1 and December 31.
To identify index admissions, identify discharges with a psychiatric principal diagnosis included
in one of the Agency for Healthcare Research and Quality (AHRQ) Clinical Classification
Software (CCS) ICD groupings below. (More information on grouping ICD codes into clinically
coherent groups is available at the following link: https://www.hcupus.ahrq.gov/toolssoftware/ccs/ccs.jsp.)
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Metric #4: 30-Day All-Cause Unplanned Readmission Following Psychiatric Hospitalization in an Inpatient
Psychiatric Facility (IPF)
Metric element
Description
Metric
calculation
o
Primary discharge diagnosis clinical categories designating psychiatric illness
for measure cohort
▪
650 - Adjustment disorders
▪
651 - Anxiety disorders
▪
652 - Attention-deficit, conduct, and disruptive behavior disorders
▪
653 - Delirium, dementia, and amnestic and other cognitive disorders
▪
654 - Developmental disorders
▪
655 - Disorders usually diagnosed in infancy, childhood, or
adolescence
▪
656 - Impulse control disorders, NEC
▪
657 - Mood disorders
▪
658 - Personality disorders
▪
659 - Schizophrenia and other psychotic disorders
▪
660 - Alcohol-related disorders
▪
661 - Substance-related disorders
▪
662- Suicide and intentional self-inflicted injury
▪
663 - Screening and history of mental health and substance abuse
codes
▪
670 - Miscellaneous disorders
Step 4: Calculate the Numerator: Count of 30-day Readmissions
Among beneficiaries identified in Step 3, identify the readmissions to an IPF or a short-stay
acute care hospital (including CAHs) that occurs within 30 days after the discharge date from an
eligible index admission to an IPF.
Step 3. Exclude admissions considered planned
Identify admission considered planned as determined by the CMS 30-day Hospital-Wide
Readmission (HWR) Measure Planned Readmission Algorithm, Version 4.0 available at:
https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQn
etTier4&cid=1219069855841.
Step 4: Calculate the rate of readmissions: number readmissions (Step 4) / number of index
admissions (Step 3)
Additional
guidance
This measure is based on the 30-Day All-Cause Unplanned Readmission Following Psychiatric
Hospitalization in an Inpatient Psychiatric Facility (IPF) in the IPFQR program. The program
manual for IPFQR is available at:
https://www.qualitynet.org/files/5d0d3993764be766b0103982?filename=181203_FY19_IPFQR_
CBM_Specs.pdf
Measurement
period
(Metric type)
Year (Established quality measure)
Reporting
category
Annual metrics that are established quality measures
Reporting level
Demonstration
Model
Subpopulations
None
Relationship to
other metrics
None
Data source
Claims
Claim type
Only use paid claims. (Do not use suspended, pending, and denied claims.)
19
1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
MATHEMATICA
Metric #5: Medication Reconciliation Upon Admission
Metric element
Description
Measure
sets/endorsements
CMS
NQF #3317
Description
Percentage of patients for whom a designated prior to admission (PTA) medication list
was generated by referencing one or more external sources of PTA medications and
for which all PTA medications have a documented reconciliation action by the end of
Day 2 of the hospitalization.
Numerator
Number of admissions with a designated PTA medication list generated by
referencing one or more external sources of medications for which all PTA
medications have a documented reconciliation action by the end of Day 2 of the
hospitalization.
Denominator
Admissions to an inpatient facility from home or a non-acute setting
Metric calculation
Calculation instructions are located in the full measure specification, which CMS will
provide separately
Additional guidance
The specifications and value sets for this measure are available to states upon
request by contacting [email protected].
Measurement period
(Metric type)
Year (Established quality measure)
Reporting category
Annual metrics that are established quality measures
Reporting level
Demonstration
Model
Subpopulations
None
Relationship to other
metrics
None
Data source
Electronic/paper medical records
Claim type
Not specified
Note:
Measure specification shown applies to 2018 and is for illustrative purposes. The measure specification will
be updated in Spring 2020 for reporting on 2019
20
1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
MATHEMATICA
Metric #6: Medication Continuation Following Inpatient Psychiatric Discharge
Metric element
Description
Measure
sets/endorsements
CMS
Based on NQF# 3205
Description
This measure assesses whether psychiatric patients admitted to an inpatient
psychiatric facility (IPF) for major depressive disorder (MDD), schizophrenia, or bipolar
disorder filled a prescription for evidence-based medication within 2 days prior to
discharge and 30 days post-discharge.
Metric calculation
Calculation instructions are located in the full measure specification, which CMS will
provide separately
Additional guidance
The specifications and value sets for this measure are available to states upon
request by contacting [email protected].
Measurement period
(Metric type)
Year (Established quality measure)
Reporting category
Annual metrics that are established quality measures
Reporting level
Demonstration
Model
Subpopulations
None
Relationship to other
metrics
None
Data source
Claims
Claim type
Use only paid claims. (Do not use suspended, pending, or denied claims.)
Note:
Measure specification shown applies to 2018 and is for illustrative purposes. The measure specification will
be updated in Spring 2020 for reporting on 2019.
21
1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
MATHEMATICA
Metric #7: Follow-up After Hospitalization for Mental Illness: Ages 6-17 (FUH-CH)
Metric element
Description
Measure
sets/endorsements
FFY 2019 Core Set of Child Health Care Quality Measures for Medicaid (Child Core
Set)
NQF #0576
Measure steward: NCQA
Description
Percentage of discharges for children ages 6 to 17 who were hospitalized for
treatment of selected mental illness or intentional self-harm diagnoses and who had a
follow-up visit with a mental health practitioner. Two rates are reported:
•
•
Percentage of discharges for which the child received follow-up within 30
days after discharge
Percentage of discharges for which the child received follow-up within 7 days
after discharge
Metric calculation
Instructions for calculating this metric can be found in Appendix D: Technical
Specifications for Established Quality Measures Adapted from FFY 2019 Child and
Adult Core Sets Measure Specifications
Additional guidance
None
Measurement period
(Metric type)
Year (Established quality measure)
Reporting category
Annual metrics that are established quality measures
Reporting level
Demonstration
Model
Subpopulations
None
Relationship to other
metrics
None
Data source
Claims
Claim type
Include paid, suspended, pending, and denied claims.
Note:
Measure specification shown applies to 2018 and is for illustrative purposes. The measure specification will
be updated in Spring 2020 for reporting on 2019.
22
1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
MATHEMATICA
Metric #8: Follow-up After Hospitalization for Mental Illness: Age 18 and Older (FUH-AD)
Metric element
Description
Measure
sets/endorsements
FFY 2019 Core Set of Adult Health Care Quality Measures for Medicaid (Adult Core
Set)
NQF #0576
Measure steward: NCQA
Description
Percentage of discharges for beneficiaries age 18 years and older who were
hospitalized for treatment of selected mental illness diagnoses or intentional self-harm
and who had a follow-up visit with a mental health practitioner. Two rates are reported:
•
•
Percentage of discharges for which the beneficiary received follow-up within
30 days after discharge
Percentage of discharges for which the beneficiary received follow-up within
7 days after discharge
Metric calculation
Instructions for calculating this metric can be found in Appendix D: Technical
Specifications for Established Quality Measures Adapted from FFY 2019 Child and
Adult Core Sets Measure Specifications
Additional guidance
None
Measurement period
(Metric type)
Year (Established quality measure)
Reporting category
Annual metrics that are established quality measures
Reporting level
Demonstration
Model
Subpopulations
None
Relationship to other
metrics
None
Data source
Claims
Claim type
Include paid, suspended, pending, and denied claims.
Note:
Measure specification shown applies to 2018 and is for illustrative purposes. The measure specification will
be updated in Spring 2020 for reporting on 2019.
23
1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
MATHEMATICA
Metric #9: Follow-up After Emergency Department Visit for Alcohol and Other Drug Abuse Dependence
(FUA-AD)
Metric element
Description
Measure
sets/endorsements
FFY 2019 Core Set of Adult Health Care Quality Measures for Medicaid (Adult Core
Set)
NQF #2605
Measure steward: NCQA
Description
Percentage of emergency department (ED) visits for beneficiaries age 18 and older
with a principal diagnosis of alcohol or other drug (AOD) abuse dependence who had
a follow-up visit for AOD abuse or dependence. Two rates are reported:
•
•
Percentage of ED visits for AOD abuse or dependence for which the
beneficiary received follow-up within 30 days of the ED visit
Percentage of ED visits for AOD abuse or dependence for which the
beneficiary received follow-up within 7 days of the ED visit
Metric calculation
Instructions for calculating this metric can be found in Appendix D: Technical
Specifications for Established Quality Measures Adapted from FFY 2019 Child and
Adult Core Sets Measure Specifications
Additional guidance
None
Measurement period
(Metric type)
Year (Established quality measure)
Reporting category
Annual metrics that are established quality measures
Reporting level
Demonstration
Model
Subpopulations
None
Relationship to other
metrics
None
Data source
Claims
Claim type
Include paid, suspended, pending, and denied claims.
Note:
Measure specification shown applies to 2018 and is for illustrative purposes. The measure specification will
be updated in Spring 2020 for reporting on 2019.
24
1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
MATHEMATICA
Metric #10: Follow-up After Emergency Department Visit for Mental Illness (FUM-AD)
Metric element
Description
Measure
sets/endorsements
FFY 2019 Core Set of Adult Health Care Quality Measures for Medicaid (Adult Core
Set)
NQF #2605
Measure steward: NCQA
Description
Percentage of emergency department (ED) visits for beneficiaries age 18 and older
with a principal diagnosis of mental illness or intentional self-harm and who had a
follow-up visit for mental illness. Two rates are reported:
•
•
Percentage of ED visits for mental illness for which the beneficiary received
follow-up within 30 days of the ED visit
Percentage of ED visits for mental illness for which the beneficiary received
follow-up within 7 days of the ED visit
Metric calculation
Instructions for calculating this metric can be found in Appendix D: Technical
Specifications for Established Quality Measures Adapted from FFY 2019 Child and
Adult Core Sets Measure Specifications
Additional guidance
None
Measurement period
(Metric type)
Year (Established quality measure)
Reporting category
Annual metrics that are established quality measures
Reporting level
Demonstration
Model
Subpopulations
None
Relationship to other
metrics
None
Data source
Claims
Claim type
Include paid, suspended, pending, and denied claims.
Note:
Measure specification shown applies to 2018 and is for illustrative purposes. The measure specification will
be updated in Spring 2020 for reporting on 2019.
25
1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
MATHEMATICA
Metric #11: Suicide or Overdose Death Within 7 and 30 Days of Discharge From an Inpatient Facility or
Residential Treatment for Mental Health Among Beneficiaries With SMI or SED (count)
Metric element
Description
Measure
sets/endorsements
None
Description
Number of suicide or overdose deaths among Medicaid beneficiaries with SMI or SED
within 7 and 30 days of discharge from an inpatient facility or residential stay for mental
health.
Count the number of suicide or overdose deaths among eligible beneficiaries
Numerator
Step 1: Determine the beneficiaries in the Denominator. Retain only stays with discharge
dates that fall within the measurement period.
Step 2: Using state data (e.g. medical examiner data or death records) identify
beneficiaries with the following ICD-10 codes for underlying cause of death in the
measurement period:
•
•
•
•
•
•
•
•
U03 (other means)
X40 – X44 (unintentional drug poisonings)
X60- X64 (suicidal drug poisonings)
X70 – X84 (intentional self-harm)
X85 (homicide drug poisoning)
Y10-Y19 (drug poisoning of undetermined intent)
Y20-Y34 (other events of undetermined intent)
Y87 (other means)
Step 3: Subtract the date of death from the death record from the discharge date for any
stays for the same beneficiary and calculate the number of beneficiaries with a date of
death within 7 and within 30 days of a mental health stay discharge date.
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1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
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Metric #11: Suicide or Overdose Death Within 7 and 30 Days of Discharge From an Inpatient Facility or
Residential Treatment for Mental Health Among Beneficiaries With SMI or SED (count)
Metric element
Population of Interest
Description
Beneficiaries with SMI/SED enrolled in Medicaid for at least one month (30 consecutive
days) during the measurement period or the 30 days prior to the beginning of the
measurement period.
Step 1a. Identify claims with a place of service or UB Revenue code listed below:
Place of Service Codes:
•
51 - Inpatient Psychiatric Facility
•
56 – Psychiatric Residential Treatment Center
•
From the 2016 HEDIS BH Stand Alone Acute Inpatient Value Set
•
From the 2016 HEDIS BH Acute Inpatient Value Set
•
From the 2016 HEDIS BH Nonacute inpatient
UB Revenue Codes:
•
1001 – Residential treatment, psychiatric
•
From the HEDIS 2016 BH Stand Alone Nonacute Inpatient Value Set
•
From the HEDIS 2019 Inpatient Stay value set
Step 1b. Identify claims with a primary mental health diagnosis from the HEDIS 2019
Mental Health Diagnosis Value Set
Step 2. Retain claims that meet the criteria in both Step 1a and 1b for residential or
inpatient treatment
Step 3. Determine the total number of unique beneficiaries (de-duplicated) with claims
that meet the criteria in Steps 1 and 2.
Metric calculation
Calculate the number of suicide or overdose deaths among Medicaid beneficiaries with
SMI or SED within 7 and 30 days of a mental health stay discharge date.
Additional guidance
Data sources for suicide deaths may vary by state. For example, some states may have
access to a centralized state medical examiner system, whereas other states may have
decentralized systems containing death records. When suicide deaths occur, coroners
and medical examiners are instructed to record the cause of death on the death
certificate using ICD-10 codes. States may also have more detailed information on cause
of death. If available, state-specific data sources may be used to identify suicide deaths.
Use the discharge date to identify claims in the measurement period. Do not count
beneficiaries for an ongoing stay during the measurement period if the patient is not
discharged in that period. If a discharge date is not explicitly reported, identify all claims
associated with a single stay and use the latest end date of service on the claims. Use
one of the following approaches to combine claims for the same stay:
•
•
combine claims for the same beneficiary, provider and admission date; or
If an admission date is not reported on all claims, then combine claims for the
same patient and provider that have less than a one day break between the end
date of the first claim and the start date of the next claim. For example, if the end
date of the first claim is December 18 and the start date of the next claim is
December 19, then combine the claims as a single stay. However, if the second
claim has a start date of December 20 or later, then do not combine the claims.
Measurement period
(Metric type)
Year (CMS-constructed)
Reporting category
Other annual metrics
27
1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
MATHEMATICA
Metric #11: Suicide or Overdose Death Within 7 and 30 Days of Discharge From an Inpatient Facility or
Residential Treatment for Mental Health Among Beneficiaries With SMI or SED (count)
Metric element
Description
Reporting level
Demonstration
Model
Subpopulations
Subpopulations
Age groups
Relationship to other
metrics
None
Data source
State data on cause of death
Claim type
Not applicable
28
1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
MATHEMATICA
Metric #12: Suicide or Overdose Death Within 7 and 30 Days of Discharge From an Inpatient Facility or
Residential Treatment for Mental Health Among Beneficiaries With SMI or SED (rate)
Metric element
Description
Measure
sets/endorsements
None
Description
Rate of suicide or overdose deaths among Medicaid beneficiaries with SMI or SED
within 7 and 30 days of discharge from an inpatient facility or residential stay for mental
health.
The number of suicide or overdose deaths among eligible beneficiaries
Numerator
Step 1: Using the beneficiaries in the identified in the Denominator. Retain only stays
with discharge dates that fall within the measurement period.
Step 2: Using state data (e.g. medical examiner data or death records) identify
beneficiaries with the following ICD-10 codes for underlying cause of death in the
measurement period:
•
•
•
•
•
•
•
•
U03 (other means)
X40 – X44 (unintentional drug poisonings)
X60- X64 (suicidal drug poisonings)
X70 – X84 (intentional self-harm)
X85 (homicide drug poisoning)
Y10-Y19 (drug poisoning of undetermined intent)
Y20-Y34 (other events of undetermined intent)
Y87 (other means)
Step 3: Subtract the date of death from the death record from the discharge date for any
stays for the same beneficiary and calculate the number of beneficiaries with a date of
death within 7 and within 30 days of a mental health stay discharge date.
29
1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
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Metric #12: Suicide or Overdose Death Within 7 and 30 Days of Discharge From an Inpatient Facility or
Residential Treatment for Mental Health Among Beneficiaries With SMI or SED (rate)
Metric element
Denominator
Description
Beneficiaries with SMI/SED enrolled in Medicaid for at least one month (30 consecutive
days) during the measurement period or the 30 days prior to the beginning of the
measurement period.
Step 1a. Identify claims for inpatient or residential stays using the place of service or UB
Revenue codes listed below:
Place of Service Codes:
•
51 - Inpatient Psychiatric Facility
•
56 – Psychiatric Residential Treatment Center
•
From the 2016 HEDIS BH Stand Alone Acute Inpatient Value Set
•
From the 2016 HEDIS BH Acute Inpatient Value Set
•
From the 2016 HEDIS BH Nonacute inpatient
UB Revenue Codes:
•
1001 – Residential treatment, psychiatric
•
From the HEDIS 2016 BH Stand Alone Nonacute Inpatient Value Set
•
From the HEDIS 2019 Inpatient Stay value set
Step 1b. Identify claims with a primary mental health diagnosis from the HEDIS 2019
Mental Health Diagnosis Value Set
Step 2. Retain claims that meet the criteria in both Step 1a and 1b for residential or
inpatient treatment
Step 3. Determine the total number of unique beneficiaries (de-duplicated) with claims
that meet the criteria in Steps 1 and 2.
Metric calculation
Calculate the rate of suicide or overdose deaths among Medicaid beneficiaries with SMI
or SED within 7 and 30 days of discharge from an inpatient facility or residential stay for
mental health by dividing the total number of beneficiaries in the numerator by the
number of beneficiaries in the denominator, as follows:
Rate for 7 days: Total of beneficiaries with a date of death within 7 days of a mental
health stay discharge date/ Total number of beneficiaries with a primary mental health
diagnosis and an inpatient or residential stay
Rate for 30 days: Total of beneficiaries with a date of death within 30 days of a mental
health stay discharge date/ Total number of beneficiaries with a primary mental health
diagnosis and an inpatient or residential stay
30
1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
MATHEMATICA
Metric #12: Suicide or Overdose Death Within 7 and 30 Days of Discharge From an Inpatient Facility or
Residential Treatment for Mental Health Among Beneficiaries With SMI or SED (rate)
Metric element
Additional guidance
Description
Data sources for suicide deaths may vary by state. For example, some states may have
access to a centralized state medical examiner system, whereas other states may have
decentralized systems containing death records. When suicide deaths occur, coroners
and medical examiners are instructed to record the cause of death on the death
certificate using ICD-10 codes. States may also have more detailed information on
cause of death. If available, state-specific data sources may be used to identify suicide
deaths
Use the discharge date to identify claims in the measurement period. Do not count
beneficiaries for an ongoing stay during the measurement period if the patient is not
discharged in that period. If a discharge date is not explicitly reported, identify all claims
associated with a single stay and use the latest end date of service on the claims. Use
one of the following approaches to combine claims for the same stay:
•
•
combine claims for the same beneficiary, provider and admission date; or
If an admission date is not reported on all claims, then combine claims for the
same patient and provider that have less than a one day break between the
end date of the first claim and the start date of the next claim. For example, if
the end date of the first claim is December 18 and the start date of the next
claim is December 19, then combine the claims as a single stay. However, if
the second claim has a start date of December 20 or later, then do not combine
the claims.
Measurement period
(Metric type)
Year (CMS-constructed)
Reporting category
Other annual metrics
Reporting level
Demonstration
Model
Subpopulations
Subpopulations
Age groups
Relationship to other
metrics
None
Data source
State data on cause of death
Claim type
Not applicable
31
1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
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Metric #13: Mental Health Services Utilization - Inpatient
Metric element
Description
Measure
sets/endorsements
None
Description
Number of beneficiaries in the demonstration or with SMI/SED who use inpatient
services related to mental health during the measurement period
The total number of unique beneficiaries (de-duplicated total) who have a claim for
inpatient services related to mental health during the measurement period
Numerator
Step 1. Identify claims that have a revenue code from the HEDIS 2019 Inpatient Stay
Value Set and have a primary diagnosis code in the HEDIS 2019 Mental Health
Diagnosis Value Set.
Population of interest
Additional guidance
Step 2. Determine the total number of unique beneficiaries (de-duplicated) with claims
that meet the criteria in Steps 1.
Medicaid beneficiaries in the demonstration or with SMI/SED enrolled for any amount of
time during the measurement period
Use the discharge date to identify claims in the measurement period. Do not count
beneficiaries for an ongoing stay during the measurement period if the patient is not
discharged in that period. If a discharge date is not explicitly reported, identify all claims
associated with a single stay and use the latest end date of service on the claims. Use
one of the following approaches to combine claims for the same stay:
•
•
combine claims for the same beneficiary, provider and admission date; or
If an admission date is not reported on all claims, then combine claims for the
same patient and provider that have less than a one day break between the
end date of the first claim and the start date of the next claim. For example, if
the end date of the first claim is December 18 and the start date of the next
claim is December 19, then combine the claims as a single stay. However, if the
second claim has a start date of December 20 or later, then do not combine the
claims.
Measurement period
(Metric type)
Month (CMS-constructed)
Reporting category
Other monthly and quarterly metrics
Reporting level
Demonstration
Model
Subpopulations
Subpopulations
Standardized Definition of SMI
State-specific Definition of SMI
Age groups
Dually eligible for Medicare and Medicaid
Eligible for Medicaid on the basis of disability
Criminal justice status
Co-occurring SUD
Co-occurring or physical health conditions
Relationship to other
metrics
None
Data source
Claims
Claim type
Only use paid claims. (Do not use suspended, pending, or denied claims.)
32
1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
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Metric #14: Mental Health Services Utilization - Intensive Outpatient and Partial Hospitalization
Metric element
Description
Measure
sets/endorsements
None
Description
Number of beneficiaries in the demonstration or with SMI/SED who used intensive
outpatient and/or partial hospitalization services related to mental health during the
measurement period
The total number of unique beneficiaries (de-duplicated total) who have a claim for
intensive outpatient and/or partial hospitalization services related to mental health during
the measurement period
Numerator
Step 1. Identify claims with a principal mental health diagnosis from the HEDIS 2019
Mental Health Diagnosis Value Set
Step 2. Retain claims with a code from any of the following HEDIS 2019 Value Sets:
•
Partial Hospitalization/Intensive Outpatient
•
MPT IOP/PH Group 1 with a corresponding code from Partial Hospitalization
POS or Community Mental Health Center POS
o States should ensure that the visit was in an intensive outpatient or
partial hospitalization setting
•
Electroconvulsive Therapy with a corresponding code from Partial
Hospitalization POS or Community Mental Health Center POS
o States should ensure that the visit was in an intensive outpatient or
partial hospitalization setting
•
Transcranial Magnetic Stimulation with a corresponding code from Partial
Hospitalization POS or Community Mental Health Center POS
o States should ensure that the visit was in an intensive outpatient or
partial hospitalization setting
•
MPT IOP/PH Group 2 with a corresponding code from Partial Hospitalization
POS
o States should ensure that the visit was billed by a mental health
practitioner
•
MPT IOP/PH Group 2 with a corresponding code from Community Mental
Health Center POS
o States should ensure that the visit was in an intensive outpatient or
partial hospitalization setting
o States should ensure that the visit was billed by a mental health
practitioner
Step 3. Exclude any claims with a code in the Telehealth Modifier or
Telehealth POS value sets
Population of interest
Additional guidance
Step 4. Determine the total number of unique beneficiaries (de-duplicated) with claims
that meet the criteria in Steps 1, 2, and 3.
Medicaid beneficiaries in the demonstration or with SMI/SED enrolled for any amount of
time during the measurement period
None
Measurement period
(Metric type)
Month (CMS-constructed)
Reporting category
Other monthly and quarterly metrics
Reporting level
Demonstration
Model
Subpopulations
Subpopulations
Standardized Definition of SMI
State-specific Definition of SMI
Age groups
33
1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
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Metric #14: Mental Health Services Utilization - Intensive Outpatient and Partial Hospitalization
Metric element
Description
Dually eligible for Medicare and Medicaid
Eligible for Medicaid on the basis of disability
Criminal justice status
Co-occurring SUD
Co-occurring or physical health condition
Relationship to other
metrics
None
Data source
Claims
Claim type
Only use paid claims. (Do not use suspended, pending, or denied claims.)
34
1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
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Metric #15: Mental Health Services Utilization - Outpatient
Metric element
Description
Measure
sets/endorsements
None
Description
Number of beneficiaries in the demonstration or with SMI/SED who used outpatient
services related to mental health during the measurement period
The number of unique beneficiaries (de-duplicated total) with an outpatient service
related to mental health during the measurement period
Numerator
Step 1. Identify claims with a principal mental health diagnosis from the HEDIS 2019
Mental Health Diagnosis Value Set
Step 2. Retain claims with a code from any of the following HEDIS 2019 Value Sets:
•
•
•
•
•
•
•
•
•
MPT Stand Alone Outpatient Group 1
MPT Stand Alone Outpatient Group 2
o States should ensure the visit was billed by a mental health
practitioner
Observation
o States should ensure the visit was billed by a mental health
practitioner
Visit Setting Unspecified with a corresponding code from Outpatient POS
Electroconvulsive Therapy with a corresponding code from Outpatient POS or
Ambulatory Surgical Center POS
Transcranial Magnetic Stimulation with a corresponding code from Outpatient
POS or Ambulatory Surgical Center POS
Visit Setting Unspecified with a corresponding code from Community Mental
Health Center POS
o States should ensure that the visit was in an outpatient setting
Electroconvulsive Therapy with a corresponding code from Community Mental
Health Center POS
o States should ensure that the visit was in an outpatient setting
Transcranial Magnetic Stimulation with a corresponding code from Community
Mental Health Center POS
o States should ensure that the visit was in an outpatient setting
Step 3. Exclude any claims with a code in the Inpatient Stay, Telehealth Modifier, or
Telehealth POS value sets
Population of interest
Additional guidance
Step 4. Determine the total number of unique beneficiaries (de-duplicated) with claims
that meet the criteria in Steps 1- 3.
Medicaid beneficiaries in the demonstration or with SMI/SED enrolled for any amount of
time during the measurement period
None
Measurement period
(Metric type)
Month (CMS-constructed)
Reporting category
Other monthly and quarterly metrics
Reporting level
Demonstration
Model
Subpopulations
35
1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
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Metric #15: Mental Health Services Utilization - Outpatient
Metric element
Description
Subpopulations
Standardized Definition of SMI
State-specific Definition of SMI
Age groups
Dually eligible for Medicare and Medicaid
Eligible for Medicaid on the basis of disability
Criminal justice status
Co-occurring SUD
Co-occurring or physical health conditions
Relationship to other
metrics
None
Data source
Claims
Claim type
Only use paid claims. (Do not use suspended, pending, or denied claims.)
36
1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
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Metric #16: Mental Health Services Utilization - ED
Metric element
Description
Measure
sets/endorsements
None
Description
Number of beneficiaries in the demonstration or with SMI/SED who use emergency
department services for mental health during the measurement period
The total number of unique beneficiaries (de-duplicated total) who have a claim for
emergency services for mental health during the measurement period
Numerator
Step 1. Identify claims with a principal mental health diagnosis from the HEDIS 2019
Mental Health Diagnosis Value Set.
Step 2. Retain claims with a code from any of the following HEDIS 2019 Value Sets:
•
•
•
ED
Visit Setting Unspecified with a corresponding code from ED POS
Visit Setting Unspecified with a corresponding code from Community Mental
Health Center POS, where the organization can confirm that the visit was in an
ED setting (this POS code can be used in settings other than the ED).
Step 3. Exclude any claims with a code in the Inpatient Stay, Telehealth Modifier, or
Telehealth POS value sets
Population of interest
Additional guidance
Step 4. Determine the total number of unique beneficiaries (de-duplicated) with claims
that meet the criteria in Steps 1- 3.
Medicaid beneficiaries in the demonstration or with SMI/SED enrolled for any amount of
time during the measurement period
None
Measurement period
(Metric type)
Month (CMS-constructed)
Reporting category
Other monthly and quarterly metrics
Reporting level
Demonstration
Model
Subpopulations
Subpopulations
Standardized Definition of SMI
State-specific Definition of SMI
Age groups
Dually eligible for Medicare and Medicaid
Eligible for Medicaid on the basis of disability
Criminal justice status
Co-occurring SUD
Co-occurring or physical health conditions
None
Relationship to other
metrics
Data source
Claims
Claim type
Only use paid claims. (Do not use suspended, pending, or denied claims.)
37
1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
MATHEMATICA
Metric #17: Mental Health Services Utilization - Telehealth
Metric element
Description
Measure
sets/endorsements
None
Description
Number of beneficiaries in the demonstration or with SMI/SED who used telehealth
services related to mental health during the measurement period
The number of unique beneficiaries (de-duplicated total) with SMI/SED with a service
claim for telehealth services related to mental health during the measurement period
Numerator
Step 1. Identify claims with a principal mental health diagnosis from the HEDIS 2019
Mental Health Diagnosis Value Set.
Step 2. Retain claims with a code from any of the following HEDIS 2019 Value Sets:
•
•
•
Population of interest
Additional guidance
Visit Setting Unspecified with a corresponding code from Telehealth Modifier
and Telehealth POS
MPT IOP/PH Group 1 with a corresponding code from Telehealth Modifier and
Telehealth POS
MPT IOP/PH Group 2 with a corresponding code from Telehealth Modifier and
Telehealth POS
o States should ensure the visit was billed by a mental health
practitioner
Step 3. Determine the total number of unique beneficiaries (de-duplicated) with claims
that meet the criteria in Steps 1 and 2.
Medicaid beneficiaries in the demonstration or with SMI/SED enrolled for any amount of
time during the measurement period
None
Measurement period
(Metric type)
Month (CMS-constructed)
Reporting category
Other monthly and quarterly metrics
Reporting level
Demonstration
Model
Subpopulations
Subpopulations
Standardized Definition of SMI
State-specific Definition of SMI
Age groups
Dually eligible for Medicare and Medicaid
Eligible for Medicaid on the basis of disability
Criminal justice status
Co-occurring SUD
Co-occurring or physical health conditions
None
Relationship to other
metrics
Data source
Claims
Claim type
Only use paid claims. (Do not use suspended, pending, or denied claims.)
38
1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
MATHEMATICA
Metric #18: Mental Health Services Utilization– Any Services
Metric element
Description
Measure
sets/endorsements
None
Description
Number of beneficiaries in the demonstration or with SMI/SED who used any services
related to mental health during the measurement period.
The number of unique beneficiaries (de-duplicated total) with a service claim for any
services related to mental health during the measurement period
Numerator
Step 1. Identify claims with a principal mental health diagnosis from the HEDIS 2019
Mental Health Diagnosis Value Set.
Step 2. Retain claims with a code from any of the following HEDIS 2019 Value Sets:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Inpatient Stay
Partial Hospitalization/Intensive Outpatient
MPT IOP/PH Group 1 with a corresponding code from Partial Hospitalization
POS or Community Mental Health Center POS
o States should ensure that the visit was in an intensive outpatient or
partial hospitalization setting
Electroconvulsive Therapy with a corresponding code from Partial
Hospitalization POS or Community Mental Health Center POS
o States should ensure that the visit was in an intensive outpatient or
partial hospitalization setting
Transcranial Magnetic Stimulation with a corresponding code from Partial
Hospitalization POS
o States should ensure that the visit was in an intensive outpatient or
partial hospitalization setting
Transcranial Magnetic Stimulation with a corresponding code from Community
Mental Health Center POS
o States should ensure that the visit was in an intensive outpatient or
partial hospitalization setting
MPT IOP/PH Group 2 with a corresponding code from Partial Hospitalization
POS
o States should ensure that the visit was billed by a mental health
practitioner
MPT IOP/PH Group 2 with a corresponding code from Community Mental
Health Center POS
o States should ensure that the visit was in an intensive outpatient or
partial hospitalization setting
o States should ensure that the visit was billed by a mental health
practitioner
MPT Stand Alone Outpatient Group 1
MPT Stand Alone Outpatient Group 2
o States should ensure the visit was billed by a mental health
practitioner
Observation
o States should ensure the visit was billed by a mental health
practitioner
Visit Setting Unspecified with a corresponding code from Outpatient POS or ED
POS or (Telehealth Modifier and Telehealth POS)
Electroconvulsive Therapy with a corresponding code from Outpatient POS or
Ambulatory Surgical Center POS
Transcranial Magnetic Stimulation with a corresponding code from Outpatient
POS or Ambulatory Surgical Center POS
39
1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
MATHEMATICA
Metric #18: Mental Health Services Utilization– Any Services
Metric element
Numerator (continued)
Description
•
•
•
•
•
•
Population of interest
Additional guidance
Visit Setting Unspecified with a corresponding code from Community Mental
Health Center POS
o States should ensure that the visit was in an outpatient setting
Electroconvulsive Therapy with a corresponding code from Community Mental
Health Center POS
o States should ensure that the visit was in an outpatient setting
Transcranial Magnetic Stimulation with a corresponding code from Community
Mental Health Center POS
o States should ensure that the visit was in an outpatient setting
ED Value Set
MPT IOP/PH Group 1 with a corresponding code from Telehealth Modifier and
Telehealth POS
MPT IOP/PH Group 2 with a corresponding code from Telehealth Modifier and
Telehealth POS
o States should ensure the visit was billed by a mental health
practitioner
Step 3. Determine the total number of unique beneficiaries (de-duplicated) with claims
that meet the criteria in Steps 1 and 2.
Medicaid beneficiaries in the demonstration or with SMI/SED enrolled for any amount of
time during the measurement period
None
Measurement period
(Metric type)
Month (CMS-constructed)
Reporting category
Other monthly and quarterly metrics
Reporting level
Demonstration
Model
Subpopulations
Subpopulations
Standardized Definition of SMI
State-specific Definition of SMI
Age groups
Dually eligible for Medicare and Medicaid
Eligible for Medicaid on the basis of disability
Criminal justice status
Co-occurring SUD
Co-occurring or physical health conditions
None
Relationship to other
metrics
Data source
Claims
Claim type
Only use paid claims. (Do not use suspended, pending, or denied claims.)
40
1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
MATHEMATICA
Metric #19a: Average Length of Stay in IMDs
Metric element
Description
Measure
sets/endorsements
None
Description
Average length of stay (ALOS) for beneficiaries with SMI discharged from an inpatient
or residential stay in an IMD.
CMS will ask states to report three rates for this metric:
Numerator
1. ALOS for all IMDs and populations
2. ALOS among short-term stays (less than or equal to 60 days)
3. ALOS among long-term stays (greater than 60 days)
For each rate (total population, short-term, and long-term stays):
Step 1. Determine length of stay for each discharge identified in the denominator.
Length of stay is calculated based on the number of days between a beneficiary’s
admission date and discharge date from an IMD. A beneficiary admitted and
discharged on the same day is treated as a one-day stay.
Step 2. Sum the total number of days in an IMD by summing the lengths of stay from
the denominator
Denominator
Separately for short-term and all stays, identify the total number of inpatient and
residential discharges from an IMD for mental health treatment.
Step 1. Identify qualifying IMD discharges for inpatient or residential treatment for
mental health during the measurement period. This method may be specific to each
state; some states maintain centralized databases of IMD stays. Alternatively, states
may be able to identify IMD stays in T-MSIS data or through other methods.
Step 1a. Identify claims for inpatient or residential stays using the place of service or
UB Revenue codes listed below:
Place of Service Codes:
•
51 - Inpatient Psychiatric Facility
•
56 – Psychiatric Residential Treatment Center
HCPCS Codes:
o
o
o
o
H0017 – Behavioral health; residential
H0018 – Behavioral health; short-term residential
H0019 – Behavioral health; long-term residential
T2048 – Behavioral health; long-term care residential
UB Revenue Codes:
•
1001 – Residential treatment, psychiatric
•
From the HEDIS 2019 Inpatient Stay Value Set
Step 1b. Identify claims with a primary mental health diagnosis from the HEDIS 2019
Mental Health Diagnosis Value Set
41
1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
MATHEMATICA
Metric #19a: Average Length of Stay in IMDs
Metric element
Denominator (continued)
Description
Step 2. Retain claims that meet the criteria in both Step 1a and 1b for residential or
inpatient treatment in an IMD. (See the additional guidance section for a definition of
IMDs).
Step 3. De-duplicate and sum the discharges from Step 2 to identify the total number
of discharges from an IMD for beneficiaries with a mental health diagnosis.
Step 4. Stratify IMD discharges during the measurement period into short-term, longterm and all stays.
Metric calculation
For each rate, calculate the mean length of stay by dividing the total number of days
in an IMD for all discharges in the numerator by the number of discharges in the
denominator, as follows:
Total number of days in an IMD / Number of discharges
Additional guidance
Use the discharge date to identify claims in the measurement period for residential
and inpatient services. Do not count beneficiaries for an ongoing stay during the
measurement period if the patient is not discharged in that period. If a discharge date
is not explicitly reported, identify all claims associated with a single stay and use the
latest end date of service on the claims. Use one of the following approaches to
combine claims for the same stay:
•
Combine claims for the same beneficiary, provider and admission date; or
•
If an admission date is not reported on all claims, combine claims for the
same patient and provider that have less than a one day break between the
end date of the first claim and the start date of the next claim. For example, if
the end date of the first claim is December 18 and the start date of the next
claim is December 19, then combine the claims as a single stay. However, if
the second claim has a start date of December 20 or later, then do not
combine the claims.
An IMD is defined as a hospital, nursing facility, or other institution that has more than
16 beds and is primarily engaged in providing diagnosis, treatment, or care for people
with mental diseases.
Some states have published lists of IMDs in which the designation is made by the
state. If available, states can use those lists to identify facilities; obtain the associated
billing provider IDs, and identify claims in Steps 1a or 1b associated with those
provider IDs. Otherwise, refer to the State Medicaid Manual for additional regulatory
guidance.
42
1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
MATHEMATICA
Metric #19a: Average Length of Stay in IMDs
Metric element
Additional guidance
(continued)
Description
Per the guidance in Section 4390 of the State Medicaid Manual, the following five
criteria should be used to evaluate whether the overall character of a facility is that of
an IMD:
1.
2.
3.
4.
5.
The facility is licensed as a psychiatric facility.
The facility is accredited as a psychiatric facility.
The facility is under the jurisdiction of the state’s mental health authority.
(This criterion does not apply to facilities under the state’s mental health
authority that are not providing services to mentally ill persons.).
The facility specializes in providing psychiatric/psychological care and
treatment. This may be ascertained through review of patients’ records. It
may also be indicated by the fact that an unusually large proportion of the
staff has specialized psychiatric/psychological training or that a large
proportion of the patients are receiving psychopharmacological drugs.
The current need for institutionalization for more than 50 percent of all the
patients in the facility results from mental diseases.
a. When applying the 50 percent guideline determine whether each
patient’s current need for institutionalization results from a mental
disease. It is not necessary to determine whether any mental health
care is being provided in applying this guideline.
b. If more than 50 percent of the patients are residing in the institution
because of implications of mental health or substance use
diagnoses, then the facility may be determined to be an IMD.
Measurement period
(Metric type)
Year (CMS-constructed)
Reporting category
Other annual metrics
Reporting level
Demonstration
Model
Subpopulations
None
Relationship to other
metrics
None
Data source
Claims
State-specific IMD database
Claim type
If using claims, only use paid claims. (Do not use suspended, pending, or denied
claims.)
Note: States may be asked to provide CMS with the standard deviation based on the mean calculated in this metric
as part of the midpoint assessment. For details, see Appendix F.
43
1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
MATHEMATICA
Metric #19b: Average Length of Stay in IMDs (IMDs receiving FFP only)
Metric element
Description
Measure
sets/endorsements
None
Description
Average length of stay (ALOS) for beneficiaries with SMI discharged from an inpatient
or residential stay in an IMD receiving federal financial participation (FFP).
CMS will ask states to report three rates for this metric:
Numerator
1. ALOS for all IMDs and populations
2. ALOS among short-term stays (less than or equal to 60 days)
3. ALOS among long-term stays (greater than 60 days)
For each rate (total population, short-term, and long-term stays):
Step 1. Determine length of stay for each discharge identified in the denominator.
Length of stay is calculated based on the number of days between a beneficiary’s
admission date and discharge date from an IMD. A beneficiary admitted and
discharged on the same day is treated as a one-day stay.
Step 2. Sum the total number of days in an IMD by summing the lengths of stay from
the denominator
Denominator
Separately for short-term and all stays, identify the total number of inpatient and
residential discharges from an IMD for mental health treatment. Limit to IMDs
receiving FFP.
Step 1. Identify qualifying IMD discharges for inpatient or residential treatment for
mental health during the measurement period. This method may be specific to each
state; some states maintain centralized databases of IMD stays. Alternatively, states
may be able to identify IMD stays in T-MSIS data or through other methods.
Step 1a. Identify claims for inpatient or residential stays using the place of service or
UB Revenue codes listed below:
Place of Service Codes:
•
51 - Inpatient Psychiatric Facility
•
56 – Psychiatric Residential Treatment Center
HCPCS Codes:
o
o
o
o
H0017 – Behavioral health; residential
H0018 – Behavioral health; short-term residential
H0019 – Behavioral health; long-term residential
T2048 – Behavioral health; long-term care residential
UB Revenue Codes:
•
1001 – Residential treatment, psychiatric
•
From the HEDIS 2019 Inpatient Stay Value Set
Step 1b. Identify claims with a primary mental health diagnosis from the HEDIS 2019
Mental Health Diagnosis Value Set
44
1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
MATHEMATICA
Metric #19b: Average Length of Stay in IMDs (IMDs receiving FFP only)
Metric element
Denominator (continued)
Description
Step 2. Retain claims that meet the criteria in both Step 1a and 1b for residential or
inpatient treatment in an IMD. (See the additional guidance section for a definition of
IMDs).
Step 3. De-duplicate and sum the discharges from Step 2 to identify the total number
of discharges from an IMD for beneficiaries with a mental health diagnosis.
Step 4. Stratify IMD discharges during the measurement period into short-term, longterm and all stays.
Metric calculation
For each rate, calculate the mean length of stay by dividing the total number of days
in an IMD for all discharges in the numerator by the number of discharges in the
denominator, as follows:
Total number of days in an IMD / Number of discharges
Additional guidance
Use the discharge date to identify claims in the measurement period for residential
and inpatient services. Do not count beneficiaries for an ongoing stay during the
measurement period if the patient is not discharged in that period. If a discharge date
is not explicitly reported, identify all claims associated with a single stay and use the
latest end date of service on the claims. Use one of the following approaches to
combine claims for the same stay:
•
Combine claims for the same beneficiary, provider and admission date; or
•
If an admission date is not reported on all claims, combine claims for the
same patient and provider that have less than a one day break between the
end date of the first claim and the start date of the next claim. For example, if
the end date of the first claim is December 18 and the start date of the next
claim is December 19, then combine the claims as a single stay. However, if
the second claim has a start date of December 20 or later, then do not
combine the claims.
An IMD is defined as a hospital, nursing facility, or other institution that has more than
16 beds and is primarily engaged in providing diagnosis, treatment, or care for people
with mental diseases. States should limit to IMDs receiving federal financial
participation (FFP).
Some states have published lists of IMDs in which the designation is made by the
state. If available, states can use those lists to identify facilities; obtain the associated
billing provider IDs, and identify claims in Steps 1a or 1b associated with those
provider IDs. Otherwise, refer to the State Medicaid Manual for additional regulatory
guidance.
45
1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
MATHEMATICA
Metric #19b: Average Length of Stay in IMDs (IMDs receiving FFP only)
Metric element
Additional guidance
(continued)
Description
Per the guidance in Section 4390 of the State Medicaid Manual, the following five
criteria should be used to evaluate whether the overall character of a facility is that of
an IMD:
1.
2.
3.
4.
5.
The facility is licensed as a psychiatric facility.
The facility is accredited as a psychiatric facility.
The facility is under the jurisdiction of the state’s mental health authority.
(This criterion does not apply to facilities under the state’s mental health
authority that are not providing services to mentally ill persons.).
The facility specializes in providing psychiatric/psychological care and
treatment. This may be ascertained through review of patients’ records. It
may also be indicated by the fact that an unusually large proportion of the
staff has specialized psychiatric/psychological training or that a large
proportion of the patients are receiving psychopharmacological drugs.
The current need for institutionalization for more than 50 percent of all the
patients in the facility results from mental diseases.
a. When applying the 50 percent guideline determine whether each
patient’s current need for institutionalization results from a mental
disease. It is not necessary to determine whether any mental health
care is being provided in applying this guideline.
b. If more than 50 percent of the patients are residing in the institution
because of implications of mental health or substance use
diagnoses, then the facility may be determined to be an IMD.
Measurement period
(Metric type)
Year (CMS-constructed)
Reporting category
Other annual metrics
Reporting level
Demonstration
Model
Subpopulations
None
Relationship to other
metrics
None
Data source
Claims
State-specific IMD database
Claim type
If using claims, only use paid claims. (Do not use suspended, pending, or denied
claims.)
Note: States may be asked to provide CMS with the standard deviation based on the mean calculated in this metric
as part of the midpoint assessment. For details, see Appendix F.
46
1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
MATHEMATICA
Metric #20: Beneficiaries With SMI/SED Treated in an IMD for Mental Health
Metric element
Description
Measure
sets/endorsements
None
Description
Number of beneficiaries with SMI/SED who have a claim for inpatient or residential
treatment for mental health in an IMD during the reporting year.
The number of unique beneficiaries (de-duplicated total) enrolled in the measurement
period who have a service claim with a mental health diagnosis and who received
inpatient/residential treatment in an IMD within the measurement period
Numerator
Step 1a. Identify qualifying IMD discharges for inpatient or residential treatment
mental health during the measurement period. This method may be specific to each
state; some states maintain centralized databases of IMD stays. Alternatively, states
may be able to identify IMD stays in T-MSIS data or through other methods.
Step 1b. Identify claims with a place of service, HCPCS, or UB Revenue code listed
below:
Place of Service Codes:
o 51 - Inpatient Psychiatric Facility
o 56 – Psychiatric Residential Treatment Center
HCPCS Codes:
o
o
o
o
H0017 – Behavioral health; residential
H0018 – Behavioral health; short-term residential
H0019 – Behavioral health; long-term residential
T2048 – Behavioral health; long-term care residential
UB Revenue Codes:
o 1001 – Residential treatment, psychiatric
o HEDIS 2019 Inpatient Stay Value Set
Step 2. Identify claims with a primary mental health diagnosis from the HEDIS 2019
Mental Health Diagnosis Value Set
Step 3. Retain claims for inpatient/residential treatment in an IMD found in Step 1a or
Step 2. (See the additional guidance section for a definition of IMDs.) Only include
IMDs receiving Federal Financial Participation under the demonstration.
Step 4. Determine the total number of unique beneficiaries (de-duplicated) with claims
that meet the criteria in Steps 1 and 2, and 3.
Population of interest
Medicaid beneficiaries in the demonstration or with SMI/SED enrolled for any amount
of time during the measurement period
Additional guidance
Use the discharge date to identify claims in the measurement period. Do not count
beneficiaries for an ongoing stay during the measurement period if the patient is not
discharged in that period. If a discharge date is not explicitly reported, identify all
claims associated with a single stay and use the latest end date of service on the
claims. Use one of the following approaches to combine claims for the same stay:
•
combine claims for the same beneficiary, provider and admission date; or
•
If an admission date is not reported on all claims, then combine claims for the
same patient and provider that have less than a one day break between the
end date of the first claim and the start date of the next claim. For example, if
the end date of the first claim is December 18 and the start date of the next
claim is December 19, then combine the claims as a single stay. However, if
the second claim has a start date of December 20 or later, then do not
combine the claims.
47
1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
MATHEMATICA
Metric #20: Beneficiaries With SMI/SED Treated in an IMD for Mental Health
Metric element
Additional guidance
(continued)
Description
An IMD is defined as a hospital, nursing facility, or other institution that has more than
16 beds and is primarily engaged in providing diagnosis, treatment, or care for people
with mental diseases. Only include IMDs receiving Federal Financial Participation
under the demonstration.
Some states have published lists of IMDs in which the designation is made by the
state. If available, use those lists to identify facilities; obtain the associated billing
provider IDs, and identify claims in Steps 1a or 1b associated with those provider IDs.
Otherwise, refer to the State Medicaid Manual for additional regulatory guidance.
Per the guidance in Section 4390 of the State Medicaid Manual, the following five
criteria should be used to evaluate whether the overall character of a facility is that of
an IMD:
1.
2.
3.
4.
5.
The facility is licensed as a psychiatric facility.
The facility is accredited as a psychiatric facility.
The facility is under the jurisdiction of the state’s mental health authority.
(This criterion does not apply to facilities under the state’s mental health
authority that are not providing services to mentally ill persons.).
The facility specializes in providing psychiatric/psychological care and
treatment. This may be ascertained through review of patients’ records. It
may also be indicated by the fact that an unusually large proportion of the
staff has specialized psychiatric/psychological training or that a large
proportion of the patients are receiving psychopharmacological drugs.
The current need for institutionalization for more than 50 percent of all the
patients in the facility results from mental diseases.
a. When applying the 50 percent guideline determine whether each
patient’s current need for institutionalization results from a mental
disease. It is not necessary to determine whether any mental health
care is being provided in applying this guideline.
b. If more than 50 percent of the patients are residing in the institution
because of implications of mental health or substance use
diagnoses, then the facility may be determined to be an IMD.
Measurement period
Year (CMS-constructed)
Reporting category
Other annual metrics
Reporting level
Demonstration
Model
Subpopulations
None
Relationship to other
metrics
None
Data source
Claims
Claim type
Only use paid claims. (Do not use suspended, pending, or denied claims.)
48
1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
MATHEMATICA
Metric #21: Count of Beneficiaries With SMI/SED (monthly)
Metric element
Description
Measure
sets/endorsements
None
Description
Count the number of unique beneficiaries (de-duplicated total) enrolled in the
measurement period who have qualifying facility, or provider claims have sufficient
qualifying facility, or provider claims to qualify as having SMI/SED-related treatment
during the measurement period and/or in the 11 months before the measurement
period
Count the number of unique beneficiaries (de-duplicated total) enrolled in the
measurement period who have qualifying facility, or provider claims to qualify as
having SMI/SED-related treatment during the measurement period and/or in the 11
months before the measurement period
Numerator
Population of interest
All Medicaid beneficiaries with SMI/SED as identified by the state
Additional guidance
States should identify the SMI/SED demonstration population used in this metric
based on a history of SMI/SED diagnosis.
Measurement period
(Metric Type)
Month (CMS-constructed)
Reporting Category
Other monthly and quarterly metrics
Reporting level
Demonstration
Model
Subpopulations
Subpopulations
Standardized Definition of SMI
State-specific Definition of SMI
Age groups
Dually eligible for Medicare and Medicaid
Eligible for Medicaid on the basis of disability
Criminal justice status
Co-occurring SUD
Co-occurring or physical health conditions
Relationship to other
metrics
The approach to identify SMI/SED beneficiaries also applies to metric #22
Data source
Claims
Claim type
Only use paid claims. (Do not use suspended, pending, or denied claims.)
49
1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
MATHEMATICA
Metric #22: Count of Beneficiaries With SMI/SED (annually)
Metric element
Description
Measure
sets/endorsements
None
Description
Numerator
Number of beneficiaries in the demonstration (with a diagnosis and service history
indicating SMI/SED) during the measurement period and/or in the 12 months before
the measurement period
Count the number of unique beneficiaries (de-duplicated total) enrolled in the
measurement period who have qualifying facility, or provider claims have sufficient
qualifying facility, or provider claims to qualify as having SMI/SED-related treatment
during the measurement period and/or in the 12 months before the measurement
period
Population of interest
All Medicaid beneficiaries with SMI/SED as identified by the state
Additional guidance
States should identify the SMI/SED demonstration population used in this metric
based on a history of SMI/SED diagnosis.
Measurement period
(Metric Type)
Year (CMS-constructed)
Reporting category
Other annual metrics
Reporting level
Demonstration
Model
Subpopulations
Subpopulations
Standardized Definition of SMI
State-specific Definition of SMI
Age groups
Dually eligible for Medicare and Medicaid
Eligible for Medicaid on the basis of disability
Criminal justice status
Co-occurring SUD
Co-occurring or physical health conditions
Relationship to other
metrics
The approach to identify SMI/SED beneficiaries also applies to metric #21
Data source
Claims
Claim type
Only use paid claims. (Do not use suspended, pending, or denied claims.)
50
1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
MATHEMATICA
Metric #23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control
(>9.0%) (HPCMI-AD)
Metric element
Description
Measure
sets/endorsements
FFY 2019 Core Set of Adult Health Care Quality Measures for Medicaid (Adult Core
Set)
NQF #2607
Measure steward: NCQA
Description
Percentage of beneficiaries ages 18 to 75 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%.
Metric calculation
Instructions for calculating this metric can be found in Appendix D: Technical
Specifications for Established Quality Measures Adapted from FFY 2019 Child and
Adult Core Sets Measure Specifications
Additional guidance
None
Measurement period
(Metric type)
Year (Established quality measure)
Reporting category
Annual metrics that are established quality measures
Reporting level
Demonstration
Model
Subpopulations
None
Relationship to other
metrics
None
Data source
Claims, Medical Records
Claim type
Include paid, suspended, pending, and denied claims.
51
1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
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Metric #24: Screening for Depression and Follow-Up Plan: Age 18 and Older (CDF-AD)
Metric element
Description
Measure
sets/endorsements
FFY 2019 Core Set of Adult Health Care Quality Measures for Medicaid (Adult Core
Set)
NQF #0418
Measure steward: CMS
Description
Percentage of beneficiaries age 18 and older screened for 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.
Metric calculation
Instructions for calculating this metric can be found in Appendix D: Technical
Specifications for Established Quality Measures Adapted from FFY 2019 Child and
Adult Core Sets Measure Specifications
Additional guidance
None
Measurement period
(Metric type)
Year (Established quality measure)
Reporting category
Annual metrics that are established quality measures
Reporting level
Demonstration
Model
Subpopulations
None
Relationship to other
metrics
None
Data source
Claims or electronic medical records
Claim type
Include paid, suspended, pending, and denied claims.
Note:
Measure specification shown applies to 2018 and is for illustrative purposes. The measure specification will
be updated in Spring 2020 for reporting on 2019.
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Metric #25: Screening for Depression and Follow-Up Plan: Ages 12–17 (CDF-CH)
Metric element
Description
Measure
sets/endorsements
FFY 2019 Core Set of Child Health Care Quality Measures for Medicaid (Child Core
Set)
NQF #0418
Measure steward: CMS
Description
Percentage of beneficiaries ages 12 to 17 screened for 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.
Metric calculation
Instructions for calculating this metric can be found in Appendix D: Technical
Specifications for Established Quality Measures Adapted from FFY 2019 Child and
Adult Core Sets Measure Specifications
Additional guidance
None
Measurement period
(Metric type)
Year (Established quality measure)
Reporting category
Annual metrics that are established quality measures
Reporting level
Demonstration
Model
Subpopulations
None
Relationship to other
metrics
None
Data source
Claims or electronic medical records
Claim type
Include paid, suspended, pending, and denied claims.
Note:
Measure specification shown applies to 2018 and is for illustrative purposes. The measure specification will
be updated in Spring 2020 for reporting on 2019.
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Metric #26: Access to Preventive/Ambulatory Health Services for Medicaid Beneficiaries With SMI
Metric element
Measure
sets/endorsements
Description
Metric calculation
Description
Adjusted, HEDIS measure
Measure steward: NCQA
The percentage of Medicaid beneficiaries with SMI who had an ambulatory or
preventive care visit during the measurement period.
Step 1. Identify claims during the measurement period with a diagnosis code (any
diagnosis code on the claim) from the HEDIS 2019 Mental Health Diagnosis Value Set
Step 2. Using the claims in step 1 to identify the denominator population, follow
instructions for calculating this metric, which can be found in the HEDIS 2019
Technical Specifications for Health Plans, Measure AAP: Adults’ Access to
Preventive/Ambulatory Health Services.
Additional guidance
The original HEDIS measure is called Access to Preventive/Ambulatory Health
Services for Adult Beneficiaries. CMS will provide this measure specification
separately.
Measurement period
(Metric type)
Year (Established quality measure)
Reporting category
Annual metrics that are established quality measures
Reporting level
Demonstration
Model
Subpopulations
None
Relationship to other
metrics
None
Data source
Claims
Claim type
Include paid, suspended, pending, and denied claims.
Note:
Measure specification shown applies to 2018 and is for illustrative purposes. The measure specification will
be updated in Spring 2020 for reporting on 2019.
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Metric #27: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or Alcohol or
Other Drug Dependence
Metric element
Description
Measure
sets/endorsements
Measure steward: NCQA
NQF #2600
Description
The percentage of patients 18 years and older with a serious mental illness or alcohol
or other drug dependence who received a screening for tobacco use and follow-up for
those identified as a current tobacco user. Two rates are reported, one for adults with
SMI and the other for adults with AOD.
Metric calculation
Calculation instructions are located in the full measure specification, which CMS will
provide separately
Additional guidance
The specifications and value sets for this measure are available to states upon
request by contacting [email protected].
Measurement period
(Metric type)
Year (Established quality measure)
Reporting category
Annual metrics that are established quality measures
Reporting level
Demonstration
Model
Subpopulations
None
Relationship to other
metrics
None
Data source
Claims
Claim type
Only use paid claims. (Do not use suspended, pending, or denied claims.
Note:
Measure specification and value set information shown was last updated in 2014. States should use their
discretion on including state-specific codes to supplement the applicable value sets.
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Metric #28: Alcohol Screening and Follow-up for People with Serious Mental Illness
Metric element
Description
Measure
sets/endorsements
Measure steward: NCQA
NQF #2599
Description
The percentage of patients 18 years and older with a serious mental illness, who were
screened for unhealthy alcohol use and received brief counseling or other follow-up
care if identified as an unhealthy alcohol user.
Metric calculation
Calculation instructions are located in the full measure specification, which CMS will
provide separately.
Additional guidance
Please use the measure steward’s instructions for identifying the SMI population for
this metric. The specifications and value sets for this measure are available to states
upon request by contacting [email protected]
Measurement period
(Metric type)
Year (Established quality measure)
Reporting category
Annual metrics that are established quality measures
Reporting level
Demonstration
Model
Subpopulations
None
Relationship to other
metrics
None
Data source
Claims
Claim type
Only use paid claims. (Do not use suspended, pending, or denied claims.)
Note:
Measure specification and value set information shown was last updated in 2014. States should use their
discretion on including state-specific codes to supplement the applicable value sets.
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Metric #29: Metabolic Monitoring for Children and Adolescents on Antipsychotics
Metric element
Measure
sets/endorsements
Description
Metric calculation
Description
HEDIS 2019
Measure steward: NCQA
The percentage of children and adolescents 1-17 years of age with ongoing
antipsychotic medication use who had metabolic testing during the year.
Follow instructions for calculating this metric, which can be found in the HEDIS 2019
Technical Specifications for Health Plans, Measure APM: Metabolic Monitoring for
Children and Adolescents on Antipsychotics.
Additional guidance
Calculation instructions are located in the full measure specification, which CMS will
provide separately.
Measurement period
(Metric type)
Year (Established quality measure)
Reporting category
Annual metrics that are established quality measures
Reporting level
Demonstration
Model
Subpopulations
None
Relationship to other
metrics
None
Data source
Claims
Claim type
Use only use paid claims. (Do not use suspended, pending, or denied claims).
Note:
Measure specification shown applies to 2018 and is for illustrative purposes. The measure specification will
be updated in Spring 2020 for reporting on 2019.
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Metric #30: Follow-Up Care for Adult Medicaid Beneficiaries Who are Newly Prescribed an Antipsychotic
Medication
Metric element
Description
Measure
sets/endorsements
Measure steward: CMS
NQF #3313
Description
Percentage of new antipsychotic prescriptions for Medicaid beneficiaries age 18 years
and older who have completed a follow-up visit with a provider with prescribing
authority within four weeks (28 days) of prescription of an antipsychotic medication.
Metric calculation
Calculation instructions are located in the full measure specification, which CMS will
provide separately.
Additional guidance
The specifications and value sets for this measure are available to states upon
request by contacting [email protected]
Measurement period
(Metric type)
Year (Established quality measure)
Reporting category
Annual metrics that are established quality measures
Reporting level
Demonstration
Model
Subpopulations
None
Relationship to other
metrics
None
Data source
Claims
Claim type
Use paid, suspended, pending, and denied claims.
Note:
Measure specification shown applies to 2018 and is for illustrative purposes. The measure specification will
be updated in Spring 2020 for reporting on 2019.
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Metric #31: Use of Multiple Concurrent Antipsychotics in Children and Adolescents (APC-CH)
Metric element
Description
Measure
sets/endorsements
FFY 2019 Core Set of Child Health Care Quality Measures for Medicaid (Child Core
Set)
Measure steward: NCQA
Description
Percentage of children and adolescents ages 1 to 17 who were treated with
antipsychotic medications and who were on two or more concurrent antipsychotic
medications for at least 90 consecutive days during the measurement year.
Metric calculation
Instructions for calculating this metric can be found in Appendix D: Technical
Specifications for Established Quality Measures Adapted from FFY 2019 Child and
Adult Core Sets Measure Specifications
Additional guidance
Measurement period
(Metric type)
Year (Established quality measure)
Reporting category
Annual metrics that are established quality measures
Reporting level
Demonstration
Model
Subpopulations
None
Relationship to other
metrics
None
Data source
Claims
Claim type
Include paid, suspended, and pending claims.
Note:
Measure specification shown applies to 2018 and is for illustrative purposes. The measure specification will
be updated in Spring 2020 for reporting on 2019.
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Metric #32: Total Costs Associated with Mental Health Services Among Beneficiaries with SMI/SED – Not
Inpatient or Residential
Metric element
Description
Measure
sets/endorsements
None
Description
Total Medicaid costs for non-inpatient or residential services for mental health, among
beneficiaries in the demonstration or with SMI/SED during the measurement period.
Numerator
The sum of all Medicaid spending for mental health services not in inpatient or
residential settings during the measurement period
Step 1. Identify FFS mental health claims as described below in the Population of
Interest section.
Step 2. Sum the total amount paid by Medicaid on these claims. If using T-MSIS data to
calculate this metric, this data element is named TOT-MEDICAID-PAID-AMT.
Step 3. Identify managed care mental health encounter records as described below in
the denominator section.
Step 4. Sum the amount paid by Medicaid for these encounters. There are several ways
to estimate the amount paid by Medicaid on encounter claims:
•
•
•
•
If available, states should use payment rates reported by managed care
organizations to identify costs for mental health encounters.
Determine the FFS cost to Medicaid for a service (such as by using an FFS
Medicaid physician fee schedule) and apply that figure to encounter claims for
the same service. This method may not be appropriate if there are no FFS
claims for the same service types to use as a reference. Many states maintain
the FFS fee schedules and frequently make them publicly available.
Use a Medicaid-to-Medicare Fee Index. These indices enable researchers to
assume that Medicaid rates for a given service are set at a certain percentage
of Medicare rates. In other words, they estimate the Medicaid fees for each
state relative to the Medicare fees and provide a conversion factor. For each
service, apply the conversion factor to the Medicare fee schedule to estimate
the cost to Medicaid.
o An example of Medicaid-to-Medicare fee comparisons is MACPAC’s
comparison of medical hospital payments between Medicaid and
Medicare, available at https://www.macpac.gov/wp-content/uploads/
2017/04/Medicaid-Hospital-Payment-A-Comparison-across-Statesand-to-Medicare.pdf.
o The Medicare fee schedule is available at https://www.cms.gov/
Medicare/Medicare-Fee-for-Service-Payment/FeeSchedule
GenInfo/index.html. CMS’s searchable Medicare Physician Fee
schedule contains Medicare payment information for more than 10,000
services and can be found at https://www.cms.gov/apps/physician-feeschedule/search/search-criteria.aspx.
Use Medicaid FFS equivalent amounts for encounter records reported in TMSIS.
Step 5. Sum the amount paid by Medicaid from Step 2 and Step 4 to determine total
Medicaid spending associated with services for mental health during the measurement
period.
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Metric #32: Total Costs Associated with Mental Health Services Among Beneficiaries with SMI/SED – Not
Inpatient or Residential
Metric element
Population of interest
Description
Mental health treatment services provided during the measurement period.
Step 1. Identify claims with a principal mental health diagnosis from the HEDIS 2019
Mental Health Diagnosis Value Set.
Step 2. Retain claims with a code from any of the following HEDIS 2019 Value Sets:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
MPT Stand Alone Outpatient Group 1
MPT Stand Alone Outpatient Group 2
o States should ensure the visit was billed by a mental health
practitioner
Observation
o States should ensure the visit was billed by a mental health
practitioner
Visit Setting Unspecified with a corresponding code from Outpatient POS
Electroconvulsive Therapy with a corresponding code from Outpatient POS
Transcranial Magnetic Stimulation with a corresponding code from Outpatient
POS
Visit Setting Unspecified with a corresponding code from Community Mental
Health Center POS
o States should ensure that the visit was in an outpatient setting
Electroconvulsive Therapy with a corresponding code from Community Mental
Health Center POS
o States should ensure that the visit was in an outpatient setting
Transcranial Magnetic Stimulation with a corresponding code from Community
Mental Health Center POS
o States should ensure that the visit was in an outpatient setting
Electroconvulsive Therapy with a corresponding code from Ambulatory
Surgical Center POS
Transcranial Magnetic Stimulation with a corresponding code from Ambulatory
Surgical Center POS
Partial Hospitalization/Intensive Outpatient
MPT IOP/PH Group 1 with a corresponding code from Partial Hospitalization
POS
o States should ensure that the visit was in an intensive outpatient or
partial hospitalization setting
Electroconvulsive Therapy with a corresponding code from Partial
Hospitalization POS
o States should ensure that the visit was in an intensive outpatient or
partial hospitalization setting
Transcranial Magnetic Stimulation with a corresponding code from Partial
Hospitalization POS
o States should ensure that the visit was in an intensive outpatient or
partial hospitalization setting
MPT IOP/PH Group 1 with a corresponding code from Community Mental
Health Center POS
o States should ensure that the visit was in an intensive outpatient or
partial hospitalization setting
Electroconvulsive Therapy with a corresponding code from Community Mental
Health Center POS
o States should ensure that the visit was in an intensive outpatient or
partial hospitalization setting
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Metric #32: Total Costs Associated with Mental Health Services Among Beneficiaries with SMI/SED – Not
Inpatient or Residential
Metric element
Population of interest
(continued)
Description
•
•
•
Transcranial Magnetic Stimulation with a corresponding code from Community
Mental Health Center POS
o States should ensure that the visit was in an intensive outpatient or
partial hospitalization setting
MPT IOP/PH Group 2 with a corresponding code from Partial Hospitalization
POS
o States should ensure that the visit was billed by a mental health
practitioner
MPT IOP/PH Group 2 with a corresponding code from Community Mental
Health Center POS
o States should ensure that the visit was in an intensive outpatient or
partial hospitalization setting
o States should ensure that the visit was billed by a mental health
practitioner
Step 3. Exclude any claims with a code in the Inpatient Stay
Step 4. Retain claims that meet the criteria in Steps 1-3.
Additional guidance
States that use fee schedules to calculate this metric should update them each year to
reflect changes in payment rates over time. However, to ensure consistency, the method
used to calculate this metric should stay the same across measurement periods. For
example, states should not calculate managed care costs using a Medicaid-to-Medicare
Fee Index in one year and the MEDICAID-FFS-EQUIVALENT-AMT field in other years.
Measurement period
(Metric type)
Year (CMS-constructed)
Reporting category
Other annual metrics
Reporting level
Demonstration
Model
Subpopulations
None
Relationship to other
metrics
Claims for services in 32 and 33 are mutually exclusive.
Data source
Claims
Claim type
Only use paid claims. (Do not use suspended, pending, or denied claims.)
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Metric #33: Total Costs Associated with Mental Health Services Among Beneficiaries with SMI/SED –
Inpatient or Residential
Metric element
Description
Measure
sets/endorsements
None
Description
Total Medicaid costs for inpatient or residential services for mental health among
beneficiaries with SMI/SED during the measurement period.
Numerator
The sum of all Medicaid costs for mental health services in inpatient or residential
settings during the measurement period
Step 1. Identify FFS mental health claims as described below in the Population of
Interest section.
Step 2. Sum the total amount paid by Medicaid on these claims. If using T-MSIS data to
calculate this metric, this data element is named TOT-MEDICAID-PAID-AMT.
Step 3. Identify managed care mental health encounter records as described below in
the population of interest section.
Step 4. Sum the amount paid by Medicaid for these encounters. There are several ways
to estimate the amount paid by Medicaid on encounter claims:
•
•
•
•
If available, states should use payment rates reported by managed care
organizations to identify costs for mental health encounters.
Determine the FFS cost to Medicaid for a service (such as by using an FFS
Medicaid physician fee schedule) and apply that figure to encounter claims for
the same service. This method may not be appropriate if there are no FFS
claims for the same service types to use as a reference. Many states maintain
the FFS fee schedules and frequently make them publicly available.
Use a Medicaid-to-Medicare Fee Index. These indices enable researchers to
assume that Medicaid rates for a given service are set at a certain percentage
of Medicare rates. In other words, they estimate the Medicaid fees for each
state relative to the Medicare fees and provide a conversion factor. For each
service, apply the conversion factor to the Medicare fee schedule to estimate
the cost to Medicaid.
o An example of Medicaid-to-Medicare fee comparisons is MACPAC’s
comparison of medical hospital payments between Medicaid and
Medicare, available at https://www.macpac.gov/wp-content/uploads/
2017/04/Medicaid-Hospital-Payment-A-Comparison-across-Statesand-to-Medicare.pdf.
o The Medicare fee schedule is available at https://www.cms.gov/
Medicare/Medicare-Fee-for-Service-Payment/FeeSchedule
GenInfo/index.html. CMS’s searchable Medicare Physician Fee
schedule contains Medicare payment information for more than 10,000
services and can be found at https://www.cms.gov/apps/physician-feeschedule/search/search-criteria.aspx.
Use Medicaid FFS equivalent amounts for encounter records reported in TMSIS.
Step 5. Sum the amount paid by Medicaid from Step 2 and Step 4 to determine total
Medicaid spending associated with mental health during the measurement period.
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Metric #33: Total Costs Associated with Mental Health Services Among Beneficiaries with SMI/SED –
Inpatient or Residential
Metric element
Population of Interest
Description
Mental health treatment services provided during the measurement period.
Step 1. Identify beneficiaries with a principal mental health diagnosis from the HEDIS
2019 Mental Health Diagnosis Value Set.
Step 2. Retain claims with a place of service, HCPCS, or UB Revenue code listed below
claims with a code from any of the following:
Place of Service Codes:
o 51 - Inpatient Psychiatric Facility
o 56 – Psychiatric Residential Treatment Center
o HEDIS 2016 BH Stand Alone Acute Inpatient Value Set
o HEDIS 2016 HEDIS BH Acute Inpatient Value Set
o HEDIS 2016 HEDIS BH Nonacute inpatient
HCPCS Codes:
o
o
o
o
H0017 – Behavioral health; residential
H0018 – Behavioral health; short-term residential
H0019 – Behavioral health; long-term residential
T2048 – Behavioral health; long-term care residential
UB Revenue Codes:
o 1001 – Residential treatment, psychiatric
o HEDIS 2016 BH Stand Alone Nonacute Inpatient Value Set
o HEDIS 2019 Inpatient Stay Value Set
Step 3. Exclude any claims with a code Telehealth Modifier, Telehealth POS, MPT Stand
Alone Outpatient Group 1, MPT Stand Alone Outpatient Group 2, Observation,
Outpatient POS, Community Mental Health Center POS, Ambulatory Surgical Center
POS, or Partial Hospitalization POS value sets
Additional guidance
Step 4. Retain claims that meet the criteria in Steps 1-3.
States that use fee schedules to calculate this metric should update them each year to
reflect changes in payment rates over time. However, to ensure consistency, the method
used to calculate this metric should stay the same across measurement periods. For
example, states should not calculate managed care costs using a Medicaid-to-Medicare
Fee Index in one year and the MEDICAID-FFS-EQUIVALENT-AMT field in other years.
Measurement period
(Metric type)
Year (CMS constructed)
Reporting category
Other annual metrics
Reporting level
Demonstration
Model
Subpopulations
None
Relationship to other
metrics
Claims for services in 32 and 33 are mutually exclusive.
Data source
Claims
Claim type
Only use paid claims. (Do not use suspended, pending, or denied claims.)
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Metric #34: Per Capita Costs Associated With Mental Health Services Among Beneficiaries with SMI/SED Not Inpatient or Residential
Metric element
Description
Measure
sets/endorsements
None
Description
Per capita costs for non-inpatient, non-residential services for mental health, among
beneficiaries with SMI/SED during the measurement period
Numerator
Total Medicaid costs for mental health services for beneficiaries with SMI/SED during the
measurement period for non-inpatient, non-residential mental health services.
Count the number of unique beneficiaries (de-duplicated total) enrolled in the
measurement period who have qualifying facility, or provider claims have sufficient
qualifying facility, or provider claims to qualify as having SMI/SED -related treatment
during the measurement period and/or in the 12 months before the measurement period.
Calculate per capita costs by dividing spending on mental health treatment in the
numerator by the number of beneficiaries in the denominator.
Denominator
Metric calculation
Additional guidance
States that use fee schedules to calculate this metric should update them each year to
reflect changes in payment rates over time. However, to ensure consistency, the method
used to calculate this metric should stay the same across measurement periods. For
example, states should not calculate managed care costs using a Medicaid-to-Medicare
Fee Index in one year and the MEDICAID-FFS-EQUIVALENT-AMT field in other years.
Measurement period
(Metric type)
Year (CMS-constructed)
Reporting category
Other annual metrics
Reporting level
Demonstration
Model
Subpopulations
None
Relationship to other
metrics
The Numerator for this metrics is the same as total spending calculated in metric #32
The Denominator is the annual count of beneficiaries that have SMI/SED as calculated in
metric #22
Claims for services in #34 and #35 are mutually exclusive.
Data source
Claims
Claim type
Only use paid claims. (Do not use suspended, pending, or denied claims.)
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Metric #35: Per Capita Costs Associated With Mental Health Services Among Beneficiaries with SMI/SED Inpatient or Residential
Metric element
Description
Measure
sets/endorsements
None
Description
Per capita costs for not inpatient or residential services for mental health, among
beneficiaries with SMI/SED during the measurement period
Numerator
Medicaid costs for mental health services for beneficiaries with SMI/SED during the
measurement period for non-inpatient, non-residential mental health services.
Count the number of unique beneficiaries (de-duplicated total) enrolled in the
measurement period who have qualifying facility, or provider claims have sufficient
qualifying facility, or provider claims to qualify as having SMI/SED -related treatment
during the measurement period and/or in the 12 months before the measurement period.
Calculate per capita spending by dividing spending on mental health treatment in the
numerator by the number of beneficiaries in the denominator.
Denominator
Metric calculation
Additional guidance
States that use fee schedules to calculate this metric should update them each year to
reflect changes in payment rates over time. However, to ensure consistency, the method
used to calculate this metric should stay the same across measurement periods. For
example, states should not calculate managed care costs using a Medicaid-to-Medicare
Fee Index in one year and the MEDICAID-FFS-EQUIVALENT-AMT field in other years.
Measurement period
(Metric type)
Year (CMS-constructed)
Reporting category
Other annual metrics
Reporting level
Demonstration
Model
Subpopulations
None
Relationship to other
metrics
The Numerator for this metrics is the same as total spending calculated in metric #33
The Denominator is the annual count of beneficiaries that have SMI/SED as calculated in
metric #22.
Claims for services in #34 and #35 are mutually exclusive.
Data source
Claims
Claim type
Only use paid claims. (Do not use suspended, pending, or denied claims.)
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Metric #36: Grievances Related to services for SMI/SED
Metric element
Description
Measure
sets/endorsements
None
Description
Number of grievances filed during the measurement period that are related to services
for SMI/SED
Numerator
Number of grievances related to SMI/SED services by or on behalf of enrollees during
the measurement period. Count each grievance once, regardless of whether more than
one grievance is filed by the same enrollee.
There is no national process for filing and resolving grievances; each state determines
the process and levels of review a grievance may take.
Additional guidance
None
Measurement period
(Metric type)
Quarter (CMS-constructed)
Reporting Category
Grievances and appeals and qualitative information on referral into treatment
Reporting level
Demonstration
Model
Subpopulations
None
Relationship to other
metrics
None
Data source
Administrative records
Claim type
Not applicable
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Metric #37: Appeals Related to Services for SMI/SED
Metric element
Description
Measure
sets/endorsements
None
Description
Number of appeals filed during the measurement period that are related to services for
SMI/SED
Numerator
Number of appeals related to SMI/SED services filed by or on behalf of enrollees during
the reporting quarter, by type (that is, reason for the appeal). Count each appeal once,
regardless of whether more than one appeal is filed by the same enrollee. Appeals that
are processed through multiple levels of review should only be counted once.
There is no typology for tracking appeals filed by Medicaid beneficiaries; each state
tracks and categorizes appeals differently. States should report appeal types according
to their own definition.
Additional guidance
None
Measurement period
(Metric type)
Quarter (CMS-constructed)
Reporting category
Grievances and appeals and qualitative information on referral into treatment
Reporting level
Demonstration
Model
Subpopulations
None
Relationship to other
metrics
None
Data source
Administrative records
Claim type
Not applicable
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Metric #38: Critical Incidents Related to Services for SMI/SED
Metric element
Description
Measure
sets/endorsements
None
Description
Number of critical incidents filed during the measurement period that are related to
services for SMI/SED
Numerator
The number of critical incidents related to SMI/SED services filed by or on behalf of
enrollees during the measurement period. Count each critical incident once, regardless
of whether more than one critical incident is filed by the same enrollee.
Additional guidance
There is no national typology for tracking critical incidents; each state tracks and
categorizes critical incidents differently.
None
Measurement period
(Metric type)
Quarter (CMS-constructed)
Reporting category
Grievances and appeals and qualitative information on referral into treatment
Reporting level
Demonstration
Model
Subpopulations
None
Relationship to other
metrics
None
Data source
Administrative records
Claim type
Not applicable
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Metric #39: Total Costs Associated With Treatment for Mental Health in an IMD Among Beneficiaries with
SMI/SED
Metric element
Description
Measure
sets/endorsements
None
Description
Total Medicaid costs for beneficiaries with SMI/SED who had claims for inpatient or
residential treatment for mental health in an IMD during the reporting year.
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Metric #39: Total Costs Associated With Treatment for Mental Health in an IMD Among Beneficiaries with
SMI/SED
Metric element
Numerator
Description
The sum of all Medicaid costs on inpatient or residential treatment for mental health
within IMDs among beneficiaries with SMI/SED during the measurement period.
Step 1. Identify FFS mental health claims as described below in the population of
interest section.
Step 2. Sum the total amount paid by Medicaid on these claims. If using T-MSIS data to
calculate this metric, this data element is named TOT-MEDICAID-PAID-AMT.
Step 3. Identify managed care mental health encounter records as described below in
the Population of interest section.
Step 4. Sum the amount paid by Medicaid for these encounters. There are several ways
to estimate the amount paid by Medicaid on encounter claims:
•
•
•
•
If available, states should use payment rates reported by managed care
organizations to identify costs for mental health encounters.
Determine the FFS cost to Medicaid for a service (such as by using an FFS
Medicaid physician fee schedule) and apply that figure to encounter claims for
the same service. This method may not be appropriate if there are no FFS
claims for the same service types to use as a reference. Many states maintain
the FFS fee schedules and frequently make them publicly available.
Use a Medicaid-to-Medicare Fee Index. These indices enable researchers to
assume that Medicaid rates for a given service are set at a certain percentage
of Medicare rates. In other words, they estimate the Medicaid fees for each
state relative to the Medicare fees and provide a conversion factor. For each
service, apply the conversion factor to the Medicare fee schedule to estimate
the cost to Medicaid.
o An example of Medicaid-to-Medicare fee comparisons is MACPAC’s
comparison of medical hospital payments between Medicaid and
Medicare, available at https://www.macpac.gov/wp-content/uploads/
2017/04/Medicaid-Hospital-Payment-A-Comparison-across-Statesand-to-Medicare.pdf.
o The Medicare fee schedule is available at https://www.cms.gov/
Medicare/Medicare-Fee-for-Service-Payment/FeeScheduleGenInfo/
index.html. CMS’s searchable Medicare Physician Fee schedule
contains Medicare payment information for more than 10,000 services
and can be found at https://www.cms.gov/apps/physician-feeschedule/search/search-criteria.aspx.
Use Medicaid FFS equivalent amounts for encounter records reported in TMSIS. This field, MEDICAID-FFS-EQUIVALENT-AMT, should be populated
with the amount that would have been paid had the services been provided on
a FFS basis.
Step 5. Exclude any room and board costs, if included in steps 2 and 4.
Step 6. Sum the net amount paid by Medicaid from steps 2 and 5 to determine total
Medicaid spending associated with treatment for mental health in an IMD during the
measurement period.
71
1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
MATHEMATICA
Metric #39: Total Costs Associated With Treatment for Mental Health in an IMD Among Beneficiaries with
SMI/SED
Metric element
Population of interest
Description
Mental health inpatient or residential treatment provided within IMDs during the
measurement period.
Step 1. Identify qualifying IMD discharges for inpatient or residential treatment mental
health during the measurement period. This method may be specific to each state; some
states maintain centralized databases of IMD stays. Alternatively, states may be able to
identify IMD stays in T-MSIS data or through other methods.
Step 1a. Identify claims with a place of service, HCPCS, or UB Revenue code listed
below:
Place of Service Codes:
•
51 - Inpatient Psychiatric Facility
•
56 – Psychiatric Residential Treatment Center
HCPCS Codes:
o H0017 – Behavioral health; residential
o H0018 – Behavioral health; short-term residential
o H0019 – Behavioral health; long-term residential
o T2048 – Behavioral health; long-term care residential
UB Revenue Codes:
•
1001 – Residential treatment, psychiatric
•
From the HEDIS 2019 Inpatient Stay Value Set
Step 2. Identify claims with a principal mental health diagnosis from the HEDIS 2019
Mental Health Diagnosis Value Set
Step 3. Among records identified in Step 1 and 2, identify inpatient or residential
treatment stays in IMDs. (See the additional guidance section for a definition of an IMD.)
Only include IMDs receiving Federal Financial Participation under the demonstration.
Step 4. Identify and retain all claims or encounter records associated with stays identified
in Step 3.
72
1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
MATHEMATICA
Metric #39: Total Costs Associated With Treatment for Mental Health in an IMD Among Beneficiaries with
SMI/SED
Metric element
Additional guidance
Description
Use the discharge date to identify claims in the measurement period for residential and
inpatient services. Do not count expenditures for an ongoing stay during the
measurement period if the patient is not discharged in that period. If a discharge date is
not explicitly reported, identify all claims associated with a single stay and use the latest
end date of service on the claims. Use one of the following approaches to combine
claims for the same stay:
•
Combine claims for the same beneficiary, provider and admission date; or
•
If an admission date is not reported on all claims, combine claims for the same
patient and provider that have less than a one day break between the end date
of the first claim and the start date of the next claim. For example, if the end
date of the first claim is December 18 and the start date of the next claim is
December 19, then combine the claims as a single stay. However, if the second
claim has a start date of December 20 or later, then do not combine the claims.
States that use fee schedules to calculate this metric should update them each year to
reflect changes in payment rates over time. However, to ensure consistency, the method
used to calculate this metric should stay the same across measurement periods. For
example, states should not calculate managed care costs using a Medicaid-to-Medicare
Fee Index in one year and the MEDICAID-FFS-EQUIVALENT-AMT field in other years.
An IMD is defined as a hospital, nursing facility, or other institution that has more than 16
beds and is primarily engaged in providing diagnosis, treatment, or care for people with
mental diseases. Only include IMDs receiving Federal Financial Participation under the
demonstration.
Some states have published lists of IMDs in which the designation is made by the state.
If available, use those lists to identify facilities; obtain the associated billing provider IDs,
and identify claims in Steps 1a or 1b associated with those provider IDs. Otherwise, refer
to the State Medicaid Manual for additional regulatory guidance.
Per the guidance in Section 4390 of the State Medicaid Manual, the following five criteria
should be used to evaluate whether the overall character of a facility is that of an IMD:
1.
2.
3.
4.
5.
Measurement period
(Metric type)
The facility is licensed as a psychiatric facility.
The facility is accredited as a psychiatric facility.
The facility is under the jurisdiction of the state’s mental health authority. (This
criterion does not apply to facilities under the state’s mental health authority that
are not providing services to mentally ill persons.).
The facility specializes in providing psychiatric/psychological care and
treatment. This may be ascertained through review of patients’ records. It may
also be indicated by the fact that an unusually large proportion of the staff has
specialized psychiatric/psychological training or that a large proportion of the
patients are receiving psychopharmacological drugs.
The current need for institutionalization for more than 50 percent of all the
patients in the facility results from mental diseases.
a. When applying the 50 percent guideline determine whether each
patient’s current need for institutionalization results from a mental
disease. It is not necessary to determine whether any mental health
care is being provided in applying this guideline.
b. If more than 50 percent of the patients are residing in the institution
because of implications of mental health or substance use diagnoses,
then the facility may be determined to be an IMD.
Year (CMS-constructed)
73
1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
MATHEMATICA
Metric #39: Total Costs Associated With Treatment for Mental Health in an IMD Among Beneficiaries with
SMI/SED
Metric element
Description
Reporting category
Other annual metrics
Reporting level
Demonstration
Model
Subpopulations
None
Relationship to other
metrics
None
Data source
Claims
Claim type
Only use paid claims. (Do not use suspended, pending, or denied claims.)
74
1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
MATHEMATICA
Metric #40: Per Capita Costs Associated With Treatment for Mental Health in an IMD Among Beneficiaries
With SMI/SED
Metric element
Description
Measure
sets/endorsements
None
Description
Per capita Medicaid costs for beneficiaries with SMI/SED who had claims for inpatient or
residential treatment for mental health in an IMD during the reporting year
Numerator
Total Medicaid costs associated with treatment for mental health within IMDs during the
measurement period.
Denominator
Number of beneficiaries with SMI/SED with a claim for inpatient or residential treatment
for mental health in an IMD during the reporting year.
Step 1a. Identify claims with a place of service, HCPCS, or UB Revenue code listed
below:
Place of Service Codes:
•
51 - Inpatient Psychiatric Facility
•
56 – Psychiatric Residential Treatment Center
HCPCS Codes:
o H0017 – Behavioral health; residential
o H0018 – Behavioral health; short-term residential
o H0019 – Behavioral health; long-term residential
o T2048 – Behavioral health; long-term care residential
UB Revenue Codes:
•
1001 – Residential treatment, psychiatric
•
From the HEDIS 2019 Inpatient Stay Value Set
Step 2. Identify claims with a principal mental health diagnosis from the HEDIS 2019
Mental Health Diagnosis Value Set
Step 3. Retain claims for inpatient or residential treatment in an IMD. (See the additional
guidance section for a definition of IMDs). Only include IMDs receiving Federal Financial
Participation under the demonstration.
Step 4. Determine the total number of unique beneficiaries (de-duplicated) with claims
that meet the criteria in Steps 1 - 3.
Metric calculation
Calculate per capita mental health spending by dividing spending on mental health
treatment in the numerator by the number of beneficiaries in the denominator, as follows:
Spending on mental health treatment / Number of beneficiaries
Additional guidance
Use the discharge date to identify claims in the measurement period for residential and
inpatient services. Do not count expenditures for an ongoing stay during the
measurement period if the patient is not discharged in that period. If a discharge date is
not explicitly reported, identify all claims associated with a single stay and use the latest
end date of service on the claims. Use one of the following approaches to combine
claims for the same stay:
•
Combine claims for the same beneficiary, provider and admission date; or
•
If an admission date is not reported on all claims, combine claims for the same
patient and provider that have less than a one day break between the end date
of the first claim and the start date of the next claim. For example, if the end
date of the first claim is December 18 and the start date of the next claim is
December 19, then combine the claims as a single stay. However, if the second
claim has a start date of December 20 or later, then do not combine the claims.
75
1115 SERIOUS MENTAL ILLNESS DEMONSTRATIONS
MATHEMATICA
Metric #40: Per Capita Costs Associated With Treatment for Mental Health in an IMD Among Beneficiaries
With SMI/SED
Metric element
Additional guidance
(continued)
Description
An IMD is defined as a hospital, nursing facility, or other institution that has more than 16
beds and is primarily engaged in providing diagnosis, treatment, or care for people with
mental diseases. Only include IMDs receiving Federal Financial Participation under the
demonstration.
Some states have published lists of IMDs in which the designation is made by the state.
If available, use those lists to identify facilities; obtain the associated billing provider IDs,
and identify claims in Steps 1a or 1b associated with those provider IDs. Otherwise, refer
to the State Medicaid Manual for additional regulatory guidance.
Per the guidance in Section 4390 of the State Medicaid Manual, the following five criteria
should be used to evaluate whether the overall character of a facility is that of an IMD:
1.
2.
3.
4.
5.
The facility is licensed as a psychiatric facility.
The facility is accredited as a psychiatric facility.
The facility is under the jurisdiction of the state’s mental health authority. (This
criterion does not apply to facilities under the state’s mental health authority that
are not providing services to mentally ill persons.).
The facility specializes in providing psychiatric/psychological care and
treatment. This may be ascertained through review of patients’ records. It may
also be indicated by the fact that an unusually large proportion of the staff has
specialized psychiatric/psychological training or that a large proportion of the
patients are receiving psychopharmacological drugs.
The current need for institutionalization for more than 50 percent of all the
patients in the facility results from mental diseases.
a. When applying the 50 percent guideline determine whether each
patient’s current need for institutionalization results from a mental
disease. It is not necessary to determine whether any mental health
care is being provided in applying this guideline.
b. If more than 50 percent of the patients are residing in the institution
because of implications of mental health or substance use diagnoses,
then the facility may be determined to be an IMD.
Measurement period
(Metric type)
Year (CMS-constructed)
Reporting category
Other annual metrics
Reporting level
Demonstration
Model
Subpopulations
None
Relationship to other
metrics
The Numerator for this metrics is the same as total costs calculated in metric #39
Data source
Claims
Claim type
Only use paid claims. (Do not use suspended, pending, or denied claims.)
76
APPENDIX A
ESTABLISHED MEASURES AND MEASURE SETS
REFERENCED IN TECHNICAL SPECIFICATIONS
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APPENDIX A
MATHEMATICA
Table A.1 defines the established measures, measure sets, and measure set versions
referenced in the specifications for these metrics.
Table A.1. Established measures and measure sets referenced in metric specifications
Metric
Number
1
2
3
4
5
6
7
8
9
10
Metric name
SUD Screening of
Beneficiaries Admitted
to Psychiatric Hospitals
or Residential
Treatment Settings
(SUB-2)
Use of First-Line
Psychosocial Care for
Children and
Adolescents on
Antipsychotics (APPCH)
All-Cause Emergency
Department Utilization
Rate for Medicaid
Beneficiaries who may
Benefit From Integrated
Physical and Behavioral
Health Care (PMH-20)
30-Day All-Cause
Unplanned
Readmission Following
Psychiatric
Hospitalization in an
Inpatient Psychiatric
Facility (IPF)
Medication
Reconciliation Upon
Admission
Medication Continuation
Following Inpatient
Psychiatric Discharge
Follow-up After
Hospitalization for
Mental Illness: Ages 617 (FUH-CH)
Follow-up After
Hospitalization for
Mental Illness: Age 18
and Older (FUH-AD)
Follow-Up After
Emergency Department
Visit for Alcohol and
Other Drug Abuse
Dependence (FUA-AD)
Follow-Up After
Emergency Department
Visit for Mental Illness
(FUM-AD)
Established measure name
Measure set
Measure set
version/reporting
period
SUB-2 Alcohol Use Brief
Intervention Provided or
Offered
SUB-2a Alcohol Use Brief
Intervention
The Joint
Commission National
Hospital Inpatient
Quality Measures
5. 6 B
Use of First-Line Psychosocial
Care for Children and
Adolescents on
Antipsychotics (APP-CH)
Child Core Set
FFY 2019 A
All-Cause Emergency
Department Utilization Rate
for Medicaid Beneficiaries
who may Benefit From
Integrated Physical and
Behavioral Health Care
(PMH-20)
30-Day All-Cause Unplanned
Readmission Following
Psychiatric Hospitalization in
an Inpatient Psychiatric
Facility (IPF)
CMS
2018 reporting B
Inpatient Psychiatric
Facility Quality
Reporting (IPFQR)
program
2019 reporting
Medication Reconciliation
Upon Admission
CMS
2018 reporting B
Medication continuation
following discharge
CMS
2018 reporting B
Follow-up After
Hospitalization for Mental
Illness: Ages 6-17 (FUH-CH)
Child Core Set
FFY 2019 A
Follow-up After
Hospitalization for Mental
Illness: Age 18 and Older
(FUH-AD)
Follow-Up After Emergency
Department Visit Alcohol and
Other Drug Abuse or
Dependence (FUA-AD)
Adult Core Set
FFY 2019 A
Adult Core Set
FFY 2019 A
Follow-Up After Emergency
Department Visit for Mental
Illness (FUM-AD)
Adult Core Set
FFY 2019 A
A.3
APPENDIX A
MATHEMATICA
Metric
Number
23
24
25
26
27
28
29
30
31
Metric name
Diabetes Care for
Patients with Serious
Mental Illness:
Hemoglobin A1c
(HbA1c) poor control
(>9.0%) (HPCMI-AD)
Screening for
Depression and Followup Plan: 18 years and
Older (CDF-AD)
Screening for
Depression and Followup Plan: Ages 1217(CDF-CH)
Access to Preventive/
Ambulatory Health
Services for Medicaid
Beneficiaries with SMI
Tobacco Use Screening
and Follow-up for
People with Serious
Mental Illness or
Alcohol or Other Drug
Dependence
Alcohol Screening and
Follow-up for People
with Serious Mental
Illness
Metabolic Monitoring for
Children and
Adolescents on
Antipsychotics
Follow-Up Care for
Adult Medicaid
Beneficiaries Who are
Newly Prescribed an
Antipsychotic
Medication
Use of Multiple
Concurrent
Antipsychotics in
Children and
Adolescents (APC-CH)
Established measure name
Measure set
Measure set
version/reporting
period
Diabetes Care for Patients
with Serious Mental Illness:
Hemoglobin A1c (HbA1c)
Poor Control (>9.0%)
(HPCMI-AD)
Adult Core Set
FFY 2019 A
Screening for Depression and
Follow-Up Plan: Age 18 and
Older (CDF-AD)
Adult Core Set
FFY 2019 A
Screening for Depression and
Follow-Up Plan: Ages 12–17
(CDF-CH)
Child Core Set
FFY 2019 A
Access to
Preventive/Ambulatory Health
Services for Beneficiaries with
SMI
Tobacco Use Screening and
Follow-up for People with
Serious Mental Illness or
Alcohol or Other Drug
Dependence
HEDIS
2019 B
NCQA
B
Alcohol Screening and
Follow-up for People with
Serious Mental Illness
NCQA
B
Metabolic Monitoring for
Children and Adolescents on
Antipsychotics
HEDIS
2019 B
Follow-Up Care for Adult
Medicaid Beneficiaries Who
are Newly Prescribed an
Antipsychotic Medication
HEDIS
2019 B
Use of Multiple Concurrent
Antipsychotics in Children and
Adolescents (APC-CH)
Child Core Set
FFY 2019 A
A Specifications
for calculating Core Set metrics can be found in Appendix D: Technical Specifications for Established
Quality Measures Adapted from FFY 2019 Child and Adult Core Sets Specifications.
B For this measure, specifications are available upon request by contacting
[email protected]
A.4
APPENDIX B
VALUE SETS REFERENCED IN METRIC SPECIFICATIONS
This page has been left blank for double-sided copying.
APPENDIX B
MATHEMATICA
Table B.1. HEDIS and other value sets referenced in metric specifications
Value Set Name
Acute Inpatient (HEDIS 2019)
Relevant metrics
•
Acute Inpatient POS (HEDIS 2019)
•
•
AOD Abuse and Dependence (HEDIS
2019)
•
AOD Procedures (HEDIS 2016)
•
Alcohol Disorders
Ambulatory Surgical Center POS (HEDIS
2019)
•
•
•
•
•
•
•
Ambulatory Visits (HEDIS 2019)
•
BH Stand Alone Acute Inpatient (HEDIS
2016)
•
•
•
BH Acute Inpatient (HEDIS 2016)
•
•
•
•
•
#23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c (HbA1c)
Poor Control (>9.0%) (HPCMI-AD)
#2: Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics
(APP-CH)
#23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c (HbA1c)
Poor Control (>9.0%) (HPCMI-AD)
#9: Follow-up After Emergency Department Visit for Alcohol and Other Drug Abuse
Dependence (FUA-AD)
#27: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or
Alcohol or Other Drug Dependence
#27: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or
Alcohol or Other Drug Dependence
#28: Alcohol Screening and Follow-up for People with Serious Mental Illness
#15: Mental Health Services Utilization - Outpatient
#16: Mental Health Services Utilization - ED
#18: Mental Health Services Utilization - Any Services
#32: Total Costs Associated With Mental Health Services Among Beneficiaries With
SMI/SED - Not Inpatient or Residential
#34: Per Capita Costs Associated with Mental Health Services Among Beneficiaries with
SMI/SED - Not Inpatient or Residential
#26: Access to Preventive/Ambulatory Health Services for Medicaid Beneficiaries With
SMI
Standardized definition of SMI
#3: All-Cause Emergency Department Utilization Rate for Medicaid Beneficiaries who
may Benefit From Integrated Physical and Behavioral Health Care (PMH-20)
#27: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or
Alcohol or Other Drug Dependence
#28: Alcohol Screening and Follow-up for People with Serious Mental Illness
Standardized definition of SMI
#3: All-Cause Emergency Department Utilization Rate for Medicaid Beneficiaries who
may Benefit From Integrated Physical and Behavioral Health Care (PMH-20)
#27: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or
Alcohol or Other Drug Dependence
#28: Alcohol Screening and Follow-up for People with Serious Mental Illness
B.3
Part of reported
Core Set
measure (Y/N)
Y
Y
Y
N
N
Y
N
Y
N
APPENDIX B
MATHEMATICA
Table B.1. (continued)
Value Set Name
BH Acute Inpatient POS (HEDIS 2016)
Relevant metrics
•
•
•
BH Stand Alone Outpatient/PH/IOP
(HEDIS 2016)
•
•
•
•
BH Outpatient (HEDIS 2019)
•
•
•
•
•
•
BH Outpatient/PH/IOP (HEDIS 2016)
•
•
•
BH Outpatient/PH/IOP POS (HEDIS 2016)
•
•
•
•
BH ED (HEDIS 2016)
•
•
•
•
•
Standardized definition of SMI
#3: All-Cause Emergency Department Utilization Rate for Medicaid Beneficiaries who
may Benefit From Integrated Physical and Behavioral Health Care (PMH-20)
#27: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or
Alcohol or Other Drug Dependence
#28: Alcohol Screening and Follow-up for People with Serious Mental Illness
Standardized definition of SMI
#3: All-Cause Emergency Department Utilization Rate for Medicaid Beneficiaries who
may Benefit From Integrated Physical and Behavioral Health Care (PMH-20)
#27: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or
Alcohol or Other Drug Dependence
#28: Alcohol Screening and Follow-up for People with Serious Mental Illness
#2: Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics
(APP-CH)
#7: Follow up After Hospitalization for Mental Illness: Ages 6-17 (FUH-CH)
#8: Follow up After Hospitalization for Mental Illness: Age 18 and older (FUH-AD)
#10:Follow-Up After Emergency Department Visit for Mental Illness (FUM-AD)
#23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c (HbA1c)
Poor Control (>9.0%) (HPCMI-AD)
Standardized definition of SMI
#3: All-Cause Emergency Department Utilization Rate for Medicaid Beneficiaries who
may Benefit From Integrated Physical and Behavioral Health Care (PMH-20)
#27: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or
Alcohol or Other Drug Dependence
#28: Alcohol Screening and Follow-up for People with Serious Mental Illness
Standardized definition of SMI
#3: All-Cause Emergency Department Utilization Rate for Medicaid Beneficiaries who
may Benefit From Integrated Physical and Behavioral Health Care (PMH-20)
#27: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or
Alcohol or Other Drug Dependence
#28: Alcohol Screening and Follow-up for People with Serious Mental Illness
Standardized definition of SMI
#3: All-Cause Emergency Department Utilization Rate for Medicaid Beneficiaries who
may Benefit From Integrated Physical and Behavioral Health Care (PMH-20)
#27: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or
Alcohol or Other Drug Dependence
#28: Alcohol Screening and Follow-up for People with Serious Mental Illness
B.4
Part of reported
Core Set
measure (Y/N)
N
N
N
N
N
APPENDIX B
MATHEMATICA
Table B.1. (continued)
Value Set Name
BH ED POS (HEDIS 2016)
Relevant metrics
•
•
•
BH Stand Alone Nonacute Inpatient
(HEDIS 2016)
•
•
•
•
BH Nonacute Inpatient (HEDIS 2016)
•
•
•
•
BH Nonacute Inpatient POS (HEDIS 2016)
•
•
•
•
Bipolar Disorder (HEDIS 2016)
•
•
•
•
Cholesterol Tests Other Than LDL (HEDIS
2019)
Community Mental Health Center POS
(HEDIS 2019)
•
•
•
•
•
•
•
•
Part of reported
Core Set
measure (Y/N)
Standardized definition of SMI
#3: All-Cause Emergency Department Utilization Rate for Medicaid Beneficiaries who
may Benefit From Integrated Physical and Behavioral Health Care (PMH-20)
#27: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or
Alcohol or Other Drug Dependence
#28: Alcohol Screening and Follow-up for People with Serious Mental Illness
Standardized definition of SMI
#3: All-Cause Emergency Department Utilization Rate for Medicaid Beneficiaries who
may Benefit From Integrated Physical and Behavioral Health Care (PMH-20)
#27: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or
Alcohol or Other Drug Dependence
#28: Alcohol Screening and Follow-up for People with Serious Mental Illness
Standardized definition of SMI
#3: All-Cause Emergency Department Utilization Rate for Medicaid Beneficiaries who
may Benefit From Integrated Physical and Behavioral Health Care (PMH-20)
#27: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or
Alcohol or Other Drug Dependence
#28: Alcohol Screening and Follow-up for People with Serious Mental Illness
Standardized definition of SMI
#3: All-Cause Emergency Department Utilization Rate for Medicaid Beneficiaries who
may Benefit From Integrated Physical and Behavioral Health Care (PMH-20)
#27: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or
Alcohol or Other Drug Dependence
#28: Alcohol Screening and Follow-up for People with Serious Mental Illness
Standardized definition of SMI
#3: All-Cause Emergency Department Utilization Rate for Medicaid Beneficiaries who
may Benefit From Integrated Physical and Behavioral Health Care (PMH-20)
#27: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or
Alcohol or Other Drug Dependence
#28: Alcohol Screening and Follow-up for People with Serious Mental Illness
#29: Metabolic Monitoring for Children and Adolescents on Antipsychotics
N
#14: Mental Health Services Utilization - Intensive Outpatient and Partial Hospitalization
#15: Mental Health Services Utilization - Outpatient
#16: Mental Health Services Utilization - ED
#18: Mental Health Services Utilization - Any Services
#32: Total Costs Associated With Mental Health Services Among Beneficiaries With
SMI/SED - Not Inpatient or Residential
#34: Per Capita Costs Associated with Mental Health Services Among Beneficiaries with
SMI/SED - Not Inpatient or Residential
Y
B.5
Y
N
N
Y
N
APPENDIX B
MATHEMATICA
Table B.1. (continued)
Value Set Name
Relevant metrics
Diabetes (HEDIS 2019)
•
Diabetes Exclusions (HEDIS 2019)
•
ED (HEDIS 2019)
•
•
•
•
ED POS (HEDIS 2019)
•
•
•
•
•
ED Procedure Code (HEDIS 2016)
Electroconvulsive Therapy (HEDIS 2019)
•
•
•
•
•
•
•
Glucose Tests (HEDIS 2019)
HbA1c Level 7.0-9.0 (HEDIS 2019)
•
•
HbA1c Level Greater Than 9.0 (HEDIS
2019)
HbA1c Level Less Than 7.0 (HEDIS 2019)
•
HbA1c Tests (HEDIS 2019)
•
•
#23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c (HbA1c)
Poor Control (>9.0%) (HPCMI-AD)
#23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c (HbA1c)
Poor Control (>9.0%) (HPCMI-AD)
#3: All-Cause Emergency Department Utilization Rate for Medicaid Beneficiaries who
may Benefit From Integrated Physical and Behavioral Health Care (PMH-20)
#16: Mental Health Services Utilization - ED
#18: Mental Health Services Utilization - Any Services
#27: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or
Alcohol or Other Drug Dependence
#28: Alcohol Screening and Follow-up for People with Serious Mental Illness
#3: All-Cause Emergency Department Utilization Rate for Medicaid Beneficiaries who
may Benefit From Integrated Physical and Behavioral Health Care (PMH-20)
#16: Mental Health Services Utilization - ED
#18: Mental Health Services Utilization - Any Services
#27: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or
Alcohol or Other Drug Dependence
#28: Alcohol Screening and Follow-up for People with Serious Mental Illness
#3: All-Cause Emergency Department Utilization Rate for Medicaid Beneficiaries who
may Benefit From Integrated Physical and Behavioral Health Care (PMH-20)
#14: Mental Health Services Utilization - Intensive Outpatient and Partial Hospitalization
#15: Mental Health Services Utilization - Outpatient
#18: Mental Health Services Utilization - Any Services
#32: Total Costs Associated With Mental Health Services Among Beneficiaries With
SMI/SED - Not Inpatient or Residential
#34: Per Capita Costs Associated with Mental Health Services Among Beneficiaries with
SMI/SED - Not Inpatient or Residential
#29: Metabolic Monitoring for Children and Adolescents on Antipsychotics
#23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c (HbA1c)
Poor Control (>9.0%) (HPCMI-AD)
#23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c (HbA1c)
Poor Control (>9.0%) (HPCMI-AD)
#23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c (HbA1c)
Poor Control (>9.0%) (HPCMI-AD)
#29: Metabolic Monitoring for Children and Adolescents on Antipsychotics
B.6
Part of reported
Core Set
measure (Y/N)
Y
Y
Y
Y
N
Y
N
Y
Y
Y
Y
APPENDIX B
MATHEMATICA
Table B.1. (continued)
Value Set Name
Hospice (HEDIS 2019)
Relevant metrics
•
•
•
•
IET POS Group 1 (HEDIS 2019)
•
•
IET POS Group 2 (HEDIS 2019)
•
IET Stand Alone Visits (HEDIS 2019)
•
•
IET Visits Group 1 (HEDIS 2019)
•
•
IET Visits Group 2 (HEDIS 2019)
•
•
Inpatient Stay (HEDIS 2019)
•
•
•
•
•
•
•
•
•
•
#8:Follow up After Hospitalization for Mental Illness: Age 18 and older (FUH-AD)
#9: Follow-up After Emergency Department Visit for Alcohol and Other Drug Abuse
Dependence (FUA-AD)
#10: Follow-Up After Emergency Department Visit for Mental Illness (FUM-AD)
#23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c (HbA1c)
Poor Control (>9.0%) (HPCMI-AD)
#31: Use of Multiple Concurrent Antipsychotics in Children and Adolescents (APC-CH)
#9: Follow-up After Emergency Department Visit for Alcohol and Other Drug Abuse
Dependence (FUA-AD)
#9: Follow-up After Emergency Department Visit for Alcohol and Other Drug Abuse
Dependence (FUA-AD)
#9: Follow-up After Emergency Department Visit for Alcohol and Other Drug Abuse
Dependence (FUA-AD)
#27: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or
Alcohol or Other Drug Dependence
#9: Follow-up After Emergency Department Visit for Alcohol and Other Drug Abuse
Dependence (FUA-AD)
#27: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or
Alcohol or Other Drug Dependence
#9: Follow-up After Emergency Department Visit for Alcohol and Other Drug Abuse
Dependence (FUA-AD)
#27: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or
Alcohol or Other Drug Dependence
#13: Mental Health Services Utilization - Inpatient
#15: Mental Health Services Utilization - Outpatient
#19: Average Length of Stay in IMDs
#20: Beneficiaries With SMI/SED Treated in an IMD for Mental Health
#32: Total Costs Associated With Mental Health Services Among Beneficiaries With
SMI/SED - Not Inpatient or Residential
#33: Total Costs Associated With Mental Health Services Among Beneficiaries With
SMI/SED - Inpatient or Residential
#34: Per Capita Costs Associated With Mental Health Services Among Beneficiaries
With SMI/SED - Not Inpatient or Residential
#35: Per Capita Costs Associated With Mental Health Services Among Beneficiaries
With SMI/SED - Inpatient or Residential
#39: Total Costs Associated With Treatment for Mental Health in an IMD Among
Beneficiaries With SMI/SED
#40: Per Capita Costs Associated With Treatment for Mental Health in an IMD Among
Beneficiaries With SMI/SED
B.7
Part of reported
Core Set
measure (Y/N)
Y
Y
Y
Y
Y
Y
Y
APPENDIX B
MATHEMATICA
Table B.1. (continued)
Value Set Name
Intentional Self-Harm (HEDIS 2019)
LDL-C Tests (HEDIS 2019)
Major Depression (HEDIS 2016)
Relevant metrics
•
•
•
•
•
•
•
Mental Health Diagnosis (HEDIS 2019)
•
•
•
•
•
•
•
•
•
•
•
•
•
Mental Illness (HEDIS 2019)
MPT IOP/PH Group 1 (HEDIS 2019)
•
•
•
•
•
•
•
•
#7: Follow up After Hospitalization for Mental Illness: Ages 6-17 (FUH-CH)
#8: Follow up After Hospitalization for Mental Illness: Age 18 and older (FUH-AD)
#10: Follow-Up After Emergency Department Visit for Mental Illness (FUM-AD)
#29: Metabolic Monitoring for Children and Adolescents on Antipsychotics
Standardized definition of SMI
#3: All-Cause Emergency Department Utilization Rate for Medicaid Beneficiaries who
may Benefit From Integrated Physical and Behavioral Health Care (PMH-20)
#27: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or
Alcohol or Other Drug Dependence
#28: Alcohol Screening and Follow-up for People with Serious Mental Illness
#11: Suicide or Overdose Death Within 7 and 30 Days of Discharge From an Inpatient
Facility or Residential Treatment for Mental Health Among Beneficiaries With SMI or
SED (count)
#12: Suicide or Overdose Death Within 7 and 30 Days of Discharge From an Inpatient
Facility or Residential Treatment for Mental Health Among Beneficiaries With SMI or
SED (rate)
#13: Mental Health Services Utilization - Inpatient
#14: Mental Health Services Utilization - Intensive Outpatient and Partial Hospitalization
#15: Mental Health Services Utilization - Outpatient
#16: Mental Health Services Utilization - ED
#17: Mental Health Services Utilization - Telehealth
#18: Mental Health Services Utilization - Any Services
#19: Average Length of Stay in IMDs
#20: Beneficiaries With SMI/SED Treated in an IMD for Mental Health
#39: Total Costs Associated With Treatment for Mental Health in an IMD Among
Beneficiaries With SMI/SED
#40: Per Capita Costs Associated With Treatment for Mental Health in an IMD Among
Beneficiaries With SMI/SED
#7: Follow up After Hospitalization for Mental Illness: Ages 6-17 (FUH-CH)
#8: Follow up After Hospitalization for Mental Illness: Age 18 and older (FUH-AD)
#10: Follow-Up After Emergency Department Visit for Mental Illness (FUM-AD)
#14: Mental Health Services Utilization - Intensive outpatient and partial
hospitalization
#17: Mental Health Services Utilization - Telehealth
#18: Mental Health Services Utilization - Any Services
#32: Total Costs Associated With Mental Health Services Among Beneficiaries With
SMI/SED - Not Inpatient or Residential
#34: Per Capita Costs Associated with Mental Health Services Among Beneficiaries with
SMI/SED - Not Inpatient or Residential
B.8
Part of reported
Core Set
measure (Y/N)
Y
N
N
Y
Y
N
APPENDIX B
MATHEMATICA
Table B.1. (continued)
Value Set Name
MPT IOP/PH Group 2 (HEDIS 2019)
Relevant metrics
•
•
•
•
•
MPT Stand Alone Outpatient Group 1
(HEDIS 2019)
•
•
•
•
MPT Stand Alone Outpatient Group 2
(HEDIS 2019)
•
•
•
•
Nonacute Inpatient (HEDIS 2019)
Nonacute Inpatient POS (HEDIS 2019)
Nonacute Inpatient Stay (HEDIS 2019)
Outpatient POS (HEDIS 2019)
•
•
•
•
•
•
•
•
Observation
(HEDIS 2019)
•
•
•
•
Online Assessments (HEDIS 2019)
•
#14: Mental Health Services Utilization - Intensive outpatient and partial
hospitalization
#17: Mental Health Services Utilization - Telehealth
#18: Mental Health Services Utilization - Any Services
#32: Total Costs Associated With Mental Health Services Among Beneficiaries With
SMI/SED - Not Inpatient or Residential
#34: Per Capita Costs Associated with Mental Health Services Among Beneficiaries with
SMI/SED - Not Inpatient or Residential
#15: Mental Health Services Utilization - Outpatient
#18: Mental Health Services Utilization - Any Services
#32: Total Costs Associated With Mental Health Services Among Beneficiaries With
SMI/SED - Not Inpatient or Residential
#34: Per Capita Costs Associated with Mental Health Services Among Beneficiaries with
SMI/SED - Not Inpatient or Residential
#15: Mental Health Services Utilization - Outpatient
#18: Mental Health Services Utilization - Any Services
#32: Total Costs Associated With Mental Health Services Among Beneficiaries With
SMI/SED - Not Inpatient or Residential
#34: Per Capita Costs Associated with Mental Health Services Among Beneficiaries with
SMI/SED - Not Inpatient or Residential
#23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c (HbA1c)
Poor Control (>9.0%) (HPCMI-AD)
#23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c (HbA1c)
Poor Control (>9.0%) (HPCMI-AD)
#7: Follow up After Hospitalization for Mental Illness: Ages 6-17 (FUH-CH)
#8: Follow up After Hospitalization for Mental Illness: Age 18 and older (FUH-AD)
#15: Mental Health Services Utilization - Outpatient
#18: Mental Health Services Utilization - Any Services
#32: Total Costs Associated With Mental Health Services Among Beneficiaries With
SMI/SED - Not Inpatient or Residential
#34: Per Capita Costs Associated with Mental Health Services Among Beneficiaries with
SMI/SED - Not Inpatient or Residential
#15: Mental Health Services Utilization - Outpatient
#18: Mental Health Services Utilization - Any Services
#32: Total Costs Associated With Mental Health Services Among Beneficiaries With
SMI/SED - Not Inpatient or Residential
#34: Per Capita Costs Associated with Mental Health Services Among Beneficiaries with
SMI/SED - Not Inpatient or Residential
#26: Access to Preventive/Ambulatory Health Services for Medicaid Beneficiaries With
SMI
B.9
Part of reported
Core Set
measure (Y/N)
N
N
N
Y
Y
Y
Y
Y
Y
APPENDIX B
MATHEMATICA
Table B.1. (continued)
Value Set Name
Relevant metrics
Other Ambulatory Visits (HEDIS 2019)
•
Other Bipolar Disorder (HEDIS 2016,
HEDIS 2019)
Other Psychotic and Developmental
Disorders (HEDIS 2019)
Outpatient (HEDIS 2019)
•
Partial Hospitalization/Intensive Outpatient
(HEDIS 2019)
•
•
•
•
•
•
Partial Hospitalization POS
(HEDIS 2019)
•
•
•
•
Schizophrenia (HEDIS 2016)
•
•
•
Telehealth Modifier (HEDIS 2019)
•
•
•
•
•
•
•
•
•
•
Part of reported
Core Set
measure (Y/N)
#26: Access to Preventive/Ambulatory Health Services for Medicaid Beneficiaries With
SMI
Standardized definition of SMI
N
#2: Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics
(APP-CH)
#23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c (HbA1c)
Poor Control (>9.0%) (HPCMI-AD)
#14: Mental Health Services Utilization - Intensive Outpatient and Partial Hospitalization
#18: Mental Health Services Utilization - Any Services
#32: Total Costs Associated With Mental Health Services Among Beneficiaries With
SMI/SED - Not Inpatient or Residential
#34: Per Capita Costs Associated with Mental Health Services Among Beneficiaries with
SMI/SED - Not Inpatient or Residential
#14: Mental Health Services Utilization - Intensive Outpatient and Partial Hospitalization
#18: Mental Health Services Utilization - Any Services
#32: Total Costs Associated With Mental Health Services Among Beneficiaries With
SMI/SED - Not Inpatient or Residential
#34: Per Capita Costs Associated with Mental Health Services Among Beneficiaries with
SMI/SED - Not Inpatient or Residential
Standardized definition of SMI
#3: All-Cause Emergency Department Utilization Rate for Medicaid Beneficiaries who
may Benefit From Integrated Physical and Behavioral Health Care (PMH-20)
#27: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or
Alcohol or Other Drug Dependence
#28: Alcohol Screening and Follow-up for People with Serious Mental Illness
#14: Mental Health Services Utilization - Intensive Outpatient and Partial Hospitalization
#15: Mental Health Services Utilization - Outpatient
#16: Mental Health Services Utilization - ED
#17: Mental Health Services Utilization - Telehealth
#32: Total Costs Associated With Mental Health Services Among Beneficiaries With
SMI/SED - Not Inpatient or Residential
#33: Total Costs Associated With Mental Health Services Among Beneficiaries With
SMI/SED - Inpatient or Residential
#34: Per Capita Costs Associated With Mental Health Services Among Beneficiaries
With SMI/SED - Not Inpatient or Residential
#35: Per Capita Costs Associated With Mental Health Services Among Beneficiaries
With SMI/SED - Inpatient or Residential
#26: Access to Preventive/Ambulatory Health Services for Medicaid Beneficiaries With
SMI
Y
B.10
N
Y
Y
Y
Y
Y
APPENDIX B
MATHEMATICA
Table B.1. (continued)
Value Set Name
Telehealth POS (HEDIS 2019)
Relevant metrics
•
•
•
•
•
•
•
•
•
Telephone Visits (HEDIS 2019)
•
Transcranial Magnetic Stimulation (HEDIS
2019)
•
•
•
•
•
Transitional Care Management Services
HEDIS 2019)
Visit Setting Unspecified (HEDIS 2019)
•
•
•
•
•
•
•
•
#14: Mental Health Services Utilization - Intensive Outpatient and Partial Hospitalization
#15: Mental Health Services Utilization - Outpatient
#16: Mental Health Services Utilization - ED
#17: Mental Health Services Utilization - Telehealth
#32: Total Costs Associated With Mental Health Services Among Beneficiaries With
SMI/SED - Not Inpatient or Residential
#33: Total Costs Associated With Mental Health Services Among Beneficiaries With
SMI/SED - Inpatient or Residential
#34: Per Capita Costs Associated With Mental Health Services Among Beneficiaries
With SMI/SED - Not Inpatient or Residential
#35: Per Capita Costs Associated With Mental Health Services Among Beneficiaries
With SMI/SED - Not Inpatient or Residential
#26: Access to Preventive/Ambulatory Health Services for Medicaid Beneficiaries With
SMI
#26: Access to Preventive/Ambulatory Health Services for Medicaid Beneficiaries With
SMI
#14: Mental Health Services Utilization - Intensive Outpatient and Partial Hospitalization
#15: Mental Health Services Utilization - Outpatient
#18: Mental Health Services Utilization - Any Services
#32: Total Costs Associated With Mental Health Services Among Beneficiaries With
SMI/SED - Not Inpatient or Residential
#34: Per Capita Costs Associated with Mental Health Services Among Beneficiaries with
SMI/SED - Not Inpatient or Residential
#7: Follow up After Hospitalization for Mental Illness: Ages 6-17 (FUH-CH)
#8: Follow up After Hospitalization for Mental Illness: Age 18 and older (FUH-AD)
#14: Mental Health Services Utilization - Intensive Outpatient and Partial Hospitalization
#15: Mental Health Services Utilization - Outpatient
#16: Mental Health Services Utilization - ED
#17: Mental Health Services Utilization - Telehealth
#32: Total Costs Associated With Mental Health Services Among Beneficiaries With
SMI/SED - Not Inpatient or Residential
#34: Per Capita Costs Associated with Mental Health Services Among Beneficiaries with
SMI/SED - Not Inpatient or Residential
B.11
Part of reported
Core Set
measure (Y/N)
Y
N
N
Y
Y
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APPENDIX C
HOW TO USE SUPPORTING MEASURE SPECIFICATIONS,
VALUE SETS, AND CODE LISTS TO CALCULATE METRICS
This page has been left blank for double-sided copying.
APPENDIX C
MATHEMATICA
Table C.1. How to use supporting measure specifications, value sets and code lists to calculate metrics
Metrics
CMS-constructed metrics that do not use supporting
measure specifications or value sets:
•
#36: Grievances related to services for
SMI/SED
•
#37: Appeals related services for to
SMI/SED
•
#38: Critical incidents related to services
for SMI/SED
CMS-constructed metrics that use HEDIS value sets.
•
#11: Suicide or Overdose Death Within 7 and
30 Days of Discharge From an Inpatient
Facility or Residential Treatment for Mental
Health Among Beneficiaries With SMI or SED
(count)
•
#12: Suicide or Overdose Death Within 7 and
30 Days of Discharge From an Inpatient
Facility or Residential Treatment for Mental
Health Among Beneficiaries With SMI or SED
(rate)
•
#13: Mental Health Services Utilization Inpatient
•
#14: Mental Health Services Utilization Intensive Outpatient and Partial
Hospitalization
•
#15: Mental Health Services Utilization Outpatient
•
#16: Mental Health Services Utilization - ED
•
#17: Mental Health Services Utilization Telehealth
•
#18: Mental Health Services Utilization - Any
Services
•
#19: Average Length of Stay in IMDs
•
#20: Beneficiaries With SMI/SED Treated in
an IMD for Mental Health
•
#39: Total Costs Associated With Treatment
for Mental Health in an IMD Among
Beneficiaries With SMI/SED
•
#40: Per Capita Costs Associated With
Treatment for Mental Health in an IMD
Among Beneficiaries With SMI/SED
Supporting Measure Specifications,
Value Sets, and Code Lists
None
Value Sets:
•
1115 SMI Monitoring Metrics
HEDIS Value Set Directory
C.3
Instructions
None
Value Sets:
•
Step 1: Open “1115 SMI Monitoring Metrics
HEDIS Value Set Directory.xlsx” file (available
upon request by contacting
[email protected]).
•
Step 2: Filter the “Value Sets to Codes” tab to
select value set names (column A) identified in
metric specification
•
Step 3: Include listed codes (column D) when
calculating metric
APPENDIX C
MATHEMATICA
Table C.1. (continued)
Metrics
Established quality measures that use HEDIS
specifications included in the Child and Adult Core
Sets Measure Specifications technical specifications
manual.
•
#2: Use of First-Line Psychosocial Care for
Children and Adolescents on Antipsychotics
(APP-CH)
•
#7: Follow-up After Hospitalization for Mental
Illness: Ages 6-17 (FUH-CH)
•
#8: Follow-up After Hospitalization for Mental
Illness: Age 18 and Older (FUH-AD)
•
#9: Follow-up After Emergency Department
Visit for Alcohol and Other Drug Abuse
Dependence (FUA-AD)
•
#10: Follow-Up After Emergency Department
Visit for Mental Illness (FUM-AD)
•
#23: Diabetes Care for People with Serious
Mental Illness: Hemoglobin A1c (HbA1c)
Poor Control (>9.0%) (HPCMI-AD)
•
#24: Screening for Depression and FollowUp Plan: Age 18 and Older (CDF-AD)
•
#25: Screening for Depression and FollowUp Plan: Ages 12–17 (CDF-CH)
•
#31: Use of Multiple Concurrent
Antipsychotics in Children and Adolescents
(APC-CH)
Supporting Measure Specifications,
Value Sets, and Code Lists
Measure Specifications:
•
The Core Set of Adult Health
Care Quality Measures for
Medicaid (Adult Core Set)and the
Core Set of Children’s Health
Care Quality Measures for
Medicaid and CHIP (Child Core
Set) Technical Specifications
and Resource Manuals for
Federal Fiscal Year 2019
Reporting
o Appendix D: Technical
Specifications for
Established Quality
Measures Adapted
From FFY 2019 Child
and Adult Core Sets
Measure Specifications
Value Sets:
•
1115 SMI Monitoring Metrics
HEDIS Value Set Directory
C.4
Instructions
Measure Specifications:
•
Step 1: Locate specifications for measures
listed at left in Appendix D of this manual.
Value Sets:
•
Step 1: Open “1115 SMI Monitoring Metrics
HEDIS Value Set Directory.xlsx” file (available
upon request by contacting
[email protected]).
•
Step 2: Filter the “Value Sets to Codes” tab to
select value set names (column A) identified in
metric specification
•
Step 3: Include listed codes (column D) when
calculating metric
APPENDIX C
MATHEMATICA
Table C.1. (continued)
Metrics
Established quality measures that use TJC
specifications (and are not part of the Medicaid Adult
Core Set).
•
#1: SUB-2 Alcohol Use Brief Intervention
Provided or Offered and SUB-2a Alcohol
Use Brief Intervention
Supporting Measure Specifications,
Value Sets, and Code Lists
Measure Specifications:
•
Specifications Manual for
National Hospital Inpatient
Quality Measures v5.4
Code Sets:
•
Appendix A .1 – ICD-10 Code
Tables
Instructions
Measure Specifications:
•
Step 1: Download manual (zip folder) from the
TJC website (available at
https://www.jointcommission.org/specifications
_manual_for_national_hospital_inpatient_qualit
y_measures.aspx)
•
Step 2: Locate specification for SUB-2 in zip
folder
•
Step 3: Follow the guidance in the measure
specification to calculate the metric
Code Sets:
•
Step 1: Download code sets from TJC website
(available at https://www.jointcommission.org/
specifications_manual_for_national_hospital_in
patient_quality_measures.aspx)
•
Step 2: Locate Appendix A.1.pdf within zip
folder, as described in the measure
specification
•
Step 3: Filter the table to select the table
numbers (column A) identified in the measure
specification
C.5
APPENDIX C
MATHEMATICA
Table C.1. (continued)
Metrics
Established quality measures that use NCQA
specifications and value sets that are part of HEDIS
(and not part of the Medicaid Core set):
•
#26: Access to Preventive/Ambulatory Health
Services for Medicaid Beneficiaries With SMI
•
#29: Metabolic Monitoring for Children and
Adolescents on Antipsychotics
Established quality measures that use NCQA
specifications (and not part of HEDIS and not part of
the Medicaid Core Set):
•
#27: Tobacco Use Screening and Follow-up
for People with Serious Mental Illness or
Alcohol or Other Drug Dependence
•
#28: Alcohol Screening and Follow-up for
People with Serious Mental Illness
Supporting Measure Specifications,
Value Sets, and Code Lists
Measure Specifications:
•
NCQA Measure specifications
Value Sets:
•
1115 SMI Monitoring Metrics
HEDIS Value Set Directory
Measure Specifications:
•
NCQA Measure specifications
Value Sets:
•
1115 SMI Monitoring Metrics
HEDIS Value Set Directory
Instructions
Measure Specifications:
•
Step 1: Open “NCQA Measure
specifications.pdf” file (available upon request
by contacting
[email protected]).
•
Step 2: Locate specification for Adults’ Access
to Preventive/Ambulatory Health services (AAP)
or Metabolic Monitoring for Children and
Adolescents on Antipsychotics
•
Step 3: Follow the guidance in the measure
specification to calculate the metric
Value Sets:
•
Step 1: Open “1115 SMI Monitoring Metrics
HEDIS Value Set Directory.xlsx” file (available
upon request by contacting
[email protected]).
•
Step 2: Filter the “Value Sets to Codes” tab to
select value set names (column A) identified in
metric specification
•
Step 3: Include listed codes (column D) when
calculating metric
Measure Specifications:
•
Step 1: Open “NCQA Measure
specifications.pdf” file (available upon request
by contacting
[email protected]).
•
Step 2: Locate specifications
•
Step 3: Follow the guidance in the measure
specification to calculate the metric
Value Sets:
•
Step 1: Open “1115 SMI Monitoring Metrics
HEDIS Value Set Directory.xlsx” file (available
upon request by contacting
[email protected]).
•
Step 2: Filter the “Value Sets to Codes” tab to
select value set names (column A) identified in
metric specification
•
Step 3: Include listed codes (column D) when
calculating metric
C.6
APPENDIX C
MATHEMATICA
Table C.1. (continued)
Metrics
Supporting Measure Specifications,
Value Sets, and Code Lists
Established quality measures that use CMS
specifications from the Inpatient Psychiatric Quality
Reporting (IPFQR) program (and are not part of the
Medicaid Adult Core Set).
•
#5: Medication Reconciliation Upon
Admission
•
#6: Medication Continuation Following
Inpatient Psychiatric Discharge
Established quality measures that are based on the
CMS specifications from the Inpatient Psychiatric
Quality Reporting (IPFQR) program.
•
#4: 30-Day All-Cause Unplanned
Readmission Following Psychiatric
Hospitalization in an Inpatient Psychiatric
Facility (IPF)
Measure Specifications:
•
IPFQR CMS Measure
Specifications
Established quality measures that use CMS
specifications (and are not part of the Medicaid Adult
Core Set or IPFQR program).
•
#3: All-Cause Emergency Department
Utilization Rate for Medicaid Beneficiaries
who may Benefit From Integrated Physical
and Behavioral Health Care (PMH-20)
•
#30: Follow-Up Care for Adult Medicaid
Beneficiaries Who are Newly Prescribed an
Antipsychotic Medication
Measure Specifications:
•
PMH-20 Tech Specs Manual
•
Follow-up Care Specs
Measure Specifications:
•
Claims-Based Measure
Specifications
Value Sets:
•
PMH-20 CCW Value Set
•
PMH-20 ED Value Set
•
PMH-20 SMI Value Set
•
Follow-up Care Codes
C.7
Instructions
Measure Specifications:
•
Step 1: Open “IPFQR_CMS_ Measure
Specifications.zip” file (available upon request
by contacting
[email protected]).
•
Step 2: Locate specifications
•
Step 3: Follow the guidance in the measure
specification to calculate the metric
Measure Specifications:
•
Step 1: Download the Claims-based measure
Specifications (available at:
https://www.qualitynet.org/files/5d0d3993764be
766b0103982?filename=181203_FY19_IPFQR
_CBM_Specs.pdf)
•
Step 2: Locate specification for 30-Day AllCause Unplanned Readmission Following
Psychiatric Hospitalization in an IPF
Measure Specifications:
•
Step 1: Open
“Other_CMS_measurespecs_valuesets.zip” file
(available upon request by contacting
[email protected]).
•
Step 2: Locate specifications
•
Step 3: Follow the guidance in the measure
specification to calculate the metric
Value Sets:
•
Step 1: Open
“Other_CMS_measurespecs_valuesets.zip”
and find the appropriate value set or code file
(available upon request by contacting
[email protected]).
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APPENDIX D
TECHNICAL SPECIFICATIONS FOR ESTABLISHED QUALITY MEASURES
ADAPTED FROM FFY 2019 ADULT CORE SET MEASURE SPECIFICATIONS
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APPENDIX D
MATHEMATICA
This appendix provides the technical specifications for the Child and Adult Core Set
measures included in the 1115 SMI/SED monitoring metrics. These specifications have been
adapted from state-level specifications for use in the 1115 SMI/SED demonstration.
I.
MEASURE ELEMENT DEFINITIONS
Measurement period. The measurement period is the time frame for which the data
should be collected (defined by start and end dates). The measurement period for each Core Set
measure included in the 1115 SMI/SED monitoring metrics can be found in Table D1. For
many measures, the denominator measurement period for FFY 2019 corresponds to calendar
year 2018 (January 1, 2018–December 31, 2018). However, for some measures, the
measurement period begins before the calendar year. For example, the Metric #2: Use of FirstLine Psychosocial Care for Children and Adolescents on Antipsychotics (APP-CH) requires
states to review utilization and continuous enrollment prior to January 1, 2018 when constructing
the denominator. This is referred to as a “look-back period” or a negative medication history
review period.
Continuous enrollment. Continuous enrollment specifies the minimum amount of time
that a beneficiary must be enrolled before becoming eligible for the measure. The continuous
enrollment period is specified for each measure in Table D1.
Allowable gap. The allowable gap specifies the maximum amount of time a beneficiary can
be unenrolled and still qualify for inclusion in the measure. The allowable gap is specified for
each measure in Table D1.
Anchor date. Some measures include an anchor date, which is the date that an individual
must be enrolled in the demonstration to be eligible for the measure. For example, if an
enrollment gap includes the anchor date, the individual is not eligible for the measure. For
several measures, the anchor date is the last day of the measure’s FFY 2019 measurement period
(December 31, 2018). States should use the specified anchor dates along with the continuous
enrollment requirements and allowable gaps for each measure to determine the measure-eligible
population. The anchor date (if any) is provided in the detailed measure specifications in the
following section.
Hospice exclusion. Some Core Set measures included in the 1115 SMI/SED monitoring
metrics exclude beneficiaries who use hospice services or elect to use a hospice benefit any time
during the measurement year, regardless of when the services began. These beneficiaries may be
identified using various methods, which may include but are not limited to enrollment data,
medical record data, or claims/encounter data. The Hospice Value Set is available to states upon
request by contacting [email protected]. States should remove these
beneficiaries prior to determining a measure’s eligible population and drawing the sample for
hybrid measures. If a beneficiary is found to be in hospice or using hospice services during
medical record review, the beneficiary is removed as a valid data error from the sample and
replaced by a beneficiary from the oversample. Documentation that a beneficiary is near the end
of life (e.g., comfort care, Do Not Resuscitate [DNR], Do Not Intubate [DNI]), or is in palliative
care does not meet criteria for the hospice exclusion. This applies to the following metrics: 7, 8,
9, 10, 12 and 33.
D.3
APPENDIX D
MATHEMATICA
Table D.1. Measurement Period for Denominators and Numerators for the 1115 SMI/SED Monitoring Metrics Adapted from FFY 2019
Child and Adult Core Sets Measures
FFY 2019 Measurement PeriodA
Measure
Denominator
Metric #2: Use of First-Line
Psychosocial Care for Children
and Adolescents on
Antipsychotics (APP-CH)
IPSD: January 1, 2018 –
December 1, 2018
Metric #7: Follow-Up After
Hospitalization for Mental
Illness: Ages 6–17 (FUH-CH)
Discharge date: January 1,
2018 – December 31, 2018
Negative medication history
review: September 3, 2017 –
August 3, 2018
(120 days before the IPSD)
Numerator
Continuous Enrollment Period
October 3, 2017 – December 31,
2018
(90 days prior to IPSD through 30
days after the IPSD)
September 3, 2017 - December 31,
2018
(120 days prior to IPSD through 30
days after IPSD)
7 Day Follow-up: January 2, 2018 –
December 8, 2018
(7 days after discharge date)
January 1, 2018 – December 31,
2018
(30 days after discharge date)
30 Day Follow-up: January 2, 2018
– December 31, 2018
(30 days after discharge date)
Metric #8: Follow-up After
Hospitalization for Mental
Illness: Age 18 and Older
(FUH-AD)
Discharge date: January 1,
2018 – December 1, 2018
Metric #9: Follow-Up After
Emergency Department Visit for
Alcohol and Other Drug Abuse
or Dependence (FUA-AD)
Emergency Department (ED)
visit date: January 1, 2018 –
December 1, 2018
7 Day Follow-up: January 2, 2018 –
December 8, 2018
(7 days after discharge date)
January 1, 2018 – December 31,
2018
(30 days after discharge date)
30 Day Follow-up: January 2, 2018
– December 31, 2018
(30 days after discharge date)
7 Day Follow-up: January 1, 2018 –
December 8, 2018
(ED visit date through 7 days after
visit date)
30 Day Follow-up: January 1, 2018
– December 31, 2018
(ED visit date through 30 days after
visit date)
D.4
January 1, 2018 – December 31,
2018
(ED visit date through 30 days after
visit date)
APPENDIX D
MATHEMATICA
FFY 2019 Measurement PeriodA
Measure
Metric #10: Follow-Up After
Emergency Department Visit for
Mental Illness (FUM-AD)
Denominator
Numerator
Continuous Enrollment Period
ED visit date: January 1, 2018 –
December 1, 2018
7 Day Follow-up: January 1, 2018 –
December 8, 2018
(ED visit date through 7 days after
visit date)
January 1, 2018 – December 31,
2018
(ED visit date through 30 days after
visit date)
30 Day Follow-up: January 1, 2018
– December 31, 2018
(ED visit date through 30 days after
visit date)
January 1, 2018 – December 31,
2018
January 1, 2018 – December 31,
2018B
January 1, 2018 – December
31, 2018
January 1, 2018 – December 31,
2018
None
Metric #25: Screening for
Depression and Follow-Up
Plan: Ages 12-17 (CDF-CH)
January 1, 2018 – December
31, 2018
January 1, 2018 – December 31,
2018
None
Metric #31: Use of Multiple
Concurrent Antipsychotics in
Children and Adolescents
(APC-CH)
First-time prescription dispense
date: January 1, 2018- October
2, 2018
January 1, 2018 - December 31,
2018
January 1, 2018 – December 31,
2018B
Metric #23: Diabetes Care for
People With Serious Mental
Illness: Hemoglobin A1c
(HBA1c) Poor Control
(>9.0%)(HPCMI-AD)
January 1, 2018 – December
31, 2018
Metric #24: Screening for
Depression and Follow-Up
Plan: Age 18 and Older (CDFAD)
Diabetes diagnosis: January 1,
2017 – December 31, 2018
(Review prescriptions through
December 31, 2018 to identify
drug events for the
denominator)
For some measures, the measurement period for the numerator, denominator, or continuous enrollment period varies depending on a specified date for each
enrollee (such as prescription or treatment start dates and discharge dates). For these measures, two ranges are shown. The first date range identifies the full
range of possible dates that states will need to use to calculate the measure for all measure-eligible enrollees. The text in parentheses describes the measurement
period that should be used for each eligible enrollee.
B No more than one gap in enrollment of up to 45 days during the continuous enrollment period.
A
D.5
APPENDIX D
MATHEMATICA
II. DEFINITION OF A MENTAL HEALTH PRACITIONER
The Child and Adult Core Sets define a mental health practitioner as a practitioner who
provides mental health services and meets any of the following criteria:
•
An MD or Doctor of Osteopathy (DO) who is certified as a psychiatrist or child
psychiatrist by the American Medical Specialties Board of Psychiatry and Neurology or
by the American Osteopathic Board of Neurology and Psychiatry; or, if not certified, who
successfully completed an accredited program of graduate medical or osteopathic
education in psychiatry or child psychiatry and is licensed to practice patient care
psychiatry or child psychiatry, if required by the state of practice
•
An individual who is licensed as a psychologist in his/her state of practice, if required by
the state of practice
•
An individual who is certified in clinical social work by the American Board of
Examiners; who is listed on the National Association of Social Worker’s Clinical
Register; or who has a master’s degree in social work and is licensed or certified to
practice as a social worker, if required by the state of practice
•
A Registered Nurse (RN) who is certified by the American Nurses Credentialing Center
(a subsidiary of the American Nurses Association) as a psychiatric nurse or mental health
clinical nurse specialist, or who has a master’s degree in nursing with a specialization in
psychiatric/mental health and two years of supervised clinical experience and is licensed
to practice as a psychiatric or mental health nurse, if required by the state of practice
•
An individual (normally with a master’s or a doctoral degree in marital and family
therapy and at least two years of supervised clinical experience) who is practicing as a
marital and family therapist and is licensed or a certified counselor by the state of
practice, or if licensure or certification is not required by the state of practice, who is
eligible for clinical membership in the American Association for Marriage and Family
Therapy
•
An individual (normally with a master’s or doctoral degree in counseling and at least two
years of supervised clinical experience) who is practicing as a professional counselor and
who is licensed or certified to do so by the state of practice, or if licensure or certification
is not required by the state of practice, is a National Certified Counselor with Specialty
Certification in Clinical Mental Health Counseling from the National Board for Certified
Counselors (NBCC)
D.6
III. TECHNICAL SPECIFICATIONS
Metric #2: Use of First-Line Psychosocial Care for Children and Adolescents on
Antipsychotics (APP-CH)
Measure Steward: National Committee for Quality Assurance
A. DESCRIPTION
Percentage of children and adolescents ages 1 to 17 who had a new prescription for an
antipsychotic medication and had documentation of psychosocial care as first-line
treatment.
Data Collection Method: Administrative
Guidance for Reporting:
• This measure intends to assess use of psychosocial care as a first-line treatment for
conditions for which antipsychotic medications are not indicated. This measure’s value
set contains typical forms of psychological services, such as behavioral interventions,
psychological therapies, and crisis intervention.
• Include all paid, suspended, pending, and denied claims.
• Beneficiaries in hospice are excluded from the eligible population. For additional
information, refer to the hospice exclusion guidance in Section I. Measure Element
Definitions
• NCQA’s Medication List Directory (MLD) of NDC codes for Antipsychotic Medications
and Antipsychotic Combination Medications can be found at
https://www.ncqa.org/hedis/measures/hedis-2019-ndc-license/hedis-2019-final-ndclists/.
The following coding systems are used in this measure: CPT, HCPCS, ICD-10-CM, ICD-10PCS, Modifier, NDC, POS, and UB. Refer to the Acknowledgments section at the beginning
of the manual for copyright information.
B. DEFINITION
Intake Period
January 1 through December 1 of the measurement year.
IPSD
Index Prescription Start Date (IPSD). The earliest prescription
dispensing date for an antipsychotic medication where the date is in
the Intake Period and there is a Negative Medication History.
Negative
Medication
History
A period of 120 days (4 months) before the IPSD when the beneficiary
had no antipsychotic medications dispensed for either new or refill
prescriptions.
C. ELIGIBLE POPULATION
Age
Ages 1 to 17 as of December 31 of the measurement year.
Continuous
enrollment
120 days (4 months) prior to the IPSD through 30 days after the IPSD.
Allowable gap
No allowable gap during the continuous enrollment period.
Version of Specification: HEDIS 2019
MEASURE APP-CH: USE OF FIRST-LINE PSYCHOSOCIAL CARE FOR CHILDREN AND ADOLESCENTS ON
ANTIPSYCHOTICS
Anchor date
IPSD.
Benefit
Medical, mental health, and pharmacy.
Event/diagnosis
Follow the steps below to identify the eligible population.
Step 1
Identify all beneficiaries who were dispensed an antipsychotic
medication (Antipsychotic Medications List and Antipsychotic
Combination Medications List, see link to Medication List Directory in
Guidance for Reporting above) during the Intake Period.
Step 2
Test for Negative Medication History. For each beneficiary identified in
step 1, test each antipsychotic prescription for a Negative Medication
History. The IPSD is the dispensing date of the earliest antipsychotic
prescription in the Intake Period with a Negative Medication History.
Step 3
Calculate continuous enrollment. Beneficiaries must be continuously
enrolled for 120 days (4 months) prior to the IPSD through 30 days
after the IPSD.
Step 4: Exclusions (required)
Exclude beneficiaries for whom first-line antipsychotic medications
may be clinically appropriate. Any of the following during the
measurement year meet criteria:
• At least one acute inpatient encounter with a diagnosis of
schizophrenia, schizoaffective disorder, bipolar disorder, other
psychotic disorder, autism, or other developmental disorder during
the measurement year. Any of the following code combinations meet
criteria:
BH Stand Alone Acute Inpatient Value Set with (Schizophrenia
Value Set; Bipolar Disorder Value Set; Other Psychotic and
Developmental Disorders Value Set)
Visit Setting Unspecified Value Set with Acute Inpatient POS
Value Set with (Schizophrenia Value Set; Bipolar Disorder
Value Set; Other Psychotic and Developmental Disorders Value
Set), with or without a telehealth modifier (Telehealth Modifier
Value Set)
Version of Specification: HEDIS 2019
8
MEASURE APP-CH: USE OF FIRST-LINE PSYCHOSOCIAL CARE FOR CHILDREN AND ADOLESCENTS ON
ANTIPSYCHOTICS
Event/diagnosis
(continued)
9
• At least two visits in an outpatient, intensive outpatient, or partial
hospitalization setting, on different dates of service, with a diagnosis
of schizophrenia, schizoaffective disorder, bipolar disorder, other
psychotic disorder, autism, or other developmental disorder during
the measurement year. Any of the following code combinations with
(Schizophrenia Value Set; Bipolar Disorder Value Set; Other
Psychotic and Developmental Disorders Value Set), with or without
a telehealth modifier (Telehealth Modifier Value Set), meet criteria:
An outpatient visit (Visit Setting Unspecified Value Set with
Outpatient POS Value Set)
An outpatient visit (BH Outpatient Value Set)
An intensive outpatient encounter or partial hospitalization (Visit
Setting Unspecified Value Set with Partial Hospitalization POS
Value Set)
An intensive outpatient encounter or partial hospitalization
(Partial Hospitalization/Intensive Outpatient Value Set)
A community mental health center visit (Visit Setting
Unspecified Value Set with Community Mental Health Center
POS Value Set)
Electroconvulsive therapy (Electroconvulsive Therapy Value
Set)
An observation visit (Observation Value Set)
A telehealth visit (Visit Setting Unspecified Value Set with
Telehealth POS Value Set)
D. ADMINISTRATIVE SPECIFICATION
Denominator
The eligible population as defined above.
Numerator
Documentation of psychosocial care (Psychosocial Care Value Set) with or without a
telehealth modifier (Telehealth Modifier Value Set) in the 121-day period from 90 days prior
to the IPSD through 30 days after the IPSD.
Version of Specification: HEDIS 2019
Metric #7: Follow-up After Hospitalization for Mental Illness: Ages 6-17
(FUH-CH)
Measure Steward: National Committee for Quality Assurance
A. DESCRIPTION
Percentage of discharges for children ages 6 to 17 who were hospitalized for treatment of
selected mental illness or intentional self-harm diagnoses and who had a follow-up visit with
a mental health practitioner. Two rates are reported:
•
Percentage of discharges for which children received follow-up within 30 days after
discharge
•
Percentage of discharges for which children received follow-up within 7 days after
discharge
Data Collection Method: Administrative
Guidance for Reporting:
• 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 7day rate.
• The 30-day follow-up rate should be greater than (or equal to) the 7-day follow-up rate.
• This measure specifies that when a visit code or procedure code must be used in
conjunction with a diagnosis code, both the visit/procedure code and the diagnosis
code must be on the same claim or be found on the same date of service.
− This measure references value sets that include codes used on professional claims
(e.g., CPT, HCPCS) and codes used on facility claims (e.g., UB). Diagnosis and
procedure codes from both facility and professional claims should be used to
identify services and diagnoses (the codes can be on the same claim or same date
of service).
− For value sets that include codes used only on facility claims (e.g., UB), use facility
claims only to identify services and diagnoses (the codes must be on the same
claim).
• Include all paid, suspended, pending, and denied claims.
• Beneficiaries in hospice are excluded from the eligible population. For additional
information, refer to the hospice exclusion guidance in Section I. Measure Element
Definitions
• Refer to Section II: Definition of a Mental Health Practitioner for the definition of a
mental health practitioner.
The following coding systems are used in this measure: CPT, HCPCS, ICD-10-CM, POS
and UB. Refer to the Acknowledgments section at the beginning of the manual for copyright
information.
Version of Specification: HEDIS 2019
MEASURE FUH-CH: FOLLOW-UP AFTER HOSPITALIZATION FOR MENTAL ILLNESS: AGES 6-17
11
B. ELIGIBLE POPULATION
Age
Continuous
enrollment
Allowable gap
Anchor date
Benefit
Event/diagnosis
Acute readmission
or direct transfer
Ages 6 to 17 as of date of discharge.
Date of discharge through 30 days after discharge.
No allowable gap during the continuous enrollment period.
None.
Medical and mental health (inpatient and outpatient).
An acute inpatient discharge with a principal diagnosis of
mental illness (Mental Illness Value Set) on or between January 1
and December 1 of the measurement year.
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 to determine whether it
falls on or between January 1 and December 1 of the
measurement year.
The denominator for this measure is based on discharges, not on
beneficiaries. If beneficiaries have more than one discharge,
include all discharges on or between January 1 and December 1 of
the measurement year.
Identify readmissions and direct transfers to an acute inpatient care
setting during the 30-day follow-up period:
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 stays to determine whether
they fall after December 1 of the measurement year.
Exclude both the initial discharge and the readmission/direct
transfer discharge if the last discharge occurs after December 1 of
the measurement year. If the readmission/direct transfer to the
acute inpatient care setting was for a principal diagnosis of mental
health disorder or intentional self-harm (Mental Health Diagnosis
Value Set; Intentional Self-Harm Value Set), count only the last
discharge. If the readmission/direct transfer to the acute inpatient
care setting was for any other principal diagnosis exclude both the
original and the readmission/direct transfer discharge.
Version of Specification: HEDIS 2019
MEASURE FUH-CH: FOLLOW-UP AFTER HOSPITALIZATION FOR MENTAL ILLNESS: AGES 6-17
Exclusions
12
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 and direct transfers 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 to determine whether it
occurs within the 30-day follow-up period.
These discharges are excluded from this measure because
rehospitalization or direct transfer may prevent an outpatient
followup visit from taking place.
C. ADMINISTRATIVE SPECIFICATION
Denominator
The eligible population as defined above.
Numerators
30 Day Follow-up: A follow-up visit with a mental health practitioner within 30 days after
discharge. Do not include visits that occur on the date of discharge.
7 Day Follow-up: A follow-up visit with a mental health practitioner within 7 days after
discharge. Do not include visits that occur on the date of discharge.
For both indicators, any of the following meet criteria for a follow-up visit:
•
An outpatient visit (Visit Setting Unspecified Value Set with Outpatient POS Value Set)
with a mental health practitioner, with or without a telehealth modifier (Telehealth
Modifier Value Set) A visit (FUH Visits Group 1 Value Set with FUH POS Group 1
Value Set) with a mental health practitioner, with or without a telehealth modifier
(Telehealth Modifier Value Set)
•
An outpatient visit (BH Outpatient Value Set) with a mental health practitioner, with or
without a telehealth modifier (Telehealth Modifier Value Set) A visit in a behavioral
healthcare setting (FUH RevCodes Group 1 Value Set)
•
An intensive outpatient encounter or partial hospitalization (Visit Setting Unspecified
Value Set with Partial Hospitalization POS Value Set) with a mental health practitioner,
with or without a telehealth modifier (Telehealth Modifier Value Set)
•
An intensive outpatient encounter or partial hospitalization (Partial
Hospitalization/Intensive Outpatient Value Set) with a mental health practitioner
•
A community mental health center visit (Visit Setting Unspecified Value Set with
Community Mental Health Center POS Value Set) with a mental health practitioner,
with or without a telehealth modifier (Telehealth Modifier Value Set) Transitional care
management services (Transitional Care Management Services Value Set), with or
without a telehealth modifier (Telehealth Modifier Value Set)
•
Electroconvulsive therapy (Electroconvulsive Therapy Value Set) with (Ambulatory
Surgical Center POS Value Set; Community Mental Health Center POS Value Set;
Version of Specification: HEDIS 2019
MEASURE FUH-CH: FOLLOW-UP AFTER HOSPITALIZATION FOR MENTAL ILLNESS: AGES 6-17
13
Outpatient POS Value Set; Partial Hospitalization POS Value Set) with a mental health
practitioner
•
A telehealth visit (Visit Setting Unspecified Value Set with Telehealth POS Value Set)
with a mental health practitioner, with or without a telehealth modifier (Telehealth
Modifier Value Set)
•
An observation visit (Observation Value Set) with a mental health practitioner
•
Transitional care management services (Transitional Care Management Services
Value Set), with a mental health practitioner, with or without a telehealth modifier
(Telehealth Modifier Value Set)
D. ADDITIONAL NOTE
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).
Version of Specification: HEDIS 2019
Metric #8: Follow-up After Hospitalization for Mental Illness: Age 18 and Older
(FUH-AD)
Measure Steward: National Committee for Quality Assurance
A. DESCRIPTION
Percentage of discharges for beneficiaries age 18 and older who were hospitalized for
treatment of selected mental illness or intentional self-harm diagnoses and who had a
follow-up visit with a mental health practitioner. Two rates are reported:
•
Percentage of discharges for which the beneficiary received follow-up within 30 days
after discharge
•
Percentage of discharges for which the beneficiary received follow-up within 7 days
after discharge
Data Collection Method: Administrative
Guidance for Reporting:
• Follow the detailed specifications to (1) include the appropriate discharge when the
beneficiary 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 beneficiary 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 follow-up rate.
• This measure specifies that when a visit code or procedure code must be used in
conjunction with a diagnosis code, both the visit/procedure code and the diagnosis code
must be on the same claim or be found on the same date of service.
This measure references value sets that include codes used on professional claims
(e.g., CPT, HCPCS) and codes used on facility claims (e.g., UB). Diagnosis and
procedure codes from both facility and professional claims should be used to identify
services and diagnoses (the codes can be on the same claim or same date of
service).
For value sets that include codes used only on facility claims (e.g., UB), use facility
claims only to identify services and diagnoses (the codes must be on the same
claim).
• Include all paid, suspended, pending, and denied claims.
• Beneficiaries in hospice are excluded from the eligible population. For additional
information, refer to the hospice exclusion guidance in Section I. Measure Element
Definitions
• Refer to Section II: Definition of a Mental Health Practitioner for the definition of a mental
health practitioner.
The following coding systems are used in this measure: CPT, HCPCS, ICD-10-CM, ICD-10PCS, Modifier, POS, and UB. Refer to the Acknowledgments section at the beginning of the
manual for copyright information.
Version of Specification: HEDIS 2019
MEASURE FUH-AD: FOLLOW-UP AFTER HOSPITALIZATION FOR MENTAL ILLNESS: AGE 18 AND OLDER
15
B. ELIGIBLE POPULATION
Age
Age 18 and older as of date of discharge.
Continuous
enrollment
Date of discharge through 30 days after discharge.
Allowable gap
No allowable gap during the continuous enrollment period.
Anchor date
None.
Benefit
Medical and mental health (inpatient and outpatient).
Event/diagnosis An acute inpatient discharge with a principal diagnosis of mental illness
or intentional self-harm (Mental Illness Value Set; Intentional Self-Harm
Value Set) on or between January 1 and December 1 of the
measurement year.
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 to determine whether it
falls on or between January 1 and December 1 of the
measurement year.
The denominator for this measure is based on discharges, not on
beneficiaries. If beneficiaries have more than one discharge, include all
discharges on or between January 1 and December 1 of the
measurement year.
Acute
readmission or
direct transfer
Identify readmissions and direct transfers to an acute inpatient care
setting during the 30-day follow-up period:
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 stays to determine whether
they occur after December 1 of the measurement year.
Exclude both the initial discharge and the readmission/direct transfer
discharge if the last discharge occurs after December 1 of the
measurement year.
If the readmission/direct transfer to the acute inpatient care setting was
for a principal diagnosis of mental health disorder or intentional selfharm (Mental Health Diagnosis Value Set; Intentional Self-Harm Value
Set), count only the last discharge.
If the readmission/direct transfer to the acute inpatient care setting was
for any other principal diagnosis exclude both the original and the
readmission/direct transfer discharge.
Version of Specification: HEDIS 2019
MEASURE FUH-AD: FOLLOW-UP AFTER HOSPITALIZATION FOR MENTAL ILLNESS: AGE 18 AND OLDER
Nonacute
readmission or
direct transfer
16
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 and direct transfers 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 to determine whether it
occurs within the 30-day follow-up period.
These discharges are excluded from this measure because
rehospitalization or direct transfer may prevent an outpatient follow-up
visit from taking place.
C. ADMINISTRATIVE SPECIFICATION
Denominator
The eligible population as defined above.
Numerators
30-Day Follow-Up: A follow-up visit with a mental health practitioner within 30 days after
discharge. Do not include visits that occur on the date of discharge.
7-Day Follow-Up: A follow-up visit with a mental health practitioner within 7 days after
discharge. Do not include visits that occur on the date of discharge.
For both indicators, any of the following meet criteria for a follow-up visit.
•
An outpatient visit (Visit Setting Unspecified Value Set with Outpatient POS Value Set)
with a mental health practitioner, with or without a telehealth modifier (Telehealth
Modifier Value Set)
•
An outpatient visit (BH Outpatient Value Set) with a mental health practitioner, with or
without a telehealth modifier (Telehealth Modifier Value Set)
•
An intensive outpatient encounter or partial hospitalization (Visit Setting Unspecified
Value Set with Partial Hospitalization POS Value Set) with a mental health practitioner,
with or without a telehealth modifier (Telehealth Modifier Value Set)
•
An intensive outpatient encounter or partial hospitalization (Partial
Hospitalization/Intensive Outpatient Value Set) with a mental health practitioner
•
A community mental health center visit (Visit Setting Unspecified Value Set with
Community Mental Health Center POS Value Set) with a mental health practitioner, with
or without a telehealth modifier (Telehealth Modifier Value Set)
•
Electroconvulsive therapy (Electroconvulsive Therapy Value Set) with (Ambulatory
Surgical Center POS Value Set; Community Mental Health Center POS Value Set;
Outpatient POS Value Set; Partial Hospitalization POS Value Set) with a mental health
practitioner
•
A telehealth visit: Visit Setting Unspecified Value Set with Telehealth POS Value Set
with a mental health practitioner, with or without a telehealth modifier (Telehealth
Modifier Value Set)
Version of Specification: HEDIS 2019
MEASURE FUH-AD: FOLLOW-UP AFTER HOSPITALIZATION FOR MENTAL ILLNESS: AGE 18 AND OLDER
17
•
An observation visit (Observation Value Set) with a mental health practitioner
•
Transitional care management services (Transitional Care Management Services Value
Set), with a mental health practitioner, with or without a telehealth modifier (Telehealth
Modifier Value Set)
D. 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 for the rate (e.g., within
30 days after discharge or within 7 days after discharge).
Version of Specification: HEDIS 2019
Metric #9: Follow-up After Emergency Department Visit for Alcohol and Other
Drug Abuse Dependence (FUA-AD)
Measure Steward: National Committee for Quality Assurance
A. DESCRIPTION
Percentage of emergency department (ED) visits for beneficiaries age 18 and older with a
principal diagnosis of alcohol or other drug (AOD) abuse or dependence who had a followup visit for AOD abuse or dependence. Two rates are reported:
•
Percentage of ED visits for AOD abuse or dependence for which the beneficiary
received follow-up within 30 days of the ED visit (31 total days)
•
Percentage of ED visits for AOD abuse or dependence for which the beneficiary
received follow-up within 7 days of the ED visit (8 total days)
Data Collection Method: Administrative
Guidance for Reporting:
• The denominator 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 follow-up rate.
• When a visit code or procedure code must be used in conjunction with a diagnosis
code, the codes must be on the same claim or be found on the same date of service.
If a value set includes codes used on professional claims (e.g., CPT, HCPCS) and
includes codes used on facility claims (e.g., UB), use diagnosis and procedure
codes from both facility and professional claims to identify services and diagnoses
(the codes can be on the same claim or same date of service).
If a value set includes codes used only on facility claims (e.g., UB) then use only
facility claims to identify services and diagnoses (the codes must be on the same
claim).
• Include all paid, suspended, pending and denied claims.
• Beneficiaries in hospice are excluded from the eligible population. For additional
information, refer to the hospice exclusion guidance in Section I. Measure Element
Definitions
The following coding systems are used in this measure: CPT, HCPCS, ICD-10-CM,
Modifier, POS, and UB. Refer to the Acknowledgments section at the beginning of the
manual for copyright information.
B. ELIGIBLE POPULATION
Age
Continuous
enrollment
Allowable gap
Anchor date
Benefit
Age 18 and older as of the ED visit.
Date of the ED visit through 30 days after the ED visit (31 total
days).
No allowable gap during the continuous enrollment period.
None.
Medical and chemical dependency.
Note: Beneficiaries with detoxification-only chemical dependency
benefits do not meet these criteria.
Version of Specification: HEDIS 2019
MEASURE FUA-AD: FOLLOW-UP AFTER EMERGENCY DEPARTMENT VISIT FOR ALCOHOL AND OTHER DRUG ABUSE OR
DEPENDENCE
19
Event/diagnosis
Multiple visits in a
31-day period
ED visits followed
by inpatient
admission
An ED visit (ED Value Set) with a principal diagnosis of AOD abuse
or dependence (AOD Abuse and Dependence Value Set) on or
between January 1 and December 1 of the measurement year
where the beneficiary was age 18 or older on the date of the visit.
The denominator for this measure is based on ED visits, not on
beneficiaries. If a beneficiary has more than one ED visit, identify
all eligible ED visits between January 1 and December 1 of the
measurement year and do not include more than one visit per 31day period as described below.
If a beneficiary has more than one ED visit in a 31-day period,
include only the first eligible ED visit. For example, if a beneficiary
has an ED visit on January 1, then include the January 1 visit and
do not include ED visits that occur on or between January 2 and
January 31; then, if applicable, include the next ED visit that occurs
on or after February 1. Identify visits chronologically including only
one per 31-day period.
Note: Removal of multiple visits in a 31-day period is based on
eligible visits. Assess each ED visit for exclusion before removing
multiple visits in a 31-day period.
Exclude ED visits that result in an inpatient stay and ED visits
followed by an admission to an acute or nonacute inpatient care
setting on the date of the ED visit or within the 30 days after the ED
visit (31 total days), regardless of principal 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.
An ED or observation visit billed on the same claim as an inpatient
stay is considered a visit that resulted in an inpatient stay.
These events are excluded from this measure because admission
to an acute or nonacute inpatient setting may prevent an outpatient
follow-up visit from taking place.
C. ADMINISTRATIVE SPECIFICATION
Denominator
The eligible population as defined above.
Numerator
30-Day Follow-Up
A follow-up visit with any practitioner, with a principal diagnosis of AOD abuse or
dependence within 30 days after the ED visit (31 total days). Include visits that occur on the
date of the ED visit.
7-Day Follow-Up
A follow-up visit with any practitioner, with a principal diagnosis of AOD abuse or
dependence within 7 days after the ED visit (8 total days). Include visits that occur on the
date of the ED visit.
For both indicators, any of the following meet criteria for a follow-up visit:
Version of Specification: HEDIS 2019
MEASURE FUA-AD: FOLLOW-UP AFTER EMERGENCY DEPARTMENT VISIT FOR ALCOHOL AND OTHER DRUG ABUSE OR
DEPENDENCE
20
•
IET Stand Alone Visits Value Set with a principal diagnosis of AOD abuse or
dependence (AOD Abuse and Dependence Value Set), with or without a telehealth
modifier (Telehealth Modifier Value Set)
•
IET Visits Group 1 Value Set with IET POS Group 1 Value Set and a principal diagnosis
of AOD abuse or dependence (AOD Abuse and Dependence Value Set), with or
without a telehealth modifier (Telehealth Modifier Value Set)
•
IET Visits Group 2 Value Set with IET POS Group 2 Value Set and a principal diagnosis
of AOD abuse or dependence (AOD Abuse and Dependence Value Set), with or
without a telehealth modifier (Telehealth Modifier Value Set)
•
An observation visit (Observation Value Set) with a principal diagnosis of AOD abuse or
dependence (AOD Abuse and Dependence Value Set)
•
A telephone visit (Telephone Visits Value Set) with a principal diagnosis of AOD abuse
or dependence (AOD Abuse and Dependence Value Set)
•
An online assessment (Online Assessments Value Set) with a principal diagnosis of
AOD abuse or dependence (AOD Abuse and Dependence Value Set)
D. 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 required period for the rate (e.g., within
30 days after the ED visit or within 7 days after the ED visit).
Version of Specification: HEDIS 2019
Metric #10: Follow-up After Emergency Department Visit for Mental Illness
(FUM-AD)
Measure Steward: National Committee for Quality Assurance
A. DESCRIPTION
Percentage of emergency department (ED) visits for beneficiaries age 18 and older with a
principal diagnosis of mental illness or intentional self-harm and who had a follow-up visit
for mental illness. Two rates are reported:
•
Percentage of ED visits for mental illness for which the beneficiary received follow-up
within 30 days of the ED visit (31 total days)
•
Percentage of ED visits for mental illness for which the beneficiary received follow-up
within 7 days of the ED visit (8 total days)
Data Collection Method: Administrative
Guidance for Reporting:
• The denominator 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 follow-up rate.
• When a visit code or procedure code must be used in conjunction with a diagnosis
code, the codes must be on the same claim or be found on the same date of service.
If a value set includes codes used on professional claims (e.g., CPT, HCPCS) and
includes codes used on facility claims (e.g., UB), use diagnosis and procedure
codes from both facility and professional claims to identify services and diagnoses
(the codes can be on the same claim or same date of service).
If a value set includes codes used only on facility claims (e.g., UB) then only use
facility claims to identify services and diagnoses (the codes must be on the same
claim).
• Include all paid, suspended, pending and denied claims.
• Beneficiaries in hospice are excluded from the eligible population. For additional
information, refer to the hospice exclusion guidance in Section I. Measure Element
Definitions
The following coding systems are used in this measure: CPT, HCPCS, ICD-10-CM, ICD-10PCS, Modifier, POS, and UB. Refer to the Acknowledgments section at the beginning of the
manual for copyright information.
B. ELIGIBLE POPULATION
Ages
Age 18 and older as of the date of the ED visit.
Continuous
enrollment
Date of the ED visit through 30 days after the ED visit (31 total
days).
Allowable gap
No allowable gap during the continuous enrollment period.
Anchor date
None.
Benefit
Medical and mental health.
Version of Specification: HEDIS 2019
MEASURE FUM-AD: FOLLOW-UP AFTER EMERGENCY DEPARTMENT VISIT FOR MENTAL ILLNESS
22
Event/diagnosis
An ED visit (ED Value Set) with a principal diagnosis of mental
illness or intentional self-harm (Mental Illness Value Set; Intentional
Self-Harm Value Set) on or between January 1 and December 1 of
the measurement year where the beneficiary was age 18 or older
on the date of the visit.
The denominator for this measure is based on ED visits, not on
beneficiaries. If a beneficiary has more than one ED visit, identify all
eligible ED visits between January 1 and December 1 of the
measurement year and do not include more than one visit per 31day period as described below.
Multiple visits in a
31-day period
If a beneficiary has more than one ED visit in a 31-day period,
include only the first eligible ED visit. For example, if a beneficiary
has an ED visit on January 1, then include the January 1 visit and
do not include ED visits that occur on or between January 2 and
January 31; then, if applicable, include the next ED visit that occurs
on or after February 1. Identify visits chronologically including only
one per 31-day period.
Note: Removal of multiple visits in a 31-day period is based on
eligible visits. Assess each ED visit for exclusion before removing
multiple visits in a 31-day period.
ED visits followed
by inpatient
admission
Exclude ED visits that result in an inpatient stay and ED visits
followed by an admission to an acute or nonacute inpatient care
setting on the date of the ED visit or within the 30 days after the ED
visit (31 total days), regardless of principal diagnosis for the
admission. To identify admissions to an acute or nonacute inpatient
care setting:
4. Identify all acute and nonacute inpatient stays (Inpatient
Stay Value Set).
5. Identify the admission date for the stay.
An ED or observation visit billed on the same claim as an inpatient
stay is considered a visit that resulted in an inpatient stay.
These events are excluded from this measure because admission
to an acute or nonacute inpatient setting may prevent an outpatient
follow-up visit from taking place.
C. ADMINISTRATIVE SPECIFICATION
Denominator
The eligible population as defined above.
Numerator
30-Day Follow-Up
A follow-up visit with any practitioner, with a principal diagnosis of a mental health disorder
or with a principal diagnosis of intentional self-harm and any diagnosis of mental health
disorder within 30 days after the ED visit (31 total days). Include visits that occur on the
date of the ED visit.
7-Day Follow-Up
A follow-up visit with any practitioner, with a principal diagnosis of a mental health disorder
or with a principal diagnosis of intentional self-harm and any diagnosis of a mental health
Version of Specification: HEDIS 2019
MEASURE FUM-AD: FOLLOW-UP AFTER EMERGENCY DEPARTMENT VISIT FOR MENTAL ILLNESS
23
disorder within 7 days after the ED visit (8 total days). Include visits that occur on the date
of the ED visit.
For both indicators, any of the following meet criteria for a follow-up visit.
•
An outpatient visit (Visit Setting Unspecified Value Set with Outpatient POS Value Set)
with a principal diagnosis of a mental health disorder (Mental Health Diagnosis Value
Set), with or without a telehealth modifier (Telehealth Modifier Value Set)
•
An outpatient visit (BH Outpatient Value Set) with a principal diagnosis of a mental
health disorder (Mental Health Diagnosis Value Set), with or without a telehealth
modifier (Telehealth Modifier Value Set)
•
An intensive outpatient encounter or partial hospitalization (Visit Setting Unspecified
Value Set with Partial Hospitalization POS Value Set), with a principal diagnosis of
mental health disorder (Mental Health Diagnosis Value Set), with or without a telehealth
modifier (Telehealth Modifier Value Set)
•
An intensive outpatient encounter or partial hospitalization (Partial
Hospitalization/Intensive Outpatient Value Set) with a principal diagnosis of a mental
health disorder (Mental Health Diagnosis Value Set)
•
A community mental health center visit (Visit Setting Unspecified Value Set with
Community Mental Health Center POS Value Set), with a principal diagnosis of a
mental health disorder (Mental Health Diagnosis Value Set), with or without a telehealth
modifier (Telehealth Modifier Value Set)
•
Electroconvulsive therapy (Electroconvulsive Therapy Value Set) with (Ambulatory
Surgical Center POS Value Set; Community Mental Health Center POS Value Set;
Outpatient POS Value Set; Partial Hospitalization POS Value Set) with a principal
diagnosis of a mental health disorder (Mental Health Diagnosis Value Set)
•
A telehealth visit (Visit Setting Unspecified Value Set with Telehealth POS Value Set),
with a principal diagnosis of a mental health disorder (Mental Health Diagnosis Value
Set), with or without a telehealth modifier (Telehealth Modifier Value Set)
•
An observation visit (Observation Value Set) with a principal diagnosis of a mental
health disorder (Mental Health Diagnosis Value Set)
•
An outpatient visit (Visit Setting Unspecified Value Set with Outpatient POS Value Set)
with a principal diagnosis of intentional self-harm (Intentional Self-Harm Value Set) with
any diagnosis of a mental health disorder (Mental Health Diagnosis Value Set), with or
without a telehealth modifier (Telehealth Modifier Value Set)
•
An outpatient visit (BH Outpatient Value Set) with a principal diagnosis of intentional
self-harm (Intentional Self-Harm Value Set), with any diagnosis of a mental health
disorder (Mental Health Diagnosis Value Set), with or without a telehealth modifier
(Telehealth Modifier Value Set)
•
An intensive outpatient encounter or partial hospitalization (Visit Setting Unspecified
Value Set with Partial Hospitalization POS Value Set), with a principal diagnosis of
intentional self-harm (Intentional Self-Harm Value Set), with any diagnosis of a mental
health disorder (Mental Health Diagnosis Value Set), with or without a telehealth
modifier (Telehealth Modifier Value Set)
Version of Specification: HEDIS 2019
MEASURE FUM-AD: FOLLOW-UP AFTER EMERGENCY DEPARTMENT VISIT FOR MENTAL ILLNESS
24
•
An intensive outpatient encounter or partial hospitalization (Partial
Hospitalization/Intensive Outpatient Value Set) with a principal diagnosis of intentional
self-harm (Intentional Self-Harm Value Set), with any diagnosis of a mental health
disorder (Mental Health Diagnosis Value Set)
•
A community mental health center visit (Visit Setting Unspecified Value Set with
Community Mental Health Center POS Value Set), with a principal diagnosis of
intentional self-harm (Intentional Self-Harm Value Set), with any diagnosis of a mental
health disorder (Mental Health Diagnosis Value Set), with or without a telehealth
modifier (Telehealth Modifier Value Set)
•
Electroconvulsive therapy (Electroconvulsive Therapy Value Set) with (Ambulatory
Surgical Center POS Value Set; Community Mental Health Center POS Value Set;
Outpatient POS Value Set; Partial Hospitalization POS Value Set) with a principal
diagnosis of intentional self-harm (Intentional Self-Harm Value Set), with any diagnosis
of a mental health disorder (Mental Health Diagnosis Value Set)
•
A telehealth visit (Visit Setting Unspecified Value Set with Telehealth POS Value Set),
with a principal diagnosis of intentional self-harm (Intentional Self-Harm Value Set), with
any diagnosis of a mental health disorder (Mental Health Diagnosis Value Set), with or
without a telehealth modifier (Telehealth Modifier Value Set)
•
An observation visit (Observation Value Set) with a principal diagnosis of intentional
self-harm (Intentional Self-Harm Value Set), with any diagnosis of a mental health
disorder (Mental Health Diagnosis Value Set)
D. 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 required period specified for the rate
(e.g., within 30 days after discharge or within 7 days after discharge).
Version of Specification: HEDIS 2019
Metric #23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin
A1c (HbA1c) Poor Control (>9.0%) (HPCMI-AD)
Measure Steward: National Committee for Quality Assurance
A. DESCRIPTION
Percentage of beneficiaries ages 18 to 75 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%.
Note: A lower rate indicates better performance.
Data Collection Method: Administrative or Hybrid
Guidance for Reporting:
• This is a NCQA owned and copyrighted measure that is not currently contained in
HEDIS®.
• This measure includes LOINC codes. Use of the LOINC codes is optional for this
measure. If LOINC codes are not available, the other code systems in the value set
may be used instead.
• Include all paid, suspended, pending, and denied claims.
• Beneficiaries in hospice are excluded from the eligible population. If a state reports this
measure using the Hybrid method, and a beneficiary is found to be in hospice or using
hospice services during medical record review, the beneficiary is removed from the
sample and replaced by a beneficiary from the oversample. For additional information,
refer to the hospice exclusion guidance in Section I. Measure Element Definitions.
• NCQA’s Medication List Directory (MLD) of NDC codes for Diabetes Medications can
be found at https://www.ncqa.org/hedis/measures/hedis-2019-ndc-license/hedis-2019final-ndc-lists/.
The following coding systems are used in this measure: CPT, HCPCS, ICD-10-CM, ICD-10PCS, LOINC, Modifier, NDC, POS, and UB. Refer to the Acknowledgments section at the
beginning of the manual for copyright information.
B. ELIGIBLE POPULATION
Age
Ages 18 to 75 as of December 31 of the measurement year.
Continuous
enrollment
The measurement year.
Allowable
gap
No more than one gap in continuous enrollment of up to 45 days during
the measurement year. To determine continuous enrollment for a
beneficiary for whom enrollment is verified monthly, the beneficiary may
not have more than a 1-month gap in coverage (i.e., a beneficiary whose
coverage lapses for 2 months [60 days] is not considered continuously
enrolled).
Anchor date
December 31 of the measurement year.
Benefit
Medical.
Version of Specification: NCQA 2019
MEASURE HPCMI-AD: DIABETES CARE FOR PEOPLE WITH SERIOUS MENTAL ILLNESS:
HEMOGLOBIN A1C (HBA1C) POOR CONTROL (>9.0%)
Event/
diagnosis
26
Follow the steps below to identify beneficiaries with diabetes and serious
mental illness.
Step 1
Identify beneficiaries ages 18 to 75 as of the end of the measurement
year.
Step 2
Identify beneficiaries from step 1 with a diagnosis of serious mental illness.
Beneficiaries are identified as having serious mental illness if they met at
least one of the following criteria during the measurement year:
• At least one acute inpatient claim/encounter with any diagnosis of
schizophrenia, schizoaffective disorder or bipolar disorder using any of
the following code combinations:
BH Stand Alone Acute Inpatient Value Set with (Schizophrenia
Value Set; Bipolar Disorder Value Set; Other Bipolar Disorder Value
Set)
Visit Setting Unspecified Value Set with Acute Inpatient POS Value
Set with Schizophrenia Value Set; Bipolar Disorder Value Set;
Other Bipolar Disorder Value Set
OR
• At least two of the following, on different dates of service, with or without
a telehealth modifier (Telehealth Modifier Value Set) where both
encounters have any diagnosis of schizophrenia or schizoaffective
disorder (Schizophrenia Value Set) or both encounters have any
diagnosis of bipolar disorder (Bipolar Disorder Value Set; Other Bipolar
Disorder Value Set)
An outpatient visit (Visit Setting Unspecified Value Set) with
Outpatient POS Value Set
An outpatient visit (BH Outpatient Value Set)
An intensive outpatient encounter or partial hospitalization (Visit
Setting Unspecified Value Set with Partial Hospitalization POS
Value Set)
An intensive outpatient encounter or partial hospitalization (Partial
Hospitalization/Intensive Outpatient Value Set)
A community mental health center visit (Visit Setting Unspecified
Value Set with Community Mental Health Center POS Value Set)
Electroconvulsive therapy (Electroconvulsive Therapy Value Set)
An observation visit (Observation Value Set)
An ED visit (ED Value Set)
An ED visit (Visit Setting Unspecified Value Set with ED POS Value
Set)
A nonacute inpatient encounter (BH Stand Alone Nonacute
Inpatient Value Set)
A nonacute inpatient encounter (Visit Setting Unspecified Value Set
with Nonacute Inpatient POS Value Set)
A telehealth visit (Visit Setting Unspecified Value Set with
Telehealth POS Value Set)
Version of Specification: NCQA 2019
MEASURE HPCMI-AD: DIABETES CARE FOR PEOPLE WITH SERIOUS MENTAL ILLNESS:
HEMOGLOBIN A1C (HBA1C) POOR CONTROL (>9.0%)
Event/
diagnosis
(continued)
27
Step 3
Identify beneficiaries from step 2 with diabetes. There are two ways to
identify beneficiaries with diabetes: by claim/encounter data and by
pharmacy data. The state must use both methods to identify the eligible
population, but a beneficiary need only be identified by one to be included
in this measure. Beneficiaries may be identified as having diabetes during
the measurement year or the year prior to the measurement year.
Claim/encounter data. Beneficiaries 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 one acute inpatient encounter (Acute Inpatient Value Set), with
a diagnosis of diabetes (Diabetes Value Set) without (Telehealth
Modifier Value Set; Telehealth POS Value Set)
• 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 encounters.
Only include nonacute inpatient encounters (Nonacute Inpatient Value
Set) without telehealth (Telehealth Modifier Value Set; Telehealth POS
Value Set)
Only one of the two visits may be a telehealth visit, a telephone visit or an
online assessment. Identify telehealth visits by the presence of a
telehealth modifier (Telehealth Modifier Value Set) or the presence of a
telehealth POS code (Telehealth POS Value Set) associated with the
outpatient visit. Use the code combinations below to identify telephone
visits and online assessments:
• A telephone visit (Telephone Visits Value Set) with any diagnosis of
diabetes (Diabetes Value Set)
• An online assessment (Online Assessments Value Set) with any
diagnosis of diabetes (Diabetes Value Set)
Pharmacy data. Beneficiaries who 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 beneficiaries with diabetes, refer
to the Diabetes Medications List (see link to Medication List Directory in
Guidance for Reporting above).
C. ADMINISTRATIVE SPECIFICATION
Denominator
The eligible population as defined above.
Numerator
Use codes (see HbA1c Tests Value Set) to identify the most recent HbA1c test during the
measurement year. The beneficiary 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 beneficiary is not numerator compliant if the result for the most recent HbA1c test
during the measurement year is ≤ 9.0%.
Version of Specification: NCQA 2019
MEASURE HPCMI-AD: DIABETES CARE FOR PEOPLE WITH SERIOUS MENTAL ILLNESS:
HEMOGLOBIN A1C (HBA1C) POOR CONTROL (>9.0%)
28
If a state uses CPT Category II codes to identify numerator compliance for this measure, it
must search for all codes in the following value sets and use the most recent code during
the measurement year to evaluate whether the beneficiary 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
Exclusions (optional)
Beneficiaries 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.
If the beneficiary was included in this measure based on claim or encounter data, as
described in the event/ diagnosis criteria, the optional exclusions do not apply because the
beneficiary had a diagnosis of diabetes.
D. HYBRID SPECIFICATION
Denominator
A systematic sample drawn from the eligible population. Sampling should be systematic to
ensure that all eligible individuals have an equal chance of inclusion. The sample size
should be 411, unless special circumstances apply. Regardless of the selected sample
size, 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.
Numerator
The most recent HbA1c level (performed during the measurement year) is > 9.0% or is
missing, or was not done during the measurement year, as documented through automated
laboratory data or medical record review.
Administrative Data
Refer to the Administrative Specification to identify positive numerator hits from
administrative data.
Medical Record Review
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 beneficiary 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 during the measurement year. The beneficiary 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.
Version of Specification: NCQA 2019
MEASURE HPCMI-AD: DIABETES CARE FOR PEOPLE WITH SERIOUS MENTAL ILLNESS:
HEMOGLOBIN A1C (HBA1C) POOR CONTROL (>9.0%)
Exclusions (optional)
Identify beneficiaries who did not have a diagnosis of diabetes, in any setting, during the
measurement year or the year prior to the measurement year and who had a diagnosis of
gestational diabetes or steroid-induced diabetes, in any setting, during the measurement
year or the year prior to the measurement year.
Version of Specification: NCQA 2019
29
Metric #24: Screening for Depression and Follow-Up Plan: Age 18 and Older
(CDF-AD)
Measure Steward: Centers for Medicare & Medicaid Services
A. DESCRIPTION
Percentage of beneficiaries age 18 and older screened for 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: Administrative or EHR
Guidance for Reporting:
• The denominator for this measure includes beneficiaries age 18 and older with an
outpatient visit during the measurement year. The numerator for this measure includes
the following two groups:
6. Those beneficiaries with a positive screen for depression during an outpatient
visit using a standardized tool with a follow-up plan documented.
7. Those beneficiaries with a negative screen for depression during an outpatient
visit using a standardized tool.
• This measure can be calculated using administrative data only. Medical record review
may be used to validate the state's administrative data (for example, documentation of
the name of the standardized depression screening tool utilized). However, validation
is not required to calculate and report this measure.
• This measure contains both exclusions and exceptions:
Denominator exclusion criteria are evaluated before checking if a beneficiary
meets the numerator criteria; a beneficiary who qualifies for the denominator
exclusion should be removed from the denominator.
Denominator exception criteria are only evaluated if the beneficiary does not meet
the numerator criteria; beneficiaries who do not meet numerator criteria and also
meet denominator exception criteria (e.g., medical reason for not performing a
screening) should be removed from the denominator.
• For a beneficiary to meet the depression or bipolar disorder exclusion criteria, there
must be an active diagnosis for one of these conditions documented prior to any
encounter during the measurement period. An active diagnosis for depression/bipolar
disorder in this case indicates the absence of an end date/time of the diagnosis.
Patients with active antidepressant medications listed in their medical record without
an active bipolar/depression diagnosis documented in their record should not be
excluded from this measure.
Version of Specification: Quality ID: 134 Claims and Registry Version 2.0 for 2018 Reporting
MEASURE CDF-AD: SCREENING FOR DEPRESSION AND FOLLOW-UP PLAN: AGE 18 AND OLDER
31
• The original specification for this measure included six G codes intended to capture
whether individual providers reported on this measure. For the purpose of 1115
SMI/SED demonstration reporting, there are two G codes included in the numerator to
capture whether depression screening was done and if the screen was positive,
whether a follow-up plan was documented.
• When multiple encounters that meet criteria for inclusion in the measure denominator
take place in the measurement year, the most recent eligible encounter at which the
screening took place should be used. The beneficiary should be counted in the
denominator and numerator only once based on the most recent screening
documented at the eligible encounter.
For example, if a beneficiary had a qualifying encounter in January of the
measurement year and no depression screening was performed and then had a
qualifying encounter in December of the same measurement year and had a
depression screening, the encounter during December would be used for the
measure denominator. If a beneficiary had an eligible encounter during January
with a depression screening performed and an encounter during December with
no screening performed, the January encounter would be used for the measure
denominator.
• The date of encounter and screening must occur on the same date of service.
• The screening tools listed in the measure specifications are examples of standardized
tools. However, states may use any 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.
• Include all paid, suspending, pending, and denied claims.
• The electronic specification for FFY 2019 is located on the eCQI resource center at
https://ecqi.healthit.gov/system/files/ecqm/measures/CMS2v7_1.html.
The following coding systems are used in this measure: CPT and HCPCS. Refer to the
Acknowledgments section at the beginning of the manual for copyright information.
B. DEFINITIONS
Screening
Completion of a 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.
Standardized
tool
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:
• Adult Screening Tools (age 18 and older)
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
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MEASURE CDF-AD: SCREENING FOR DEPRESSION AND FOLLOW-UP PLAN: AGE 18 AND OLDER
32
Standardized
tool
(continued)
(DADS), Geriatric Depression Scale (GDS), Cornell Scale for
Depression in Dementia (CSDD), PRIME MD-PHQ2, Hamilton Rating
Scale for Depression (HAM-D), and Quick Inventory of Depressive
Symptomatology Self-Report (QID-SR)
• Perinatal Screening Tools
Edinburgh Postnatal Depression Scale, Postpartum Depression
Screening Scale, Patient Health Questionnaire 9 (PHQ-9), Beck
Depression Inventory, Beck Depression Inventory–II, Center for
Epidemiologic Studies Depression Scale, and Zung Self-rating
Depression Scale
Follow-up
plan
Proposed outline of treatment to be conducted as a result of depression
screening. Follow-up for a positive depression screening must include
one (1) or more of the following:
• Additional evaluation for depression
• 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
Note: Pharmacologic treatment for depression is often indicated during
pregnancy and/or lactation. Review and discussion of the risks of
untreated versus treated depression is advised. Consideration of each
patient’s prior disease and treatment history, along with the risk profiles
for individual pharmacologic agents, is important when selecting
pharmacologic therapy with the greatest likelihood of treatment effect.
The documented follow-up plan must be related to positive depression
screening, for example: “Patient referred for psychiatric evaluation due to
positive depression screening.”
C. ELIGIBLE POPULATION
Age
Age 18 or older on date of encounter.
Event/diagnosis
Outpatient visit (Table CDF-A) during the measurement year.
Continuous
enrollment
None.
D. ADMINISTRATIVE SPECIFICATION
Denominator
The eligible population with an outpatient visit during the measurement year (Table CDF-A).
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MEASURE CDF-AD: SCREENING FOR DEPRESSION AND FOLLOW-UP PLAN: AGE 18 AND OLDER
33
Table CDF-A. Codes to Identify Outpatient Visits
CPT
HCPCS
59400, 59510, 59610, 59618, 90791, 90792, 90832,
90834, 90837, 92625, 96116, 96118, 96150, 96151,
97165, 97166, 97167, 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215, 99384, 99385,
99386, 99387, 99394, 99395, 99396, 99397
G0101, G0402, G0438,
G0439, G0444, G0502,
G0503, G0504, G0505,
G0507
Numerator
Beneficiaries screened for depression using a standardized tool AND, if positive, a followup plan is documented on the date of the positive screen using one of the codes in Table
CDF-B.
Table CDF-B. Codes to Document Depression Screen
Code
Description
G8431
Screening for depression is documented as being positive and a follow-up
plan is documented
G8510
Screening for depression is documented as negative, a follow-up plan is not
required
Exclusions
A beneficiary is not eligible if one or more of the following conditions are documented in the
beneficiary medical record:
•
Beneficiary has an active diagnosis of depression or bipolar disorder
Use the codes in Table CDF-C, CDF-D, and CDF-E to identify exclusions.
Table CDF-C. HCPCS Code to Identify Exclusions
Code
G9717
Description
Documentation stating the patient has an active diagnosis of depression or has
a diagnosed bipolar disorder, therefore screening or follow-up not required
Table CDF-D. ICD-10 Codes to Identify Active Diagnosis of Depression (Exclusions)
ICD-10 Code
Description
F01.51
Vascular dementia with behavioral disturbance
F32.0
Major depressive disorder, single episode, mild
F32.1
Major depressive disorder, single episode, moderate
F32.2
Major depressive disorder, single episode, severe without psychotic
features
F32.3
Major depressive disorder, single episode, severe with psychotic
features
F32.4
Major depressive disorder, single episode, in partial remission
F32.5
Major depressive disorder, single episode, in full remission
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ICD-10 Code
Description
F32.89
Other specified depressive episodes
F32.9
Major depressive disorder, single episode, unspecified
F33.0
Major depressive disorder, recurrent, mild
F33.1
Major depressive disorder, recurrent, moderate
F33.2
Major depressive disorder, recurrent severe without psychotic features
F33.3
Major depressive disorder, recurrent, severe with psychotic symptoms
F33.40
Major depressive disorder, recurrent, in remission, unspecified
F33.41
Major depressive disorder, recurrent, in partial remission
F33.42
Major depressive disorder, recurrent, in full remission
F33.8
Other recurrent depressive disorders
F33.9
Major depressive disorder, recurrent, unspecified
F34.1
Dysthymic disorder
F34.81
Disruptive mood dysregulation disorder
F34.89
Other specified persistent mood disorders
F43.21
Adjustment disorder with depressed mood
F43.23
Adjustment disorder with mixed anxiety and depressed mood
F53.0
Postpartum depression
F53.1
Puerperal psychosis
O90.6
Postpartum mood disturbance
O99.340
Other mental disorders complicating pregnancy, unspecified trimester
O99.341
Other mental disorders complicating pregnancy, first trimester
O99.342
Other mental disorders complicating pregnancy, second trimester
O99.343
Other mental disorders complicating pregnancy, third trimester
O99.345
Other mental disorders complicating the puerperium
Table CDF-E. ICD-10 Codes to Identify Diagnosed Bipolar Disorder (Exclusions)
ICD-10 Code
Description
F31.10
Bipolar disorder, current episode manic without psychotic features,
unspecified
F31.11
Bipolar disorder, current episode manic without psychotic features, mild
F31.12
Bipolar disorder, current episode manic without psychotic features,
moderate
F31.13
Bipolar disorder, current episode manic without psychotic features,
severe
F31.2
Bipolar disorder, current episode manic severe with psychotic features
F31.30
Bipolar disorder, current episode depressed, mild or moderate severity,
unspecified
F31.31
Bipolar disorder, current episode depressed, mild
F31.32
Bipolar disorder, current episode depressed, moderate
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MEASURE CDF-AD: SCREENING FOR DEPRESSION AND FOLLOW-UP PLAN: AGE 18 AND OLDER
35
ICD-10 Code
Description
F31.4
Bipolar disorder, current episode depressed, severe, without psychotic
features
F31.5
Bipolar disorder, current episode depressed, severe, with psychotic
features
F31.60
Bipolar disorder, current episode mixed, unspecified
F31.61
Bipolar disorder, current episode mixed, mild
F31.62
Bipolar disorder, current episode mixed, moderate
F31.63
Bipolar disorder, current episode mixed, severe, without psychotic
features
F31.64
Bipolar disorder, current episode mixed, severe, with psychotic features
F31.70
Bipolar disorder, currently in remission, most recent episode unspecified
F31.71
Bipolar disorder, in partial remission, most recent episode hypomanic
F31.72
Bipolar disorder, in full remission, most recent episode hypomanic
F31.73
Bipolar disorder, in partial remission, most recent episode manic
F31.74
Bipolar disorder, in full remission, most recent episode manic
F31.75
Bipolar disorder, in partial remission, most recent episode depressed
F31.76
Bipolar disorder, in full remission, most recent episode depressed
F31.77
Bipolar disorder, in partial remission, most recent episode mixed
F31.78
Bipolar disorder, in full remission, most recent episode mixed
F31.81
Bipolar II disorder
F31.89
Other bipolar disorder
F31.9
Bipolar disorder, unspecified
Exceptions
A beneficiary that does not meet the numerator criteria and meets the following exception
criteria should be excluded from the measure denominator. However, if the beneficiary
meets the numerator criteria, the beneficiary would be included in the measure
denominator.
•
Beneficiary refuses to participate
•
Beneficiary is in an urgent or emergent situation where time is of the essence and to
delay treatment would jeopardize the beneficiary’s health status
•
Situations where the beneficiary’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
Table CDF-F. HCPCS Code to Identify Exceptions
Code
Description
G8433
Screening for depression not completed, documented reason
Version of Specification: Quality ID: 134 Claims and Registry Version 2.0 for 2018 Reporting
Metric #25: Screening for Depression and Follow-Up Plan: Ages 12–17
(CDF-CH)
Measure Steward: Centers for Medicare & Medicaid Services
A. DESCRIPTION
Percentage of beneficiaries ages 12 to 17 screened for 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: Administrative or EHR
Guidance for Reporting:
• The denominator for this measure includes beneficiaries ages 12 to 17 with an
outpatient visit during the measurement year. The numerator for this measure includes
the following two groups:
8. Those beneficiaries with a positive screen for depression during an outpatient
visit using a standardized tool with a follow-up plan documented.
9. Those beneficiaries with a negative screen for depression during an outpatient
visit using a standardized tool.
• This measure can be calculated using administrative data only. Medical record review
may be used to validate the state's administrative data (for example, documentation of
the name of the standardized depression screening tool utilized). However, validation
is not required to calculate and report this measure.
• This measure contains both exclusions and exceptions:
Denominator exclusion criteria are evaluated before checking if a beneficiary
meets the numerator criteria; a beneficiary who qualifies for the denominator
exclusion should be removed from the denominator.
Denominator exception criteria are only evaluated if the beneficiary does not meet
the numerator criteria; beneficiaries who do not meet numerator criteria and also
meet denominator exception criteria (e.g., medical reason for not performing a
screening) should be removed from the denominator.
• For a beneficiary to meet the depression or bipolar disorder exclusion criteria, there
must be an active diagnosis for one of these conditions documented prior to any
encounter during the measurement period. An active diagnosis for depression/bipolar
disorder in this case indicates the absence of an end date/time of the diagnosis.
Patients with active antidepressant medications listed in their medical record without
an active bipolar/depression diagnosis documented in their record should not be
excluded from this measure.
• The original specification for this measure included six G codes intended to capture
whether individual providers reported on this measure. For the purpose of 1115
SMI/SED demonstration reporting, there are two G codes included in the numerator to
capture whether depression screening was done and if the screen was positive,
whether a follow-up plan was documented.
• When multiple encounters that meet criteria for inclusion in the measure denominator
take place in the measurement year, the most recent eligible encounter at which the
screening took place should be used. The beneficiary should be counted in the
denominator and numerator only once based on the most recent screening
documented at the eligible encounter.
For example, if a beneficiary had a qualifying encounter in January of the
measurement year and no depression screening was performed and then had a
qualifying encounter in December of the same measurement year and had a
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MEASURE CDF-CH: SCREENING FOR DEPRESSION AND FOLLOW-UP PLAN: AGES 12-17
•
•
•
•
37
depression screening, the encounter during December would be used for the
measure denominator. If a beneficiary had an eligible encounter during January
with a depression screening performed and an encounter during December with
no screening performed, the January encounter would be used for the measure
denominator.
The date of encounter and screening must occur on the same date of service.
The screening tools listed in the measure specifications are examples of standardized
tools. However, states may use any 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.
Include all paid, suspended, pending, and denied claims.
The electronic specification for FFY 2019 is located on the eCQI resource center at
https://ecqi.healthit.gov/system/files/ecqm/measures/CMS2v7_1.html.
The following coding systems are used in this measure: CPT and HCPCS. Refer to the
Acknowledgments section at the beginning of the manual for copyright information.
B. DEFINITIONS
Screening
Completion of a 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.
Standardized
tool
An assessment tool that has been appropriately normalized and validated
for the population in which it is being utilized. The name of the ageappropriate standardized depression screening tool utilized must be
documented in the medical record. Some depression screening tools are:
• Adolescent Screening Tools (12-17 years)
Patient Health Questionnaire for Adolescents (PHQ-A), Beck
Depression Inventory-Primary Care Version (BDI-PC), Mood Feeling
Questionnaire (MFQ), Center for Epidemiologic Studies Depression
Scale (CES-D), Patient Health Questionnaire (PHQ-9), Pediatric
Symptom Checklist (PSC-17), and PRIME MD-PHQ2
• Perinatal Screening Tools
Edinburgh Postnatal Depression Scale, Postpartum Depression
Screening Scale, Patient Health Questionnaire 9 (PHQ-9), Beck
Depression Inventory, Beck Depression Inventory–II, Center for
Epidemiologic Studies Depression Scale, and Zung Self-rating
Depression Scale
Follow-up
plan
Proposed outline of treatment to be conducted as a result of depression
screening. Follow-up for a positive depression screening must include
one (1) or more of the following:
• Additional evaluation for depression
• Suicide risk assessment
• Referral to a practitioner who is qualified to diagnose and treat
depression
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MEASURE CDF-CH: SCREENING FOR DEPRESSION AND FOLLOW-UP PLAN: AGES 12-17
38
• Pharmacological interventions
• Other interventions or follow-up for the diagnosis or treatment of
depression
Note: Pharmacologic treatment for depression is often indicated during
pregnancy and/or lactation. Review and discussion of the risks of
untreated versus treated depression are advised. Consideration of each
patient’s prior disease and treatment history, along with the risk profiles
for individual pharmacologic agents, is important when selecting
pharmacologic therapy with the greatest likelihood of treatment effect.
The documented follow-up plan must be related to positive depression
screening, for example: “Patient referred for psychiatric evaluation due to
positive depression screening.”
C. ELIGIBLE POPULATION
Age
Ages 12 to 17 on date of encounter.
Event/diagnosis
Outpatient visit (Table CDF-A) during the measurement year.
Continuous
enrollment
None.
D. ADMINISTRATIVE SPECIFICATION
Denominator
The eligible population with an outpatient visit during the measurement year (Table CDF-A).
Table CDF-A. Codes to Identify Outpatient Visits
CPT
HCPCS
59400, 59510, 59610, 59618, 90791, 90792, 90832,
90834, 90837, 92625, 96116, 96118, 96150, 96151,
97165, 97166, 97167, 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215, 99384, 99385,
99386, 99387, 99394, 99395, 99396, 99397
G0101, G0402, G0438,
G0439, G0444, G0502,
G0503, G0504, G0505,
G0507
Numerator
Beneficiaries screened for depression using a standardized tool AND, if positive, a followup plan is documented on the date of the positive screen using one of the codes in Table
CDF-B.
Table CDF-B. Codes to Document Depression Screen
Code
Description
G8431
Screening for depression is documented as being positive and a follow-up
plan is documented
G8510
Screening for depression is documented as negative, a follow-up plan is not
required
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MEASURE CDF-CH: SCREENING FOR DEPRESSION AND FOLLOW-UP PLAN: AGES 12-17
39
Exclusions
A beneficiary is not eligible if one or more of the following conditions are documented in the
beneficiary medical record:
•
Beneficiary has an active diagnosis of Depression or Bipolar Disorder
Use the codes in Table CDF-C, CDF-D, and CDF-E to identify exclusions.
Table CDF-C. HCPCS Code to Identify Exclusions
Code
G9717
Description
Documentation stating the patient has an active diagnosis of
depression or has a diagnosed bipolar disorder, therefore screening
or follow-up not required
Table CDF-D. ICD-10 Codes to Identify Active Diagnosis of Depression (Exclusions)
ICD-10 Code
Description
F01.51
Vascular dementia with behavioral disturbance
F32.0
Major depressive disorder, single episode, mild
F32.1
Major depressive disorder, single episode, moderate
F32.2
Major depressive disorder, single episode, severe without psychotic
features
F32.3
Major depressive disorder, single episode, severe with psychotic
features
F32.4
Major depressive disorder, single episode, in partial remission
F32.5
Major depressive disorder, single episode, in full remission
F32.89
Other specified depressive episodes
F32.9
Major depressive disorder, single episode, unspecified
F33.0
Major depressive disorder, recurrent, mild
F33.1
Major depressive disorder, recurrent, moderate
F33.2
Major depressive disorder, recurrent severe without psychotic
features
F33.3
Major depressive disorder, recurrent, severe with psychotic
symptoms
F33.40
Major depressive disorder, recurrent, in remission, unspecified
F33.41
Major depressive disorder, recurrent, in partial remission
F33.42
Major depressive disorder, recurrent, in full remission
F33.8
Other recurrent depressive disorders
F33.9
Major depressive disorder, recurrent, unspecified
F34.1
Dysthymic disorder
F34.81
Disruptive mood dysregulation disorder
F34.89
F43.21
F43.23
Other specified persistent mood disorders
Adjustment disorder with depressed mood
Adjustment disorder with mixed anxiety and depressed mood
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MEASURE CDF-CH: SCREENING FOR DEPRESSION AND FOLLOW-UP PLAN: AGES 12-17
ICD-10 Code
F53.0
F53.1
O90.6
O99.340
O99.341
O99.342
O99.343
O99.345
40
Description
Postpartum depression
Puerperal psychosis
Postpartum mood disturbance
Other mental disorders complicating pregnancy, unspecified trimester
Other mental disorders complicating pregnancy, first trimester
Other mental disorders complicating pregnancy, second trimester
Other mental disorders complicating pregnancy, third trimester
Other mental disorders complicating the puerperium
Table CDF-E. ICD-10 Codes to Identify Diagnosed Bipolar Disorder (Exclusions)
ICD-10 Code
Description
F31.10
Bipolar disorder, current episode manic without psychotic features,
unspecified
F31.11
Bipolar disorder, current episode manic without psychotic features, mild
F31.12
Bipolar disorder, current episode manic without psychotic features,
moderate
F31.13
Bipolar disorder, current episode manic without psychotic features,
severe
F31.2
Bipolar disorder, current episode manic severe with psychotic features
F31.30
Bipolar disorder, current episode depressed, mild or moderate severity,
unspecified
F31.31
Bipolar disorder, current episode depressed, mild
F31.32
Bipolar disorder, current episode depressed, moderate
F31.4
Bipolar disorder, current episode depressed, severe, without psychotic
features
F31.5
Bipolar disorder, current episode depressed, severe, with psychotic
features
F31.60
Bipolar disorder, current episode mixed, unspecified
F31.61
Bipolar disorder, current episode mixed, mild
F31.62
Bipolar disorder, current episode mixed, moderate
F31.63
Bipolar disorder, current episode mixed, severe, without psychotic
features
F31.64
Bipolar disorder, current episode mixed, severe, with psychotic features
F31.70
Bipolar disorder, currently in remission, most recent episode unspecified
F31.71
Bipolar disorder, in partial remission, most recent episode hypomanic
F31.72
Bipolar disorder, in full remission, most recent episode hypomanic
F31.73
Bipolar disorder, in partial remission, most recent episode manic
F31.74
Bipolar disorder, in full remission, most recent episode manic
F31.75
Bipolar disorder, in partial remission, most recent episode depressed
F31.76
Bipolar disorder, in full remission, most recent episode depressed
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MEASURE CDF-CH: SCREENING FOR DEPRESSION AND FOLLOW-UP PLAN: AGES 12-17
ICD-10 Code
Description
F31.77
Bipolar disorder, in partial remission, most recent episode mixed
F31.78
Bipolar disorder, in full remission, most recent episode mixed
F31.81
Bipolar II disorder
F31.89
Other bipolar disorder
F31.9
Bipolar disorder, unspecified
Exceptions
A beneficiary that does not meet the numerator criteria and meets the following exception
criteria should be excluded from the measure denominator. However, if the beneficiary
meets the numerator criteria, the beneficiary would be included in the measure
denominator.
•
Beneficiary refuses to participate
•
Beneficiary is in an urgent or emergent situation where time is of the essence and to
delay treatment would jeopardize the beneficiary’s health status
•
Situations where the beneficiary’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
Table CDF-F. HCPCS Code to Identify Exceptions
Code
Description
G8433
Screening for depression not completed, documented reason
Version of Specification: Quality ID: 134 Claims and Registry Version 2.0 for 2018 Reporting
41
Metric #31: Use of Multiple Concurrent Antipsychotics in Children and
Adolescents (APC-CH)
Measure Steward: National Committee for Quality Assurance
A. DESCRIPTION
Percentage of children and adolescents ages 1 to 17 who were treated with antipsychotic
medications and who were on two or more concurrent antipsychotic medications for at least
90 consecutive days during the measurement year.
Note: A lower rate indicates better performance.
Data Collection Method: Administrative
Guidance for Reporting:
• This measure was developed by the National Collaborative for Innovation in Quality
Measurement, and has been included in HEDIS® since 2017. More information about
this measure and six other measures developed for assessing safe and judicious use
of antipsychotic medications in children and adolescents is available at
http://www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/chipra_1
415-p011-1-ef_0.pdf.
• To be eligible for this measure, beneficiaries must have at least 90 days of continuous
antipsychotic medication treatment during the measurement year. Continuous
treatment can include different medications; however, first-time prescriptions for a
beneficiary must be dispensed prior to October 3 to meet the eligibility criteria as
described in Step 5 of the Denominator Specifications.
• Supplemental data may not be used for this measure.
• Include all paid, suspended, and pending claims when identifying the eligible
population. Do not include denied claims when identifying the eligible population or
assessing the numerator for this measure.
• Beneficiaries in hospice are excluded from the eligible population. For additional
information, refer to the hospice exclusion guidance in Section I. Measure Element
Definitions.
• NCQA’s Medication List Directory (MLD) of NDC codes for Antipsychotic Medications
can be found at https://www.ncqa.org/hedis/measures/hedis-2019-ndclicense/hedis2019-final-ndc-lists/.
The following coding system is used in this measure: CPT, HCPCS, NDC, and UB. Refer to
the Acknowledgments section at the beginning of the manual for copyright information.
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MEASURE APC-CH: USE OF MULTIPLE CONCURRENT ANTIPSYCHOTICS IN CHILDREN AND ADOLESCENTS
43
B. ELIGIBLE POPULATION
Age
Continuous
enrollment
Allowable gap
Anchor date
Benefit
Event/diagnosis
Ages 1 to 17 as of December 31 of the measurement year.
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 beneficiary for whom enrollment is verified monthly, the
beneficiary may not have more than a 1-month gap in coverage
(i.e., a beneficiary whose coverage lapses for 2 months [60 days] is
not considered continuously enrolled).
December 31 of the measurement year.
Medical and pharmacy.
Beneficiaries with 90 days of continuous antipsychotic medication
treatment during the measurement year. Use the steps below to
determine the eligible population.
Step 1
Identify beneficiaries in the specified age range who were
dispensed an antipsychotic medication (Antipsychotic Medications
List, see link to Medication List Directory in Guidance for Reporting
above) during the measurement year.
Step 2
Calculate continuous enrollment. The beneficiary must be
continuously enrolled during the measurement year.
Step 3
For each beneficiary, identify all antipsychotic medication
dispensing events during the measurement year.
Step 4
Identify start and end dates for drug events. Drug events are
defined separately by drug using the Drug ID field in the Medication
List Directory (MLD) of NDC codes, see link to Medication List
Directory in Guidance for Reporting above.
For each drug ID, sort dispensing events chronologically by
dispense date. If there is more than one prescription for the same
medication dispensed on the same day, use only the prescription
with the longest days supply in the calculation.
Starting with the first prescription in the measurement year determine if there is a second dispense date with the same Drug ID.
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MEASURE APC-CH: USE OF MULTIPLE CONCURRENT ANTIPSYCHOTICS IN CHILDREN AND ADOLESCENTS
Event/diagnosis
(continued)
44
If there is no second dispensing event with the same Drug ID,
the start date is the first prescription’s dispense date and the
end date is the start date plus the days supply minus one. For
example, a January 1 prescription with a 30 days supply has an
end date of January 30.
• If there is a second dispensing event with the same Drug ID,
determine if there are gap days (a gap of up to 32 days is
allowed). Calculate the number of days between (but not
including) the first prescription’s dispense date and the second
prescription’s dispense date. If the number of days is less than
or equal to the first prescription’s days supply plus 32 days, the
gap is less than or equal to 32 days and is allowed. The start
date is the first prescription’s dispense date and the end date is
the second prescription’s dispense date plus days supply minus
one. Continue assessing all subsequent dispensing events with
allowable gaps for the same Drug ID and adjust end dates as
needed.
- For example, a beneficiary has two dispensing events with
the same Drug ID. The first is on July 1, with a 30 days
supply. The second is on September 1, with a 30 days
supply. The number of days between (but not including) the
dispense dates is 61 (July 2–August 31). The gap is
allowed because 61 is less than the first prescription’s days
supply plus 32 days (30 + 32 = 62). The start date is July 1
and the end date is September 30.
• If there is a second dispensing event with the same Drug ID
and there is a gap that exceeds the allowable gap, assign an
end date for this drug event and follow the beginning of step 4
for the remaining dispensing events. A beneficiary can have
multiple start and end dates per Drug ID during the
measurement year.
Continue assessing each dispensed prescription for each Drug ID
until all dispensing events are exhausted. If a dispensing event
goes beyond December 31 of the measurement year, assign the
end date as December 31.
Step 5
For each beneficiary, identify those with ≥90 consecutive treatment
days.
For each beneficiary, using the start and end dates from all drug
events identified in step 4 (which may include events for the same
or different medications and may include events with allowable
gaps), determine all calendar days covered by at least one
antipsychotic medication. If there were ≥90 consecutive calendar
days, include the beneficiary in the measure.
•
C. ADMINISTRATIVE SPECIFICATION
Denominator
The eligible population as defined above.
Version of Specification: Quality ID: 134 Claims and Registry Version 2.0 for 2018 Reporting
MEASURE APC-CH: USE OF MULTIPLE CONCURRENT ANTIPSYCHOTICS IN CHILDREN AND ADOLESCENTS
45
Numerator
Beneficiaries on two or more concurrent antipsychotic medications for at least 90
consecutive days during the measurement year. Do not include denied claims.
Use the steps below to determine the numerator.
Step 1
For each beneficiary, identify Drug ID, identify all drug events identified in step 4 of the
event/diagnosis criteria (used to identify the eligible population [denominator]). Exclude
denied claims and recalculate start dates and end dates (using steps 1-4 of the
event/diagnosis criteria used to identify the eligible population [denominator]).
Step 2
Identify concurrent antipsychotic medication treatment events as follows:
•
For each beneficiary, identify the first day during the measurement year when the
beneficiary was treated with two or more different antipsychotic medications (use the
Drug ID to identify different drugs, see link to Medication List Directory in Guidance for
Reporting above). This is the concurrent antipsychotic medication treatment event start
date.
•
Beginning with (and including) the start date, identify the number of consecutive days
the beneficiary remains on two or more different antipsychotic medications. If the
number of days is ≥90 days, the beneficiary is numerator compliant.
•
If the number of consecutive days on multiple antipsychotic medications is <90 days,
identify the end date and identify the next day during the measurement year when the
beneficiary was treated with two or more different antipsychotic medications. If the
number of days between the end date and the next start date is ≤15 days, include the
days in the concurrent antipsychotic medication treatment event (concurrent
antipsychotic medication treatment events allow a gap of up to 15 days).
•
If the number of days between the end date and the next start date exceeds 15 days,
end the event; using the new start date, continue to assess for concurrent antipsychotic
medication treatment events.
•
Continue this process until the number of concurrent antipsychotic medication treatment
days is ≥90 consecutive days (i.e., the beneficiary is numerator compliant) or until the
measurement year is exhausted (i.e., no concurrent antipsychotic medication treatment
events were identified during the measurement year).
Version of Specification: Quality ID: 134 Claims and Registry Version 2.0 for 2018 Reporting
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APPENDIX E
STANDARDIZED DEFINITION OF SMI
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APPENDIX E
MATHEMATICA
We refer to the National Committee for Quality Assurance (NCQA) definition of SMI as the
standardized definition of SMI. NCQA defines individuals with SMI as those who meet at
least one of the following criteria within the measurement period:
•
At least one inpatient visit or two outpatient visits for schizophrenia OR
-
Schizophrenia is defined in the Schizophrenia value set (2019 Value Sets to Codes sheet,
column D, rows471-542)
-
Inpatient visits are defined in
o BH Stand Alone Acute Inpatient Value Set or (2016 Value Sets to Codes sheet,
column D, rows 137-194)
o BH Acute Inpatient Value Set (2016 Value Sets to Codes sheet, column D, rows 235) with BH Acute Inpatient POS Value Set (2016 Value Sets to Codes sheet,
column D, rows 36-37)
-
Outpatient visits are in defined in:
o BH Stand Alone Outpatient/PH/IOP Value Set (2016 Value Sets to Codes sheet,
column D, rows 245-356) or
o BH Outpatient/PH/IOP Value Set (2016 Value Sets to Codes sheet, column D, rows
84-117) with BH Outpatient/PH/IOP POS Value Set (2016 Value Sets to Codes
sheet, column D, rows 118-136) or
o ED Value Set (2019 Value Sets to Codes sheet, column D, rows 1197-1207) or
o BH ED Value Set (2016 Value Sets to Codes sheet, column D, rows 38-58) with BH
ED POS Value Set or (2016 Value Sets to Codes sheet, column D, rows 59)
o BH Stand Alone Nonacute Inpatient Value Set (2016 Value Sets to Codes sheet,
column D, rows 195-244) or
o BH Nonacute Inpatient Value Set (2016 Value Sets to Codes sheet, column D, rows
60-80) with BH Nonacute Inpatient POS Value Set (2016 Value Sets to Codes sheet,
column D, rows 81-83)
•
At least one inpatient or two outpatient visits for bipolar I disorder, OR
-
Bipolar Disorder is defined in the Bipolar Disorder value set (2016 Value Sets to Codes
sheet, column D, rows 378-426) OR Other Bipolar Disorder (2016 Value Sets to Codes
sheet, column D, rows 464-470)
-
Inpatient visits are defined in
o BH Stand Alone Acute Inpatient Value Set (2016 Value Sets to Codes sheet, column
D, rows 137-194) or
o BH Acute Inpatient Value Set (2016 Value Sets to Codes sheet, column D, rows 235) with BH Acute Inpatient POS Value Set (2016 Value Sets to Codes sheet,
column D, rows 36-37)
-
Outpatient visits are in defined in:
o BH Stand Alone Outpatient/PH/IOP Value Set (2016 Value Sets to Codes sheet,
column D, rows 245-356) or
E.3
APPENDIX E
MATHEMATICA
o BH Outpatient/PH/IOP Value Set (2016 Value Sets to Codes sheet, column D, rows
84-117) with BH Outpatient/PH/IOP POS Value Set (2016 Value Sets to Codes
sheet, column D, rows 118-136) or
o ED Value Set (2019 Value Sets to Codes sheet, column D, rows 1197-1207) or
o BH ED Value Set (2016 Value Sets to Codes sheet, column D, rows 38-58) with BH
ED POS Value Set (2016 Value Sets to Codes sheet, column D, row 59) or
o BH Stand Alone Nonacute Inpatient Value Set (2016 Value Sets to Codes sheet,
column D, rows 195-244) or
o BH Nonacute Inpatient Value Set (2016 Value Sets to Codes sheet, column D, rows
60-80) with BH Nonacute Inpatient POS Value Set (2016 Value Sets to Codes sheet,
column D, rows 81-83)
•
At least one inpatient visit for major depression
-
Major Depression is defined in the Major Depression value set (2016 Value Sets to
Codes sheet, column D, rows 438-463)
-
Inpatient visits are defined in
o BH Stand Alone Acute Inpatient Value Set (2016 Value Sets to Codes sheet, column
D, rows 137-194) or
o BH Acute Inpatient Value Set (2016 Value Sets to Codes sheet, column D, rows 235) with BH Acute Inpatient POS Value Set (2016 Value Sets to Codes sheet,
column D, rows 36-37)
E.4
APPENDIX F
ALOS STANDARD DEVIATIONS
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APPENDIX F
MATHEMATICA
For Metric #19, the state’s goal should be to decrease the average length of stay in
participating psychiatric hospitals and residential settings to achieve an overall demonstration
target of no more than 30 days. If requested by CMS at the midpoint assessment, states may be
required to provide the standard deviation based on the mean in Metric #19.
States should review the distribution of the lengths of stay data to assess normality of the
data. If the length of stay data are skewed, states should determine if data transformation is
appropriate. Table F.1 provides example transformation methods states may consider for skewed
data. For example, a state with substantial right-skewed data may consider using log
transformation to calculate the standard deviation. States should assess the normalization of the
transformed data before proceeding to the standard deviation calculation.
Table F.1. Data distribution and transformation methods
Data Distribution
Transformation Methods
Moderate positive skew
Square root
Substantial positive skewa
Logarithmic (Log 10)
Moderate negative skew
Reflect and Square root
Substantial negative
skewa
Reflect and Logarithmic (Log 10)
a
Substantial skewness can be assessed using the rule of thumb of -1 to 1 amplitude.
Source: Tabachnick, B. G., & Fidell, L. S. (2007). Using multivariate statistics (5th ed.). Boston: Allyn
and Bacon.
After reviewing the data’s skewness and transforming the data, as appropriate, states should
calculate the standard deviation of the data. Standard deviation can be calculated as:
=
( X − )
2
n
= population standard deviation
= sum of
= population mean
n = number scores in the sample
As requested by CMS at the midpoint assessment, states should provide CMS with the
information in Table F.2.
F.3
APPENDIX F
MATHEMATICA
Table F.2. State data for average length of stay and standard deviation
Data type
Description of data
Data Transformation Used (if any)
Average Length of Stay
(transformed, if applying data
transformation methods)
Standard Deviation
(transformed, if applying data
transformation methods)
State data
E.g., normal, right skewed, left skewed, outliers present
E.g., log 10 transformation
If not transforming data, use value from metric #19.
F.4
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| File Type | application/pdf |
| File Title | Section 1115 Serious Mental Illness and Serious Emotional Disturbance Demonstrations Monitoring Metrics Technical Specifications |
| Subject | Serious Mental Illness, SMI, Severe Emotional Disturbance, SED, monitoring, metrics, section 1115" |
| Author | Centers for Medicare & Medicaid Services |
| File Modified | 2020-04-21 |
| File Created | 2020-01-30 |