M1-100: Initiation and Engagement of Alcohol and Other ...
DSRIP Category CMeasure Specifications: DY7-8Part 4 of 4: Community Mental Health Center SpecificationsContents TOC \o "1-3" \h \z \u M1-100: Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (IET) PAGEREF _Toc504413563 \h 3M1-103: Controlling High Blood Pressure PAGEREF _Toc504413564 \h 7M1-105: Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention PAGEREF _Toc504413565 \h 12M1-115: Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) PAGEREF _Toc504413566 \h 18M1-124: Medication Reconciliation Post-Discharge PAGEREF _Toc504413567 \h 23M1-125: Antidepressant Medication Management (AMM-AD) PAGEREF _Toc504413568 \h 25M1-146: Screening for Clinical Depression and Follow-Up Plan (CDF-AD) PAGEREF _Toc504413569 \h 29M1-147: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up PAGEREF _Toc504413570 \h 34M1-160: Follow-Up After Hospitalization for Mental Illness PAGEREF _Toc504413571 \h 40M1-165: Depression Remission at Twelve Months PAGEREF _Toc504413572 \h 43M1-180: Adherence to Antipsychotics for Individuals with Schizophrenia (SAA-AD) PAGEREF _Toc504413573 \h 48M1-181: Depression Response at Twelve Months- Progress Towards Remission PAGEREF _Toc504413574 \h 53M1-182: Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (SSD-AD) PAGEREF _Toc504413575 \h 57M1-203: Hepatitis C: One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk PAGEREF _Toc504413576 \h 64M1-205: Third next available appointment PAGEREF _Toc504413577 \h 67M1-207: Diabetes care: BP control (<140/90mm Hg) PAGEREF _Toc504413578 \h 70M1-210: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented PAGEREF _Toc504413579 \h 74M1-211: Weight Assessment and Counseling for Nutrition and Physical Activity for Children/ Adolescents PAGEREF _Toc504413580 \h 82M1-216: Risk Adjusted Behavioral Health/ Substance Abuse 30-Day Readmission Rate PAGEREF _Toc504413581 \h 87M1-241: Decrease in mental health admissions and readmissions to criminal justice settings such as jails or prisons PAGEREF _Toc504413582 \h 89M1-255: Follow-up Care for Children Prescribed ADHD Medication (ADD) PAGEREF _Toc504413583 \h 91M1-256: Initiation of Depression Treatment PAGEREF _Toc504413584 \h 98M1-257: Care Planning for Dual Diagnosis PAGEREF _Toc504413585 \h 100M1-259: Assignment of Primary Care Physician to Individuals with Schizophrenia PAGEREF _Toc504413586 \h 102M1-260: Annual Physical Exam for Persons with Mental Illness PAGEREF _Toc504413587 \h 104M1-261: Assessment for Substance Abuse Problems of Psychiatric Patients PAGEREF _Toc504413588 \h 106M1-262: Assessment of Risk to Self/ Others PAGEREF _Toc504413589 \h 108M1-263: Assessment for Psychosocial Issues of Psychiatric Patients PAGEREF _Toc504413590 \h 110M1-264: Vocational Rehabilitation for Schizophrenia PAGEREF _Toc504413591 \h 112M1-265: Housing Assessment for Individuals with Schizophrenia PAGEREF _Toc504413592 \h 114M1-266: Independent Living Skills Assessment for Individuals with Schizophrenia PAGEREF _Toc504413593 \h 116M1-280: Chlamydia Screening in Women (CHL) PAGEREF _Toc504413594 \h 118M1-286: Depression Remission at Six Months PAGEREF _Toc504413595 \h 123M1-287: Documentation of Current Medications in the Medical Record PAGEREF _Toc504413596 \h 126M1-305: Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment (SRA-CH) PAGEREF _Toc504413597 \h 129M1-306: Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP-CH)* PAGEREF _Toc504413598 \h 132M1-317: Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling PAGEREF _Toc504413599 \h 137M1-319: Adult Major Depressive Disorder (MDD): Suicide Risk Assessment (eMeasure) PAGEREF _Toc504413600 \h 140M1-339: Alcohol & Other Drug Use Disorder Treatment Provided or Offered at Discharge SUB-3 / Alcohol and Other Drug Use Disorder Treatment at Discharge SUB-3a PAGEREF _Toc504413601 \h 144M1-340: Substance use disorders: Percentage of patients aged 18 years and older with a diagnosis of current opioid addiction who were counseled regarding psychosocial AND pharmacologic treatment options for opioid addiction within the 12 month reporting period PAGEREF _Toc504413602 \h 156M1-341: Substance use disorders: Percentage of patients aged 18 years and older with a diagnosis of current alcohol dependence who were counseled regarding psychosocial AND pharmacologic treatment options for alcohol dependence within the 12 month reporting period PAGEREF _Toc504413603 \h 158M1-342: Time to Initial Evaluation: Evaluation within 10 Business Days PAGEREF _Toc504413604 \h 160M1-385: Assessment of Functional Status or QoL (Modified from NQF# 0260/2624) PAGEREF _Toc504413605 \h 163M1-386: Improvement in Functional Status or QoL (Modified from PQRS #435) PAGEREF _Toc504413606 \h 165M1-387: Reduce Emergency Department visits for Behavioral Health and Substance Abuse (Reported as two rates) PAGEREF _Toc504413607 \h 167M1-390: Time to Initial Evaluation: Mean Days to Evaluation PAGEREF _Toc504413608 \h 169M1-400: Tobacco Use and Help with Quitting Among Adolescents PAGEREF _Toc504413609 \h 172M1-405: Bipolar Disorder and Major Depression: Appraisal for alcohol or chemical substance use PAGEREF _Toc504413610 \h 174M1-100: Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (IET)Measure Description:Percentage of patients 13 years of age and older with a new episode of alcohol and other drug (AOD) dependence who received the following. Two rates are reported. a. Percentage of patients who initiated treatment within 14 days of the diagnosis.b. Percentage of patients who initiated treatment and who had two or more additional services with an AOD diagnosis within 30 days of the initiation visit.M1-100: Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (IET)DY7/DY8 Program IDM1-100Measure DetailsSteward: NCQANQF #: 0004Source: eMeasure: SourceE.H.R.Required StatusOptionalMeasure ClassificationType: Clinical OutcomeMeasure Parts: 2Achievement CalculationsCategory: P4PGoal Calculation: QISMCHPL: Initiation: 0.4628Engagement: 0.1695MPL: Initiation: 0.3439Engagement: 0.0692National Quality Compass 2016 - All LOBs: Average (90th and 25th percentiles)Directionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionPatients age 13 years of age and older who were diagnosed with a new episode of alcohol or drug dependency during a visit in the first 11 months of the measurement period. Exclusions: Patients with a previous active diagnosis of alcohol or drug dependence in the 60 days prior to the first episode of alcohol or drug dependence. Exclude patients who were in hospice care during the measurement year.Denominator InclusionsAND: Age>= 13 year(s) at: "Measurement Period" AND: $FirstAlcoholDrugDependenceDxDenominator ExclusionsOR: "Diagnosis: Alcohol and Drug Dependence" <= 60 day(s) starts before start of $FirstAlcoholDrugDependenceDx OR: "Encounter, Performed: Encounter Inpatient (discharge status: Discharged to Home for Hospice Care)" ends during "Measurement Period" OR: "Encounter, Performed: Encounter Inpatient (discharge status: Discharged to Health Care Facility for Hospice Care)" ends during "Measurement Period" OR: Union of: "Intervention, Order: Hospice care ambulatory" "Intervention, Performed: Hospice care ambulatory" overlaps "Measurement Period"Numerator DescriptionRate 1: Patients who initiated treatment within 14 days of the diagnosis Rate 2: Patients who initiated treatment and who had two or more additional services with an AOD diagnosis within 30 days of the initiation visitNumerator Inclusions (Performance Met)Population Criteria 1: AND: $DrugDependenceTreatmentOrPsychVisit Population Critieria 2: AND: Occurrence A of $DrugDependenceTreatmentOrPsychVisit AND: Count>= 2 : Union of: "Encounter, Performed: Alcohol and Drug Dependence Treatment" "Encounter, Performed: Psych Visit - Psychotherapy" <= 30 day(s) starts after start of Occurrence A of $DrugDependenceTreatmentOrPsychVisitNumerator Exclusions (Performance Not Met)NoneDSRIP Specific ModificationsNoneAdditional InformationGuidance:The new episode of alcohol and other drug dependence should be the first episode of the measurement period that is not preceded in the 60 days prior by another episode of alcohol or other drug dependence. Data Criteria (QDM Variables)? $DrugDependenceTreatmentOrPsychVisit = o Union of: "Encounter, Performed: Alcohol and Drug Dependence Treatment" "Encounter, Performed: Psych Visit - Psychotherapy" <= 14 day(s) starts after start of $FirstAlcoholDrugDependenceDx? $FirstAlcoholDrugDependenceDx = o First: "Diagnosis: Alcohol and Drug Dependence" satisfies all: < 319 day(s) starts after start of "Measurement Period" starts during (Union of: "Encounter, Performed: Office Visit" "Encounter, Performed: Emergency Department Visit" "Encounter, Performed: Detoxification Visit" "Encounter, Performed: Hospital Observation Care - Initial" "Encounter, Performed: Hospital Inpatient Visit - Initial" "Encounter, Performed: Discharge Services - Hospital Inpatient Same Day Discharge" "Encounter, Performed: Discharge Services - Hospital Inpatient" "Encounter, Performed: Face-to-Face Interaction" during "Measurement Period" )Data Criteria (QDM Data Elements):? "Diagnosis: Alcohol and Drug Dependence" using "Alcohol and Drug Dependence Grouping Value Set (2.16.840.1.113883.3.464.1003.106.12.1001)"? "Encounter, Performed: Alcohol and Drug Dependence Treatment" using "Alcohol and Drug Dependence Treatment Grouping Value Set (2.16.840.1.113883.3.464.1003.106.12.1005)"? "Encounter, Performed: Detoxification Visit" using "Detoxification Visit Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1059)"? "Encounter, Performed: Discharge Services - Hospital Inpatient" using "Discharge Services - Hospital Inpatient Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1007)"? "Encounter, Performed: Discharge Services - Hospital Inpatient Same Day Discharge" using "Discharge Services - Hospital Inpatient Same Day Discharge Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1006)"? "Encounter, Performed: Emergency Department Visit" using "Emergency Department Visit Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1010)"? "Encounter, Performed: Encounter Inpatient" using "Encounter Inpatient SNOMEDCT Value Set (2.16.840.1.113883.3.666.5.307)"? "Encounter, Performed: Face-to-Face Interaction" using "Face-to-Face Interaction Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1048)"? "Encounter, Performed: Hospital Inpatient Visit - Initial" using "Hospital Inpatient Visit - Initial Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1004)"? "Encounter, Performed: Hospital Observation Care - Initial" using "Hospital Observation Care - Initial Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1002)"? "Encounter, Performed: Office Visit" using "Office Visit Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1001)"? "Encounter, Performed: Psych Visit - Psychotherapy" using "Psych Visit - Psychotherapy Grouping Value Set (2.16.840.1.113883.3.526.3.1496)"? "Intervention, Order: Hospice care ambulatory" using "Hospice care ambulatory SNOMEDCT Value Set (2.16.840.1.113762.1.4.1108.15)"? "Intervention, Performed: Hospice care ambulatory" using "Hospice care ambulatory SNOMEDCT Value Set (2.16.840.1.113762.1.4.1108.15)"? Attribute: "Discharge status: Discharged to Health Care Facility for Hospice Care" using "Discharged to Health Care Facility for Hospice Care SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.207)"? Attribute: "Discharge status: Discharged to Home for Hospice Care" using "Discharged to Home for Hospice Care SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.209)"M1-103: Controlling High Blood PressureMeasure Description:The percentage of Consumers 18 to 85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled (<140/90) during the measurement year.M1-103: Controlling High Blood PressureDY7/DY8 Program IDM1-103Measure DetailsSteward: NCQANQF #: 0018Source: CMS MIPS #236 (Claims/Registry) eMeasure: SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusOptionalMeasure ClassificationType: Clinical OutcomeMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: QISMCHPL: 0.7041MPL: 0.4687National Quality Compass 2016 - All LOBs: Average (90th and 25th percentiles)Directionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsMeasure is NOT eligible for a shortened baseline measurement period.Measure is not eligible for a baseline of 0.Denominator DescriptionConsumers 18-85 years of age who had a diagnosis of essential hypertension within the first six months of the measurement period or any time prior to the measurement periodDenominator InclusionsCLAIMS/REGISTRY:Consumers 18 to 85 years of age on date of encounterANDDiagnosis for hypertension (ICD-10-CM): I10ANDConsumer encounter during performance period (CPT or HCPCS): 99201, 99202, 99203, 99204, 99205,99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0402, G0438, G0439 E.H.R.: AND: Age>= 18 year(s) at: "Measurement Period" AND: Age< 85 year(s) at: "Measurement Period" AND: "Occurrence A of Diagnosis: Essential Hypertension" satisfies any: < 6 month(s) starts after or concurrent with start of "Measurement Period" satisfies all: starts before start of "Measurement Period" overlaps "Measurement Period" AND: Union of: "Encounter, Performed: Office Visit" "Encounter, Performed: Face-to-Face Interaction" "Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up" "Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up" "Encounter, Performed: Home Healthcare Services" "Encounter, Performed: Annual Wellness Visit" during "Measurement Period"Denominator ExclusionsCLAIMS/REGISTRY:Hospice services given to Consumer any time during the measurement period: G9740ORDocumentation of end stage renal disease (ESRD), dialysis, renal transplant before or during the measurement period or pregnancy during the measurement period: G9231 E.H.R.: OR: "Encounter, Performed: Encounter Inpatient (discharge status: Discharged to Home for Hospice Care)" ends during "Measurement Period" OR: "Encounter, Performed: Encounter Inpatient (discharge status: Discharged to Health Care Facility for Hospice Care)" ends during "Measurement Period" OR: Union of: "Intervention, Order: Hospice care ambulatory" "Intervention, Performed: Hospice care ambulatory" overlaps "Measurement Period" OR: Union of: "Diagnosis: Pregnancy" "Diagnosis: End Stage Renal Disease" "Diagnosis: Chronic Kidney Disease, Stage 5" overlaps "Measurement Period" OR: Union of: "Procedure, Performed: Vascular Access for Dialysis" "Encounter, Performed: ESRD Monthly Outpatient Services" "Procedure, Performed: Kidney Transplant" "Procedure, Performed: Dialysis Services" starts before end of "Measurement Period"Numerator DescriptionConsumers whose blood pressure at the most recent visit is adequately controlled (systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg) during the measurement period Numerator Instructions: To describe both systolic and diastolic blood pressure values, each must be reported separately. If there are multiple blood pressures on the same date of service, use the lowest systolic and lowest diastolic blood pressure on that date as the representative blood pressure. NUMERATOR NOTE: In reference to the numerator element, only blood pressure readings performed by an eligible clinician in the provider office are acceptable for numerator compliance with this measure. Blood pressure readings from the Consumer's home (including readings directly from monitoring devices) are not acceptable.If no blood pressure is recorded during the measurement period, the Consumer's blood pressure is assumed "not controlled."If there are multiple blood pressure readings on the same day, use the lowest systolic and the lowest diastolic reading as the most recent blood pressure reading.Numerator Inclusions (Performance Met)CLAIMS/REGISTRY:Most recent systolic blood pressure < 140 mmHg (G8752)ANDMost recent diastolic blood pressure < 90 mmHg (G8754) E.H.R.: AND: Most Recent: "Occurrence A of Encounter, Performed: Adult Outpatient Visit" satisfies all: during "Measurement Period" overlaps "Physical Exam, Performed: Diastolic Blood Pressure (result)" overlaps "Physical Exam, Performed: Systolic Blood Pressure (result)" overlaps "Occurrence A of Diagnosis: Essential Hypertension" AND: "Occurrence A of Diagnosis: Essential Hypertension" satisfies all: starts before start of "Occurrence A of Encounter, Performed: Adult Outpatient Visit" overlaps "Occurrence A of Encounter, Performed: Adult Outpatient Visit" AND: "Physical Exam, Performed: Diastolic Blood Pressure" satisfies all: Most Recent: during "Occurrence A of Encounter, Performed: Adult Outpatient Visit" (result < 90 mmHg) AND: "Physical Exam, Performed: Systolic Blood Pressure" satisfies all: Most Recent: during "Occurrence A of Encounter, Performed: Adult Outpatient Visit" (result < 140 mmHg)Numerator Exclusions (Performance Not Met)CLAIMS/REGISTRY:Most recent systolic blood pressure ≥ 140 mmHg (G8753)ORMost recent diastolic blood pressure ≥ 90 mmHg (G8755)ORNo documentation of blood pressure measurement, reason not given (G8756) E.H.R.:NoneDSRIP Specific ModificationsFor DSRIP reporting purposes, HHSC replaced the word "Consumers" with "consumers"Additional InformationMeasure is a clinic-reported measure for Certified Community Behavioral Health Clinics (CCBHCs) as part of the Demonstration Program to Improve Community Mental Health Services, found in Section 223 of the federal Protecting Access to Medicare Act of 2014 (PAMA). For DSRIP reporting purposes, measure has been specified using a source specified at the clinic level. E.H.R.Data Criteria (QDM Data Elements):? "Diagnosis: Chronic Kidney Disease, Stage 5" using "Chronic Kidney Disease, Stage 5 Grouping Value Set (2.16.840.1.113883.3.526.3.1002)"? "Diagnosis: End Stage Renal Disease" using "End Stage Renal Disease Grouping Value Set (2.16.840.1.113883.3.526.3.353)"? "Diagnosis: Essential Hypertension" using "Essential Hypertension Grouping Value Set (2.16.840.1.113883.3.464.1003.104.12.1011)"? "Diagnosis: Pregnancy" using "Pregnancy Grouping Value Set (2.16.840.1.113883.3.526.3.378)"? "Encounter, Performed: Adult Outpatient Visit" using "Adult Outpatient Visit Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1065)"? "Encounter, Performed: Annual Wellness Visit" using "Annual Wellness Visit Grouping Value Set (2.16.840.1.113883.3.526.3.1240)"? "Encounter, Performed: Encounter Inpatient" using "Encounter Inpatient SNOMEDCT Value Set (2.16.840.1.113883.3.666.5.307)"? "Encounter, Performed: ESRD Monthly Outpatient Services" using "ESRD Monthly Outpatient Services Grouping Value Set (2.16.840.1.113883.3.464.1003.109.12.1014)"? "Encounter, Performed: Face-to-Face Interaction" using "Face-to-Face Interaction Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1048)"? "Encounter, Performed: Home Healthcare Services" using "Home Healthcare Services Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1016)"? "Encounter, Performed: Office Visit" using "Office Visit Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1001)"? "Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up" using "Preventive Care Services - Established Office Visit, 18 and Up Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1025)"? "Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up" using "Preventive Care Services-Initial Office Visit, 18 and Up Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1023)"? "Intervention, Order: Hospice care ambulatory" using "Hospice care ambulatory SNOMEDCT Value Set (2.16.840.1.113762.1.4.1108.15)"? "Intervention, Performed: Hospice care ambulatory" using "Hospice care ambulatory SNOMEDCT Value Set (2.16.840.1.113762.1.4.1108.15)"? "Physical Exam, Performed: Diastolic Blood Pressure" using "Diastolic Blood Pressure Grouping Value Set (2.16.840.1.113883.3.526.3.1033)"? "Physical Exam, Performed: Systolic Blood Pressure" using "Systolic Blood Pressure Grouping Value Set (2.16.840.1.113883.3.526.3.1032)"? "Procedure, Performed: Dialysis Services" using "Dialysis Services Grouping Value Set (2.16.840.1.113883.3.464.1003.109.12.1013)"? "Procedure, Performed: Kidney Transplant" using "Kidney Transplant Grouping Value Set (2.16.840.1.113883.3.464.1003.109.12.1012)"? "Procedure, Performed: Vascular Access for Dialysis" using "Vascular Access for Dialysis Grouping Value Set (2.16.840.1.113883.3.464.1003.109.12.1011)"? Attribute: "Discharge status: Discharged to Health Care Facility for Hospice Care" using "Discharged to Health Care Facility for Hospice Care SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.207)"? Attribute: "Discharge status: Discharged to Home for Hospice Care" using "Discharged to Home for Hospice Care SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.209)"M1-105: Preventive Care & Screening: Tobacco Use: Screening & Cessation InterventionMeasure Description:Percentage of Consumers aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco userM1-105: Preventive Care & Screening: Tobacco Use: Screening & Cessation InterventionDY7/DY8 Program IDM1-105Measure DetailsSteward: NCQANQF #: 0028Source: CMS MIPS #226 (Claims/Registry) eMeasure: SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusOptionalMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionAll Consumers aged 18 years and olderDENOMINATOR NOTE: *Signifies that this CPT Category I code is a non-covered service under the PFS (Physician Fee Schedule). These non-covered services will not be counted in the denominator population for claims-based measures.Denominator InclusionsCLAIMS/REGISTRY:Consumers aged ≥ 18 years on date of encounter AND Consumer encounter during the performance period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 90845, 92002, 92004, 92012, 92014, 92521, 92522, 92523, 92524, 92540, 92557, 92625, 96150, 96151, 96152, 96160, 96161 97165, 97166, 97167, 97168, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99385*, 99386*, 99387*, 99395*, 99396*, 99397*, 99401*, 99402*, 99403*, 99404*, 99406, 99407, 99411*, 99412*, 99429*, G0438, G0439 WITHOUT Telehealth Modifier: GQ, GT E.H.R.:Initial Population = AND: Age>= 18 year(s) at: "Measurement Period" AND: OR: Count>= 2 : Union of: "Encounter, Performed: Face-to-Face Interaction" "Encounter, Performed: Health & Behavioral Assessment - Individual" "Encounter, Performed: Health and Behavioral Assessment - Initial" "Encounter, Performed: Health and Behavioral Assessment, Reassessment" "Encounter, Performed: Home Healthcare Services" "Encounter, Performed: Occupational Therapy Evaluation" "Encounter, Performed: Office Visit" "Encounter, Performed: Ophthalmological Services" "Encounter, Performed: Psych Visit - Diagnostic Evaluation" "Encounter, Performed: Psych Visit - Psychotherapy" "Encounter, Performed: Psychoanalysis" "Encounter, Performed: Speech and Hearing Evaluation" during "Measurement Period" OR: Count>= 1 : Union of: "Encounter, Performed: Annual Wellness Visit" "Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up" "Encounter, Performed: Preventive Care Services - Group Counseling" "Encounter, Performed: Preventive Care Services - Other" "Encounter, Performed: Preventive Care Services-Individual Counseling" "Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up" during "Measurement Period" Population Criteria 1:Denominator = AND: Initial Population Population Criteria 2: Denominator = AND: Initial Population AND: $TobaccoUseScreeningUser Population Criteria 3:Denominator = AND: Initial PopulationDenominator ExclusionsCLAIMS/REGISTRY:Documentation of medical reason(s) for notscreening for tobacco use (eg, limited life expectancy, other medical reason) (4004F with 1P) E.H.R.:Denominator Exceptions = OR: AND: "Occurrence A of Diagnosis: Limited Life Expectancy" starts before end of "Measurement Period" AND NOT: "Occurrence A of Diagnosis: Limited Life Expectancy" ends before end of "Measurement Period" OR: "Assessment, Performed not done: Medical Reason" for "Tobacco Use Screening" <= 24 month(s) starts before end of "Measurement Period" Numerator DescriptionConsumers who were screened for tobacco use at least once within 24 months AND who received tobacco cessation intervention if identified as a tobacco user Definitions: Tobacco Use – Includes any type of tobacco Tobacco Cessation Intervention – Includes brief counseling (3 minutes or less), and/or pharmacotherapy NUMERATOR NOTE: In the event that a Consumer is screened for tobacco use and identified as a user but did not receive tobacco cessation intervention or tobacco status is unknown report 4004F with8P.This measure defines tobacco cessation counseling as lasting 3 minutes or less. Services typically provided under CPT codes 99406 and 99407 satisfy the requirement of tobacco cessation intervention, as these services provide tobacco cessation counseling for 3-10 minutes. If a Consumer received these types of services, report CPT II 4004F.Numerator Inclusions (Performance Met)CLAIMS/REGISTRY:Consumer screened for tobacco use AND received tobacco cessation intervention (counseling, pharmacotherapy, or both), if identified as a tobacco user (4004F)ORCurrent tobacco non-user (1036F) E.H.R.:Population Criteria 1: AND: OR: $TobaccoUseScreeningNonUser OR: $TobaccoUseScreeningUser Population Criteria 2: AND: Occurrence A of $TobaccoCessationIntervention starts after or concurrent with start of $TobaccoUseScreeningUser AND: Occurrence A of $TobaccoCessationIntervention starts before end of "Measurement Period" Population Criteria 3: AND: OR: $TobaccoUseScreeningNonUser OR: AND: Occurrence A of $TobaccoCessationIntervention starts after or concurrent with start of $TobaccoUseScreeningUser AND: Occurrence A of $TobaccoCessationIntervention starts before end of "Measurement Period"Numerator Exclusions (Performance Not Met)CLAIMS/REGISTRY:Tobacco screening OR tobacco cessation intervention not performed, reason not otherwise specified (4004F with 8P) E.H.R.:NoneDSRIP Specific ModificationsNOTE: For DSRIP Reporting Purposes, only one rate is reported. If using the E.H.R. version of the specifications, the denominator is all individiuals that meet the initial population (Criteria 1) and the numerator is all individuals from the denominator that meet all applicable criteria (for example, meet numerator criteria 1 if included only in denominator criteria 1, or meet numerator criteria 1, 2, and 3, if included in denominator criteria 1, 2, and 3). Additional InformationMeasure is a clinic-reported measure for Certified Community Behavioral Health Clinics (CCBHCs) as part of the Demonstration Program to Improve Community Mental Health Services, found in Section 223 of the federal Protecting Access to Medicare Act of 2014 (PAMA). For DSRIP reporting purposes, measure has been specified using the same source measure used for CCBHC reporting requirements. E.H.R.Data Criteria (QDM Variables):? $TobaccoCessationIntervention = o Union of: "Intervention, Performed: Tobacco Use Cessation Counseling" "Medication, Active: Tobacco Use Cessation Pharmacotherapy" "Medication, Order: Tobacco Use Cessation Pharmacotherapy"? $TobaccoUseScreeningNonUser = o "Assessment, Performed: Tobacco Use Screening" satisfies all: Most Recent: <= 24 month(s) starts before end of "Measurement Period" (result: Tobacco Non-User)? $CounselingNotPerformed = o "Intervention, Performed not done: Medical Reason" for "Tobacco Use Cessation Counseling" starts before end of "Measurement Period"? $TobaccoUseScreeningUser = o "Assessment, Performed: Tobacco Use Screening" satisfies all: Most Recent: <= 24 month(s) starts before end of "Measurement Period" (result: Tobacco User)? $MedicationNotOrdered = o "Medication, Order not done: Medical Reason" for "Tobacco Use Cessation Pharmacotherapy" starts before end of "Measurement Period" Data Criteria (QDM Data Elements):? "Assessment, Performed: Tobacco Use Screening" using "Tobacco Use Screening Grouping Value Set (2.16.840.1.113883.3.526.3.1278)"? "Assessment, Performed not done: Medical Reason" using "Medical Reason Grouping Value Set (2.16.840.1.113883.3.526.3.1007)"? "Diagnosis: Limited Life Expectancy" using "Limited Life Expectancy Grouping Value Set (2.16.840.1.113883.3.526.3.1259)"? "Encounter, Performed: Annual Wellness Visit" using "Annual Wellness Visit Grouping Value Set (2.16.840.1.113883.3.526.3.1240)"? "Encounter, Performed: Face-to-Face Interaction" using "Face-to-Face Interaction Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1048)"? "Encounter, Performed: Health & Behavioral Assessment - Individual" using "Health & Behavioral Assessment - Individual Grouping Value Set (2.16.840.1.113883.3.526.3.1020)"? "Encounter, Performed: Health and Behavioral Assessment - Initial" using "Health and Behavioral Assessment - Initial Grouping Value Set (2.16.840.1.113883.3.526.3.1245)"? "Encounter, Performed: Health and Behavioral Assessment, Reassessment" using "Health and Behavioral Assessment, Reassessment Grouping Value Set (2.16.840.1.113883.3.526.3.1529)"? "Encounter, Performed: Home Healthcare Services" using "Home Healthcare Services Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1016)"? "Encounter, Performed: Occupational Therapy Evaluation" using "Occupational Therapy Evaluation Grouping Value Set (2.16.840.1.113883.3.526.3.1011)"? "Encounter, Performed: Office Visit" using "Office Visit Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1001)"? "Encounter, Performed: Ophthalmological Services" using "Ophthalmological Services Grouping Value Set (2.16.840.1.113883.3.526.3.1285)"? "Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up" using "Preventive Care Services - Established Office Visit, 18 and Up Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1025)"? "Encounter, Performed: Preventive Care Services - Group Counseling" using "Preventive Care Services - Group Counseling Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1027)"? "Encounter, Performed: Preventive Care Services - Other" using "Preventive Care Services - Other Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1030)"? "Encounter, Performed: Preventive Care Services-Individual Counseling" using "Preventive Care Services-Individual Counseling Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1026)"? "Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up" using "Preventive Care Services-Initial Office Visit, 18 and Up Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1023)"? "Encounter, Performed: Psych Visit - Diagnostic Evaluation" using "Psych Visit - Diagnostic Evaluation Grouping Value Set (2.16.840.1.113883.3.526.3.1492)"? "Encounter, Performed: Psych Visit - Psychotherapy" using "Psych Visit - Psychotherapy Grouping Value Set (2.16.840.1.113883.3.526.3.1496)"? "Encounter, Performed: Psychoanalysis" using "Psychoanalysis Grouping Value Set (2.16.840.1.113883.3.526.3.1141)"? "Encounter, Performed: Speech and Hearing Evaluation" using "Speech and Hearing Evaluation Grouping Value Set (2.16.840.1.113883.3.526.3.1530)"? "Intervention, Performed: Tobacco Use Cessation Counseling" using "Tobacco Use Cessation Counseling Grouping Value Set (2.16.840.1.113883.3.526.3.509)"? "Intervention, Performed not done: Medical Reason" using "Medical Reason Grouping Value Set (2.16.840.1.113883.3.526.3.1007)"? "Medication, Active: Tobacco Use Cessation Pharmacotherapy" using "Tobacco Use Cessation Pharmacotherapy Grouping Value Set (2.16.840.1.113883.3.526.3.1190)"? "Medication, Order: Tobacco Use Cessation Pharmacotherapy" using "Tobacco Use Cessation Pharmacotherapy Grouping Value Set (2.16.840.1.113883.3.526.3.1190)"? "Medication, Order not done: Medical Reason" using "Medical Reason Grouping Value Set (2.16.840.1.113883.3.526.3.1007)"? Attribute: "Result: Tobacco Non-User" using "Tobacco Non-User Grouping Value Set (2.16.840.1.113883.3.526.3.1189)"? Attribute: "Result: Tobacco User" using "Tobacco User Grouping Value Set (2.16.840.1.113883.3.526.3.1170)"M1-115: Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9.0%)Measure Description:Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period.M1-115: Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9.0%)DY7/DY8 Program IDM1-115Measure DetailsSteward: NCQANQF #: 0059Source: CMS MIPS #1 (Claims/Registry) eMeasure: SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusOptionalMeasure ClassificationType: Clinical OutcomeMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: QISMCHPL: 0.2936MPL: 0.522National Quality Compass 2016 - All LOBs: Average (90th and 25th percentiles)Directionality: NegativeUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionPatients 18 - 75 years of age with diabetes with a visit during the measurement periodDenominator InclusionsCLAIMS/REGISTRY:Patients aged 18 years to 75 years on date of encounterANDDiagnosis for diabetes (ICD-10-CM): E10.10, E10.11, E10.21, E10.22, E10.29, E10.311, E10.319, E10.3211, E10.3212, E10.3213, E10.3219, E10.3291, E10.3292, E10.3293, E10.3299, E10.3311, E10.3312, E10.3313, E10.3319, E10.3391, E10.3392, E10.3393, E10.3399, E10.3411, E10.3412, E10.3413, E10.3419, E10.3491, E10.3492, E10.3493, E10.3499, E10.3511, E10.3512, E10.3513, E10.3519, E10.3521, E10.3522, E10.3523, E10.3529, E10.3531, E10.3532, E10.3533, E10.3539, E10.3541, E10.3542, E10.3543, E10.3549, E10.3551, E10.3552, E10.3553, E10.3559, E10.3591, E10.3592, E10.3593, E10.3599, E10.36, E10.37X1, E10.37X2, E10.37X3, E10.37X9, E10.39, E10.40, E10.41, E10.42, E10.43, E10.44, E10.49, E10.51, E10.52, E10.59, E10.610, E10.618, E10.620, E10.621, E10.622, E10.628, E10.630, E10.638, E10.641, E10.649, E10.65, E10.69, E10.8, E10.9, E11.00, E11.01, E11.21, E11.22, E11.29, E11.311, E11.319, E11.3211, E11.3212, E11.3213, E11.3219, E11.3291, E11.3292, E11.3293, E11.3299, E11.3311, E11.3312, E11.3313, E11.3319, E11.3391, E11.3392, E11.3393, E11.3399, E11.3411, E11.3412, E11.3413, E11.3419, E11.3491, E11.3492, E11.3493, E11.3499, E11.3511, E11.3512, E11.3513, E11.3519, E11.3521, E11.3522, E11.3523, E11.3529, E11.3531, E11.3532, E11.3533, E11.3539, E11.3541, E11.3542, E11.3543, E11.3549, E11.3551, E11.3552, E11.3553, E11.3559, E11.3591, E11.3592, E11.3593, E11.3599, E11.36, E11.37X1, E11.37X2, E11.37X3, E11.37X9, E11.39, E11.40, E11.41, E11.42, E11.43, E11.44, E11.49, E11.51, E11.52, E11.59, E11.610, E11.618, E11.620, E11.621, E11.622, E11.628, E11.630, E11.638, E11.641, E11.649, E11.65, E11.69, E11.8, E11.9, E13.00, E13.01, E13.10, E13.11, E13.21, E13.22, E13.29, E13.311, E13.319, E13.3211, E13.3212, E13.3213, E13.3219, E13.3291, E13.3292, E13.3293, E13.3299, E13.3311, E13.3312, E13.3313, E13.3319 E13.3391, E13.3392, E13.3393, E13.3399, E13.3411, E13.3412, E13.3413, E13.3419, E13.3491, E13.3492, E13.3493, E13.3499, E13.3511, E13.3512, E13.3513, E13.3519, E13.3521, E13.3522, E13.3523, E13.3529, E13.3531, E13.3532, E13.3533, E13.3539, E13.3541, E13.3542, E13.3543, E13.3549, E13.3551, E13.3552, E13.3553, E13.3559, E13.3591, E13.3592, E13.3593, E13.3599, E13.36, E13.37X1, E13.37X2, E13.37X3, E13.37X9, E13.39, E13.40, E13.41, E13.42, E13.43, E13.44, E13.49, E13.51, E13.52, E13.59, E13.610, E13.618, E13.620, E13.621, E13.622, E13.628, E13.630, E13.638, E13.641, E13.649, E13.65, E13.69, E13.8, E13.9, O24.011, O24.012, O24.013, O24.019, O24.02, O24.03, O24.111, O24.112, O24.113, O24.119, O24.12, O24.13, O24.311, O24.312, O24.313, O24.319, O24.32, O24.33, O24.811, O24.812, O24.813, O24.819, O24.82, O24.83ANDPatient encounter during performance period (CPT or HCPCS): 97802, 97803, 97804, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99281, 99282, 99283, 99284, 99285, 99291, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0270, G0271, G0402, G0438, G0439 E.H.R: AND: "Diagnosis: Diabetes" overlaps "Measurement Period" AND: Age>= 18 year(s) at: "Measurement Period" AND: Age< 75 year(s) at: "Measurement Period" AND: Union of: "Encounter, Performed: Office Visit" "Encounter, Performed: Face-to-Face Interaction" "Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up" "Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up" "Encounter, Performed: Home Healthcare Services" "Encounter, Performed: Annual Wellness Visit" during "Measurement Period"Denominator ExclusionsCLAIMS/REGISTRY:Hospice services provided to patient any time during the measurement period: G9687 E.H.R.: OR: "Encounter, Performed: Encounter Inpatient (discharge status: Discharged to Home for Hospice Care)" ends during "Measurement Period" OR: "Encounter, Performed: Encounter Inpatient (discharge status: Discharged to Health Care Facility for Hospice Care)" ends during "Measurement Period" OR: Union of: "Intervention, Order: Hospice care ambulatory" "Intervention, Performed: Hospice care ambulatory" overlaps "Measurement Period"Numerator DescriptionPatients whose most recent HbA1c level (performed during the measurement period) is > 9.0% Numerator Instructions:INVERSE MEASURE - A lower calculated performance rate for this measure indicates better clinical care or control. The “Performance Not Met” numerator option for this measure is the representation of the better clinical quality or control. Reporting that numerator option will produce a performance rate that trends closer to 0%, as quality increases. For inverse measures, a rate of 100% means all of the denominator eligible patients did not receive the appropriate care or were not in proper control. Patient is numerator compliant if most recent HbA1c level >9% or is missing a result or if an HbA1c test was not done during the measurement year. Ranges and thresholds do not meet criteria for this indicator. A distinct numeric result is required for numerator compliance.Numerator Inclusions (Performance Met)CLAIMS/REGISTRY:Most recent hemoglobin A1c level > 9.0% (3046F)ORHemoglobin A1c level was not performed during the measurement period (12 months) (3046F with 8P) E.H.R.: AND: OR: "Laboratory Test, Performed: HbA1c Laboratory Test" satisfies all: Most Recent: (result) during "Measurement Period" (result > 9 %) OR: AND: Most Recent: "Occurrence A of Laboratory Test, Performed: HbA1c Laboratory Test" during "Measurement Period" AND NOT: "Occurrence A of Laboratory Test, Performed: HbA1c Laboratory Test (result)" OR NOT: "Laboratory Test, Performed: HbA1c Laboratory Test" during "Measurement Period"Numerator Exclusions (Performance Not Met)CLAIMS/REGISTRY:Most recent hemoglobin A1c (HbA1c) level < 7.0% (3044F)ORMost recent hemoglobin A1c (HbA1c) level 7.0 to 9.0% (3045F) E.H.R.:NoneDSRIP Specific ModificationsNoneAdditional InformationE.H.R.:Data Criteria (QDM Data Elements):? "Diagnosis: Diabetes" using "Diabetes Grouping Value Set (2.16.840.1.113883.3.464.1003.103.12.1001)"? "Encounter, Performed: Annual Wellness Visit" using "Annual Wellness Visit Grouping Value Set (2.16.840.1.113883.3.526.3.1240)"? "Encounter, Performed: Encounter Inpatient" using "Encounter Inpatient SNOMEDCT Value Set (2.16.840.1.113883.3.666.5.307)"? "Encounter, Performed: Face-to-Face Interaction" using "Face-to-Face Interaction Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1048)"? "Encounter, Performed: Home Healthcare Services" using "Home Healthcare Services Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1016)"? "Encounter, Performed: Office Visit" using "Office Visit Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1001)"? "Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up" using "Preventive Care Services - Established Office Visit, 18 and Up Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1025)"? "Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up" using "Preventive Care Services-Initial Office Visit, 18 and Up Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1023)"? "Intervention, Order: Hospice care ambulatory" using "Hospice care ambulatory SNOMEDCT Value Set (2.16.840.1.113762.1.4.1108.15)"? "Intervention, Performed: Hospice care ambulatory" using "Hospice care ambulatory SNOMEDCT Value Set (2.16.840.1.113762.1.4.1108.15)"? "Laboratory Test, Performed: HbA1c Laboratory Test" using "HbA1c Laboratory Test Grouping Value Set (2.16.840.1.113883.3.464.1003.198.12.1013)"? Attribute: "Discharge status: Discharged to Health Care Facility for Hospice Care" using "Discharged to Health Care Facility for Hospice Care SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.207)"? Attribute: "Discharge status: Discharged to Home for Hospice Care" using "Discharged to Home for Hospice Care SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.209)"M1-124: Medication Reconciliation Post-DischargeMeasure Description:The percentage of discharges for patients 18 years of age and older for whom the discharge medication list was reconciled with the current medication list in the outpatient medical record by a prescribing practitioner, clinical pharmacist or registered nurse.M1-124: Medication Reconciliation Post-DischargeDY7/DY8 Program IDM1-124Measure DetailsSteward: NCQANQF #: 0097Source: CMS MIPS #46 (Claims/Registry)Data SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusOptionalMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: PositiveUnit of Measurement for Payer TypeUnit: EncountersMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionAll discharges from any inpatient facility (e.g., hospital, skilled nursing facility, or rehabilitation facility) for patients18 years of age seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care.Denominator InclusionsAll Patients 18 years of age and older ANDPatient encounter during the performance period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 90839, 90845, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99495, 99496, G0402, G0438, G0439 AND Patient discharged from an inpatient facility (e.g., hospital, skilled nursing facility, or rehabilitation facility) within the last 30 daysDenominator ExclusionsPatient had hospice services any time during the measurement period: G9691Numerator DescriptionMedication reconciliation conducted by a prescribing practitioner, clinical pharmacists or registered nurse on or within 30 days of discharge. Definition: Medication Reconciliation – A type of review in which the discharge medications are reconciled withthe most recent medication list in the outpatient medical record. Documentation in the outpatient medical record must include evidence of medication reconciliation and the date on which it was performed. Any of the following evidence meets criteria: (1) Documentation of the current medications with a notation that references the discharge medications (e.g., no changes in meds since discharge, same meds atdischarge, discontinue all discharge meds), (2) Documentation of the patient’s current medications with a notation that the discharge medications were reviewed, (3) Documentation that the provider “reconciled the current and discharge meds,” (4) Documentation of a current medication list, a discharge medication list and notation that the appropriate practitioner type reviewed both lists on the same date of service, (5) Notation that no medications were prescribed or ordered upon discharge NUMERATOR NOTE: Medication reconciliation should be completed and documented on or within 30 days of discharge. If the patient has an eligible discharge but medication reconciliation is not performed and documented within 30 days, report 1111F with 8P.Numerator Inclusions (Performance Met)Discharge medications reconciled with the current medication list in outpatient medical record (1111F)Numerator Exclusions (Performance Not Met)Discharge medications not reconciled with the current medication list in outpatient medical record, reason not otherwise specified (1111F with 8P)DSRIP Specific ModificationsNoneAdditional InformationNoneM1-125: Antidepressant Medication Management (AMM-AD)Measure Description:The percentage of patients 18 years of age and older with a diagnosis of major depression and were treated with antidepressant medication, and who remained on an antidepressant medication treatment. Two rates are reported.a) Effective Acute Phase Treatment. The percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks). b) Effective Continuation Phase Treatment. The percentage of patients who remained on an antidepressant medication for at least 180 days (6 months).M1-125: Antidepressant Medication Management (AMM-AD)DY7/DY8 Program IDM1-125Measure DetailsSteward: NCQANQF #: 0105Source: eMeasure: SourceE.H.R.Required StatusOptionalMeasure ClassificationType: Clinical OutcomeMeasure Parts: 2Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionPatients 18 years of age and older with a visit during the measurement period who were dispensed antidepressant medications in the time within 270 days (9 months) prior to the measurement period through the first 90 days (3 months) of the measurement period, and were diagnosed with major depression 60 days prior to, or 60 days after the dispensing event. Exclusions: Patients who were actively on an antidepressant medication in the 105 days prior to the Index Prescription Start Date. Exclude patients who were in hospice care during the measurement year.Denominator InclusionsAND: Age>= 18 year(s) at: "Measurement Period" AND: $InitialMajDepressionDiagnosis AND: $InitialDepMedication AND: Union of: "Encounter, Performed: Office Visit" "Encounter, Performed: Face-to-Face Interaction" "Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up" "Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up" "Encounter, Performed: Home Healthcare Services" "Encounter, Performed: Annual Wellness Visit" "Encounter, Performed: Psych Visit - Diagnostic Evaluation" "Encounter, Performed: Psych Visit - Psychotherapy" during "Measurement Period"Denominator ExclusionsOR: "Encounter, Performed: Encounter Inpatient (discharge status: Discharged to Home for Hospice Care)" ends during "Measurement Period" OR: "Encounter, Performed: Encounter Inpatient (discharge status: Discharged to Health Care Facility for Hospice Care)" ends during "Measurement Period" OR: Union of: "Intervention, Order: Hospice care ambulatory" "Intervention, Performed: Hospice care ambulatory" overlaps "Measurement Period" OR: "Medication, Active: Antidepressant Medication" <= 105 day(s) starts before start of $InitialDepMedicationNumerator DescriptionRate 1: Patients who have received antidepressant medication for at least 84 days (12 weeks) of continuous treatment during the 114-day period following the Index Prescription Start Date Rate 2: Patients who have received antidepressant medications for at least 180 days (6 months) of continuous treatment during the 231-day period following the Index Prescription Start DateNumerator Inclusions (Performance Met)Population Criteria 1: AND: Sum>= 84 day(s): "Medication, Active: Antidepressant Medication (cumulative medication duration)" <= 114 day(s) ends after start of $InitialDepMedication Population Criteria 2: AND: Sum>= 180 day(s): "Medication, Active: Antidepressant Medication (cumulative medication duration)" <= 231 day(s) ends after start of $InitialDepMedicationNumerator Exclusions (Performance Not Met)NoneDSRIP Specific ModificationsNoneAdditional InformationGuidance:- To identify new treatment episodes for major depression, there must be a 90-day negative medication history (a period during which the patient was not taking antidepressant medication) prior to the first dispensing event associated with the Index Episode Start Date (Index Prescription Start Date).- CUMULATIVE MEDICATION DURATION is an individual's total number of medication days over a specific period; the period counts multiple prescriptions with gaps in between, but does not count the gaps during which a medication was not dispensed.- To determine the cumulative medication duration, determine first the number of the Medication Days for each prescription in the period: the number of doses divided by the dose frequency per day. Then add the Medication Days for each prescription without counting any days between the prescriptions.- For example, there is an original prescription for 30 days with 2 refills for thirty days each. After a gap of 3 months, the medication was prescribed again for 60 days with 1 refill for 60 days. The cumulative medication duration is (30 x 3) + (60 x 2) = 210 days over the 10 month period. Data Criteria (QDM Variables):? $InitialDepMedication = o First: "Medication, Dispensed: Antidepressant Medication" satisfies any: <= 270 day(s) starts before or concurrent with start of "Measurement Period" <= 90 day(s) starts after start of "Measurement Period"? $InitialMajDepressionDiagnosis = o First: "Diagnosis: Major Depression" satisfies any: <= 60 day(s) starts before or concurrent with start of $InitialDepMedication <= 60 day(s) starts after start of $InitialDepMedicationData Criteria (QDM Data Elements):? "Diagnosis: Major Depression" using "Major Depression Grouping Value Set (2.16.840.1.113883.3.464.1003.105.12.1007)"? "Encounter, Performed: Annual Wellness Visit" using "Annual Wellness Visit Grouping Value Set (2.16.840.1.113883.3.526.3.1240)"? "Encounter, Performed: Encounter Inpatient" using "Encounter Inpatient SNOMEDCT Value Set (2.16.840.1.113883.3.666.5.307)"? "Encounter, Performed: Face-to-Face Interaction" using "Face-to-Face Interaction Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1048)"? "Encounter, Performed: Home Healthcare Services" using "Home Healthcare Services Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1016)"? "Encounter, Performed: Office Visit" using "Office Visit Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1001)"? "Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up" using "Preventive Care Services - Established Office Visit, 18 and Up Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1025)"? "Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up" using "Preventive Care Services-Initial Office Visit, 18 and Up Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1023)"? "Encounter, Performed: Psych Visit - Diagnostic Evaluation" using "Psych Visit - Diagnostic Evaluation Grouping Value Set (2.16.840.1.113883.3.526.3.1492)"? "Encounter, Performed: Psych Visit - Psychotherapy" using "Psych Visit - Psychotherapy Grouping Value Set (2.16.840.1.113883.3.526.3.1496)"? "Intervention, Order: Hospice care ambulatory" using "Hospice care ambulatory SNOMEDCT Value Set (2.16.840.1.113762.1.4.1108.15)"? "Intervention, Performed: Hospice care ambulatory" using "Hospice care ambulatory SNOMEDCT Value Set (2.16.840.1.113762.1.4.1108.15)"? "Medication, Active: Antidepressant Medication" using "Antidepressant Medication Grouping Value Set (2.16.840.1.113883.3.464.1003.196.12.1213)"? "Medication, Dispensed: Antidepressant Medication" using "Antidepressant Medication Grouping Value Set (2.16.840.1.113883.3.464.1003.196.12.1213)"? Attribute: "Discharge status: Discharged to Health Care Facility for Hospice Care" using "Discharged to Health Care Facility for Hospice Care SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.207)"? Attribute: "Discharge status: Discharged to Home for Hospice Care" using "Discharged to Home for Hospice Care SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.209)"M1-146: Screening for Clinical Depression and Follow-Up Plan (CDF-AD)Measure Description:Percentage of Consumers aged 12 years and older screened for clinical depression using an age appropriate standardized tool AND follow-up plan documentedM1-146: Screening for Clinical Depression and Follow-Up Plan (CDF-AD)DY7/DY8 Program IDM1-146Measure DetailsSteward: CMSNQF #: 0418Source: CMS MIPS #134 (Claims/Registry) eMeasure: SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusOptionalMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionAll Consumers aged 12 years and olderDenominator InclusionsCLAIMS/REGISTRY:Consumers aged ≥ 12 years on date of encounterANDConsumer encounter during the performance period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 92625, 96116, 96118, 96150, 96151, 97165, 97166, 97167, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, G0101, G0402, G0438, G0439, G0444 E.H.R.: AND: Age>= 12 year(s) at: "Measurement Period" AND: "Encounter, Performed: Depression Screening Encounter Codes" during "Measurement Period"Denominator ExclusionsCLAIMS/REGISTRY:Documentation stating the Consumer has an active diagnosis of depression or has a diagnosed bipolar disorder, therefore screening or follow-up not required: G9717ORScreening for depression not completed, documented reason (G8433) E.H.R.: OR: "Diagnosis: Depression diagnosis" satisfies all: starts before start of ("Encounter, Performed: Depression Screening Encounter Codes" during "Measurement Period" ) overlaps ("Encounter, Performed: Depression Screening Encounter Codes" during "Measurement Period" ) OR: "Diagnosis: Bipolar Diagnosis" satisfies all: starts before start of ("Encounter, Performed: Depression Screening Encounter Codes" during "Measurement Period" ) overlaps ("Encounter, Performed: Depression Screening Encounter Codes" during "Measurement Period" )Numerator DescriptionConsumers screened for depression on the date of the encounter using an age appropriate standardized tool AND, if positive, a follow-up plan is documented on the date of the positive screenNumerator Instructions: The name of the age appropriate standardized depression screening tool utilized must be documented in the medical record. The depression screening must be reviewed and addressed in the office of the provider filing the code on the date of the encounter. Definitions:Screening – Completion of a clinical or diagnostic tool used to identify people at risk of developing or having a certain disease or condition, even in the absence of symptoms. Standardized Depression Screening Tool – A normalized and validated depression screening tool developed for the Consumer 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. Examples of depression screening tools include but are not limited to:? Adolescent Screening Tools (12-17 years):Consumer 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), Consumer Health Questionnaire (PHQ-9), Pediatric Symptom Checklist (PSC-17), and PRIME MD-PHQ2? Adult Screening Tools (18 years and older)Consumer Health Questionnaire (PHQ-9), Beck Depression Inventory (BDI or BDI-II), Center for Epidemiologic Studies Depression Scale (CES-D), Depression Scale (DEPS), Duke Anxiety- Depression Scale (DADS), Geriatric Depression Scale (GDS), Cornell Scale Screening, and PRIME MD-PHQ2Follow-Up Plan – Documented follow-up for a positive depression screening must include one 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 depressionNot Eligible for Depression Screening or Follow-Up Plan –? Consumer has an active diagnosis of Depression? Consumer has a diagnosed Bipolar DisorderConsumers with a Documented Reason for not Screening for Depression –One or more of the following conditions are documented:? Consumer refuses to participate? Consumer is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the Consumer’s health status? Situations where the Consumer’s functional capacity or motivation to improve may impact the accuracy of results of standardized depression assessment tools. For example: certain court appointed cases or cases of deliriumNumerator Inclusions (Performance Met)CLAIMS/REGISTRY:Screening for depression is documented as being positive AND a follow-up plan is documented (G8431)ORScreening for depression is documented as negative, a follow-up plan is not required (G8510) E.H.R.: AND: OR: AND: Most Recent: "Occurrence A of Risk Category Assessment: Adolescent Depression Screening (result)" during ("Encounter, Performed: Depression Screening Encounter Codes" during "Measurement Period" ) AND: "Occurrence A of Risk Category Assessment: Adolescent Depression Screening (result: Negative Depression Screening)" AND: Age< 18 year(s) at: "Measurement Period" OR: AND: Most Recent: "Occurrence A of Risk Category Assessment: Adolescent Depression Screening (result)" during ("Encounter, Performed: Depression Screening Encounter Codes" during "Measurement Period" ) AND: "Occurrence A of Risk Category Assessment: Adolescent Depression Screening (result: Positive Depression Screening)" AND: Union of: "Intervention, Performed: Additional evaluation for depression - adolescent" "Intervention, Order: Referral for Depression Adolescent" "Medication, Order: Depression medications - adolescent" "Intervention, Performed: Follow-up for depression - adolescent" "Procedure, Performed: Suicide Risk Assessment" <= 1 day(s) starts after or concurrent with start of "Occurrence A of Risk Category Assessment: Adolescent Depression Screening" AND: Age< 18 year(s) at: "Measurement Period" OR: AND: Most Recent: "Occurrence A of Risk Category Assessment: Adult Depression Screening (result)" during ("Encounter, Performed: Depression Screening Encounter Codes" during "Measurement Period" ) AND: "Occurrence A of Risk Category Assessment: Adult Depression Screening (result: Negative Depression Screening)" AND: Age>= 18 year(s) at: "Measurement Period" OR: AND: Most Recent: "Occurrence A of Risk Category Assessment: Adult Depression Screening (result)" during ("Encounter, Performed: Depression Screening Encounter Codes" during "Measurement Period" ) AND: "Occurrence A of Risk Category Assessment: Adult Depression Screening (result: Positive Depression Screening)" AND: Union of: "Intervention, Performed: Additional evaluation for depression - adult" "Intervention, Order: Referral for Depression Adult" "Medication, Order: Depression medications - adult" "Intervention, Performed: Follow-up for depression - adult" "Procedure, Performed: Suicide Risk Assessment" <= 1 day(s) starts after or concurrent with start of "Occurrence A of Risk Category Assessment: Adult Depression Screening" AND: Age>= 18 year(s) at: "Measurement Period"Numerator Exclusions (Performance Not Met)CLAIMS/REGISTRY:Depression screening not documented, reason not given (G8432)ORScreening for depression documented as positive, follow-up plan not documented, reason not given (G8511) E.H.R.:NoneDSRIP Specific ModificationsNoneAdditional InformationMeasure is a clinic-reported measure for Certified Community Behavioral Health Clinics (CCBHCs) as part of the Demonstration Program to Improve Community Mental Health Services, found in Section 223 of the federal Protecting Access to Medicare Act of 2014 (PAMA). For DSRIP reporting purposes, measure has been specified using the same source measure used for CCBHC reporting requirements. E.H.R.Data Criteria (QDM Data Elements):? "Diagnosis: Bipolar Diagnosis" using "Bipolar Diagnosis Grouping Value Set (2.16.840.1.113883.3.600.450)"? "Diagnosis: Depression diagnosis" using "Depression diagnosis Grouping Value Set (2.16.840.1.113883.3.600.145)"? "Encounter, Performed: Depression Screening Encounter Codes" using "Depression Screening Encounter Codes Grouping Value Set (2.16.840.1.113883.3.600.1916)"? "Intervention, Order: Referral for Depression Adolescent" using "Referral for Depression Adolescent SNOMEDCT Value Set (2.16.840.1.113883.3.600.537)"? "Intervention, Order: Referral for Depression Adult" using "Referral for Depression Adult SNOMEDCT Value Set (2.16.840.1.113883.3.600.538)"? "Intervention, Performed: Additional evaluation for depression - adolescent" using "Additional evaluation for depression - adolescent SNOMEDCT Value Set (2.16.840.1.113883.3.600.1542)"? "Intervention, Performed: Additional evaluation for depression - adult" using "Additional evaluation for depression - adult SNOMEDCT Value Set (2.16.840.1.113883.3.600.1545)"? "Intervention, Performed: Follow-up for depression - adolescent" using "Follow-up for depression - adolescent SNOMEDCT Value Set (2.16.840.1.113883.3.600.467)"? "Intervention, Performed: Follow-up for depression - adult" using "Follow-up for depression - adult SNOMEDCT Value Set (2.16.840.1.113883.3.600.468)"? "Medication, Order: Depression medications - adolescent" using "Depression medications - adolescent RXNORM Value Set (2.16.840.1.113883.3.600.469)"? "Medication, Order: Depression medications - adult" using "Depression medications - adult RXNORM Value Set (2.16.840.1.113883.3.600.470)"? "Procedure, Performed: Suicide Risk Assessment" using "Suicide Risk Assessment SNOMEDCT Value Set (2.16.840.1.113883.3.600.559)"? "Risk Category Assessment: Adolescent Depression Screening" using "Adolescent Depression Screening LOINC Value Set (2.16.840.1.113883.3.600.2452)"? "Risk Category Assessment: Adult Depression Screening" using "Adult Depression Screening LOINC Value Set (2.16.840.1.113883.3.600.2449)"? "Risk Category Assessment not done: Medical or Other reason not done" using "Medical or Other reason not done SNOMEDCT Value Set (2.16.840.1.113883.3.600.1.1502)"? "Risk Category Assessment not done: Consumer Reason refused" using "Consumer Reason refused SNOMEDCT Value Set (2.16.840.1.113883.3.600.791)"? Attribute: "Result: Negative Depression Screening" using "Negative Depression Screening SNOMEDCT Value Set (2.16.840.1.113883.3.600.2451)"? Attribute: "Result: Positive Depression Screening" using "Positive Depression Screening SNOMEDCT Value Set (2.16.840.1.113883.3.600.2450)"M1-147: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-UpMeasure Description:Percentage of consumers aged 18 years and older with a documented BMI during the encounter or during the previous twelve months AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the previous twelve months of the encounterNormal Parameters: Age 65 years and older BMI >= 23 and < 30 Age 18 – 64 years BMI >= 18.5 and < 25M1-147: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-UpDY7/DY8 Program IDM1-147Measure DetailsSteward: CMSNQF #: 0421 / 2828 eMeasureSource: CMS MIPS #128 (Claims V2.0 12/11/2017) eMeasure: updated 10/25/2017Data SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusOptionalMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: QISMCHPL: 0.9254MPL: 0.7651National Quality Compass 2016 - All LOBs: Average (90th and 25th percentiles)Directionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is eligible for a baseline numerator of 0 per PFM Section VI.22.b.i (page 24). If approved for a baseline of zero, the DY7 goal will be 89.35% and DY8 goal of 89.67%.Denominator DescriptionAll Consumers aged 18 years and older on the date of the encounter with at least one eligible encounter during the measurement periodDenominator InclusionsCLAIMS/REGISTRY:Consumers aged ≥18 years on date of encounterANDConsumer encounter during the performance period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 96150, 96151, 96152, 97161, 97162, 97163, 97165, 97166, 97167, 97802, 97803, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99385, 99386, 99387, 99395, 99396, 99397, D7140, D7210, G0101, G0108, G0270, G0271, G0402, G0438, G0439, G0447WITHOUTTelehealth Modifier: GQ, GT, 95, POS 02 E.H.R.: AND: Age>= 18 year(s) at: "Occurrence A of Encounter, Performed: BMI Encounter Code Set" AND: "Occurrence A of Encounter, Performed: BMI Encounter Code Set" during "Measurement Period"Denominator ExclusionsCLAIMS/REGISTRY:BMI not documented, documentation the consumer is not eligible for BMI calculation: G8422ORBMI is documented as being outside of normal limits, follow-up plan is not documented, documentation the consumer is not eligible: G8938ORBMI is documented as being outside of normal limits, follow-up plan is not completed for documented reason: G9716Not Eligible for BMI Calculation or Follow-Up Plan (Denominator Exclusion) – A consumer is not eligible if one or more of the following reasons are documented:? Consumer receiving palliative care? Consumers who are pregnant? Consumers who refuse measurement of height and/or weight or refuse follow-upConsumers with a documented BMI outside normal limits and a documented reason for not completing BMI follow-up plan (Denominator Exception) –? The Medical Reason exception could include, but is not limited to, the following patients as deemed appropriate by the health care provider? Elderly Patients (65 or older) for whom weight reduction/weight gain would complicate other underlying health conditions such as the following examples:? Illness or physical disability? Mental illness, dementia, confusion? Nutritional deficiency, such as Vitamin/mineral deficiency? Consumer is in an urgent or emergent medical situation where time is of the essence, and to delay treatment would jeopardize the patient’s health statusE.H.R.:Denominator Exclusions: OR: Union of: - "Encounter, Performed: Palliative care encounter" starts before or concurrent with end of "Occurrence A of Encounter, Performed: BMI Encounter Code Set" - "Intervention, Order: Palliative Care" starts before or concurrent with end of "Occurrence A of Encounter, Performed: BMI Encounter Code Set" - "Physical Exam, Performed not done: Patient Reason refused" for "BMI LOINC Value" during "Occurrence A of Encounter, Performed: BMI Encounter Code Set" - "Diagnosis: Pregnancy Dx" overlaps "Measurement Period"Denominator Exceptions: OR: Union of: - "Intervention, Order not done: Medical or Other reason not done" for "Above Normal Follow-up" - "Intervention, Order not done: Medical or Other reason not done" for "Referrals where weight assessment may occur" - "Medication, Order not done: Medical or Other reason not done" for "Above Normal Medications" - "Intervention, Order not done: Medical or Other reason not done" for "Below Normal Follow up" - "Medication, Order not done: Medical or Other reason not done" for "Below Normal Medications" - <= 12 month(s) starts before or concurrent with end of "Occurrence A of Encounter, Performed: BMI Encounter Code Set"Numerator DescriptionConsumers with a documented BMI during the encounter or during the previous six months, AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the previous sixmonths of the current encounter Numerator Instructions:? Height and Weight - An eligible professional or their staff is required to measure both height andweight. Both height and weight must be measured within six months of the current encounter and may be obtained from separate encounters. Self-reported values cannot be used.? Follow-Up Plan – If the most recent documented BMI is outside of normal parameters, then a follow-up plan is documented during the encounter or during the previous six months of the current encounter.The documented follow-up plan must be based on the most recent documented BMI, outside of normal parameters, example: “Consumer referred to nutrition counseling for BMI above or below normal parameters”. (See Definitions for examples of follow-up plan treatments).? Performance Met for G8417 & G8418? If the provider documents a BMI and a follow-up plan at the current visit OR? If the Consumer has a documented BMI within the previous six months of the current encounter, the provider documents a follow-up plan at the current visit OR? If the Consumer has a documented BMI within the previous six months of the current encounter ANDthe Consumer has a documented follow-up plan for a BMI outside normal parameters within the previoussix months of the current visit Definitions:BMI – Body mass index (BMI), is a number calculated using the Quetelet index: weight divided byheight squared (W/H2) and is commonly used to classify weight categories. BMI can be calculated using:Metric Units: BMI = Weight (kg) / (Height (m) x Height (m))OREnglish Units: BMI = Weight (lbs) / (Height (in) x Height (in)) x 703Follow-Up Plan – Proposed outline of treatment to be conducted as a result of a BMI out of normal parameters. A follow-up plan may include, but is not limited to:? Documentation of education? Referral (for example a registered dietitian, nutritionist, occupational therapist, physical therapist, primary care provider, exercise physiologist, mental health professional, or surgeon)? Pharmacological interventions? Dietary supplements? Exercise counseling? Nutrition counselingNumerator Inclusions (Performance Met)CLAIMS/REGISTRY:BMI is documented within normal parameters and no follow-up plan is required (G8420)ORPerformance Met: BMI is documented above normal parameters and a follow-up plan is documented (G8417)ORPerformance Met: BMI is documented below normal parameters and a follow-up plan is documented (G8418) E.H.R.: AND: OR: "Physical Exam, Performed: BMI LOINC Value" satisfies all: Most Recent: (result) <= 12 month(s) starts before or concurrent with end of "Occurrence A of Encounter, Performed: BMI Encounter Code Set" (result >= 18.5 kg/m2) (result < 25 kg/m2) OR: AND: Union of: "Intervention, Order: Above Normal Follow-up" "Intervention, Order: Referrals where weight assessment may occur (reason: Overweight)" "Medication, Order: Above Normal Medications" <= 12 month(s) starts before or concurrent with end of "Occurrence A of Encounter, Performed: BMI Encounter Code Set" AND: "Physical Exam, Performed: BMI LOINC Value" satisfies all: Most Recent: (result) <= 12 month(s) starts before or concurrent with end of "Occurrence A of Encounter, Performed: BMI Encounter Code Set" (result >= 25 kg/m2) OR: AND: Union of: "Intervention, Order: Below Normal Follow up" "Intervention, Order: Referrals where weight assessment may occur (reason: Underweight)" "Medication, Order: Below Normal Medications" <= 12 month(s) starts before or concurrent with end of "Occurrence A of Encounter, Performed: BMI Encounter Code Set" AND: "Physical Exam, Performed: BMI LOINC Value" satisfies all: Most Recent: (result) <= 12 month(s) starts before or concurrent with end of "Occurrence A of Encounter, Performed: BMI Encounter Code Set" (result < 18.5 kg/m2)Numerator Exclusions (Performance Not Met)CLAIMS/REGISTRY:BMI not documented and no reason is given (G8421)ORBMI documented outside normal parameters, no follow-up plan documented, no reason given (G8419) E.H.R.:NoneDSRIP Specific ModificationsFor DSRIP reporting purposes, replace the word "Consumers" with "consumers"Additional InformationMeasure is a clinic-reported measure for Certified Community Behavioral Health Clinics (CCBHCs) as part of the Demonstration Program to Improve Community Mental Health Services, found in Section 223 of the federal Protecting Access to Medicare Act of 2014 (PAMA). For DSRIP reporting purposes, measure has been specified using the same source measure used for CCBHC reporting requirements. E.H.R.Data Criteria (QDM Data Elements):? "Diagnosis: Pregnancy Dx" using "Pregnancy Dx Grouping Value Set (2.16.840.1.113883.3.600.1.1623)"? "Encounter, Performed: BMI Encounter Code Set" using "BMI Encounter Code Set Grouping Value Set (2.16.840.1.113883.3.600.1.1751)"? "Encounter, Performed: Palliative care encounter" using "Palliative care encounter ICD10CM Value Set (2.16.840.1.113883.3.600.1.1575)"? "Intervention, Order: Above Normal Follow-up" using "Above Normal Follow-up Grouping Value Set (2.16.840.1.113883.3.600.1.1525)"? "Intervention, Order: Below Normal Follow up" using "Below Normal Follow up Grouping Value Set (2.16.840.1.113883.3.600.1.1528)"? "Intervention, Order: Palliative Care" using "Palliative Care Grouping Value Set (2.16.840.1.113883.3.600.1.1579)"? "Intervention, Order: Referrals where weight assessment may occur" using "Referrals where weight assessment may occur Grouping Value Set (2.16.840.1.113883.3.600.1.1527)"? "Intervention, Order not done: Medical or Other reason not done" using "Medical or Other reason not done SNOMEDCT Value Set (2.16.840.1.113883.3.600.1.1502)"? "Medication, Order: Above Normal Medications" using "Above Normal Medications RXNORM Value Set (2.16.840.1.113883.3.600.1.1498)"? "Medication, Order: Below Normal Medications" using "Below Normal Medications RXNORM Value Set (2.16.840.1.113883.3.600.1.1499)"? "Medication, Order not done: Medical or Other reason not done" using "Medical or Other reason not done SNOMEDCT Value Set (2.16.840.1.113883.3.600.1.1502)"? "Physical Exam, Performed: BMI LOINC Value" using "BMI LOINC Value LOINC Value Set (2.16.840.1.113883.3.600.1.681)"? "Physical Exam, Performed not done: Consumer Reason refused" using "Consumer Reason refused SNOMEDCT Value Set (2.16.840.1.113883.3.600.791)"? Attribute: "Reason: Overweight" using "Overweight SNOMEDCT Value Set (2.16.840.1.113883.3.600.2387)"? Attribute: "Reason: Underweight" using "Underweight SNOMEDCT Value Set (2.16.840.1.113883.3.600.2388)"M1-160: Follow-Up After Hospitalization for Mental IllnessMeasure Description:The percentage of discharges for patients 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner. Two rates are reported: - The percentage of discharges for which the patient received follow-up within 30 days of discharge - The percentage of discharges for which the patient received follow-up within 7 days of discharge.M1-160: Follow-Up After Hospitalization for Mental IllnessDY7/DY8 Program IDM1-160Measure DetailsSteward: NCQANQF #: 0576Source: CMS MIPS #391 (Claims/Registry)Data SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusOptionalMeasure ClassificationType: Clinical OutcomeMeasure Parts: 2Achievement CalculationsCategory: P4PGoal Calculation: QISMCHPL: 30 Days: 0.78527 Days: 0.6423MPL: 30 Days: 0.54087 Days: 0.342National Quality Compass 2016 - All LOBs: Average (90th and 25th percentiles)Directionality: PositiveUnit of Measurement for Payer TypeUnit: EncountersMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionRate 1 & 2: Patients 6 years of age and older who were discharged from an acute inpatient setting (including acutecare psychiatric facilities) with a principal diagnosis of mental illness on or between January 1 and December 1 of the measurement periodDenominator InclusionsRate 1 & 2: Patients aged 6 years and older as of the date of dischargeANDDiagnosis for mental illness (ICD-10-CM): F20.0, F20.1, F20.2, F20.3, F20.5, F20.81, F20.89, F20.9, F21, F22, F23, F24, F25.0, F25.1, F25.8, F25.9, F28, F29, F30.10, F30.11, F30.12, F30.13, F30.2,F30.3, F30.4, F30.8, F30.9, F31.0, F31.10, F31.11, F31.12, F31.13, F31.2, F31.30, F31.31, F31.32, F31.4,F31.5, F31.60, F31.61, F31.62, F31.63, F31.64, F31.70, F31.71, F31.72, F31.73, F31.74, F31.75, F31.76,F31.77, F31.78, F31.81, F31.89, F31.9, F32.0, F32.1, F32.2, F32.3, F32.4, F32.5, F32.81, F32.89, F32.9, F33.0,F33.1, F33.2, F33.3, F33.40, F33.41, F33.42, F33.8, F33.9, F34.0, F34.1, F34.81, F34.89, F34.9, F39, F42.2, F42.3, F42.8, F42.9, F43.0, F43.10, F43.11, F43.12, F43.20, F43.21, F43.22, F43.23, F43.24, F43.25, F43.29, F43.8, F43.9, F44.89, F53, F60.0, F60.1, F60.2, F60.3, F60.4, F60.5, F60.6, F60.7, F60.81, F60.89, F60.9, F63.0, F63.1, F63.2, F63.3, F63.81, F63.89, F63.9, F68.10, F68.11, F68.12, F68.13, F68.8, F84.0, F84.2, F84.3, F84.5, F84.8,F84.9, F90.0, F90.1, F90.2, F90.8, F90.9, F91.0, F91.1, F91.2, F91.3, F91.8, F91.9, F93.0, F93.8, F93.9,F94.0, F94.1, F94.2, F94.8, F94.9ANDPatient encounter during the performance period (CPT): 99221, 99222, 99223, 99231, 99232,99233,99238, 99239, 99291ANDPatient alive at time of acute inpatient setting dischargeANDPatient is discharged from an acute inpatient setting on or between January 1 and December 1 of the measurement periodANDExclude discharges followed by readmission or direct transfer to a Non-acute facility within the 30- day follow-up period, regardless of principal diagnosis for the readmission.ANDExclude discharges followed by readmission or direct transfer to an acute facility within the 30-day follow-up period if the principal diagnosis was for non-mental healthNOTE: These discharges are excluded from the measure because readmission or transfer may preventan outpatient follow-up visit from taking place.Denominator ExclusionsRate 1: Patients who use hospice services any time during the measurement period: G9760ORClinician documented reason patient was not able to complete 30 day follow-up from acute inpatient setting discharge (e.g., patient death prior to follow-up visit, patient non-compliant for visit follow-up) (G9403) Rate 2: Patients who use hospice services any time during the measurement period: G9760OR Clinician documented reason patient was not able to complete 7 day follow-up from acute inpatient setting discharge (i.e., patient death prior to follow-up visit, patient non-compliance for visit follow-up) (G9406)Numerator DescriptionRate 1: An outpatient visit, intensive outpatient visit or partial hospitalization with a mental health practitioner within 30 days after acute inpatient discharge. Include outpatient visits, intensive outpatient visits or partial hospitalizationsthat occur on the date of discharge Rate 2: Patient received follow-up within 7 days fromdischarge (G9405)Numerator Inclusions (Performance Met)Rate 1: Patient received follow-up on the date of discharge or within 30 days after discharge (G9402) Rate 2: Patient received follow-up within 7 days from discharge (G9405)Numerator Exclusions (Performance Not Met)Rate 1: Patient did not receive follow-up on the date of discharge or within 30 days after discharge (G9404)Rate 2:Patient did not receive follow-up on or within 7 days after discharge (G9407)DSRIP Specific ModificationsNoneAdditional InformationNoneM1-165: Depression Remission at Twelve MonthsMeasure Description:Adult Consumers age 18 and older with major depression or dysthymia and an initial PHQ-9 score > 9 who demonstrate remission at twelve months defined as a PHQ-9 score less than 5. This measure applies to both consumers with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment. This measure additionally promotes ongoing contact between the Consumer and provider as Consumers who do not have a follow-up PHQ-9 score at twelve months (+/- 30 days) are also included in the denominator.M1-165: Depression Remission at Twelve MonthsDY7/DY8 Program IDM1-165Measure DetailsSteward: MN Community MeasurementNQF #: 0710Source: CMS MIPS #370 (Claims/Registry) eMeasure: SourceE.H.R.Required StatusOptionalMeasure ClassificationType: Clinical OutcomeMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionConsumers age 18 and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 score greater than nine during the index visit Definition: Index Date - The first instance of elevated PHQ-9 greater than 9 and diagnosis of depression or dysthymiaAn index visit occurs when ALL of the following criteria are met:? A PHQ-9 result greater than nine? An active diagnosis of Major Depression or Dysthymia? The Consumer is NOT in a prior index periodAn index period begins with an index visit and is 13 months in duration.**For behavioral health providers only: The diagnosis of Major Depression or Dysthymia must be the primary diagnosis.Note: This distinction between behavioral health providers and other providers is only meaningful for CMHCs that include non-behavioral health healthcare providers who may screen for depression as a part of providing general health care.Denominator InclusionsRegistry:Consumers aged ≥ 18 years ANDDiagnosis for MDD (ICD-10-CM): F32.0, F32.1, F32.2, F32.3, F32.4, F32.5, F32.9, F33.0, F33.1, F33.2, F33.3, F33.40, F33.41, F33.42, F33.9, F34.1 AND Consumer encounter during the performance period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, G0402, G0438, G0439 ANDIndex Date PHQ-9 Score greater than 9 documented during the twelve month denominator identification period: G9511 E.H.R.: AND: Age>= 18 year(s) at: $DepressionIndexDenominator ExclusionsRequired Exclusions: Consumers with a diagnosis of bipolar disorder ICD10-CM: F30.10, F30.11, F30.12, F30.13, F30.2, F30.3, F30.4, F30.8, F30.9, F31.0, F31.10, F31.11, F31.12, F31.13, F31.2, F31.30, F31.31, F31.32, F31.4, F31.5, F31.60, F31.61, F31.62, F31.63, F31.64, F31.70, F31.71, F31.72, F31.73, F31.74, F31.75, F31.76, F31.77, F31.78, F31.81, F31.89, F31.9ICD-9-CM: 296.00, 296.01, 296.02, 296.03, 296.04, 296.05, 296.06, 296.10, 296.11, 296.12, 296.13, 296.14, 296.15, 296.16, 296.40, 296.41, 296.42, 296.43, 296.44, 296.45, 296.46, 296.50, 296.51, 296.52, 296.53, 296.54, 296.55, 296.56, 296.60, 296.61, 296.62, 296.63, 296.64, 296.65, 296.66, 296.7, 296.80, 296.81, 296.82, 296.89ORConsumers with a diagnosis of personality disorder:ICD-10-CM: F21, F34.0, F60.0, F60.1, F60.2, F60.3, F60.4, F60.5, F60.6, F60.7, F60.81, F60.89, F60.9, F68.10, F68.11, F68.12, F68.13ICD-9-CM: 301.0, 301.10, 301.11, 301.12, 301.13, 301.20, 301.21, 301.22, 301.3, 301.4, 301.50, 301.51, 301.59, 301.6, 301.7, 301.81, 301.82, 301.83, 301.84, 301.89, 301.9Optional Exclusions: Consumers who diedORConsumers who received hospice or palliative care serviceORConsumers who were permanent nursing home residentsNumerator DescriptionConsumers who achieved remission at twelve months as demonstrated by a twelve month (+/- 30 days grace period) PHQ-9 score of less than five Definitions:Remission - a PHQ-9 score of less than five.Twelve Months - the point in time from the index date extending out twelve months (+/- 30 days). The most recent PHQ-9 score less than five obtained during this two month period is deemed as remission at twelve months, values obtained prior to or after this period are not counted as numerator compliant (remission).Numerator Inclusions (Performance Met)Registry:Remission at twelve months as demonstrated by a twelve month (+/-30 days) PHQ-9 score of less than 5 (G9509 or equivelant record of score) E.H.R.: AND: "Assessment, Performed: PHQ-9 Tool" satisfies all: (result < 5 ) < 13 month(s) starts after end of First: $DepressionIndex > 10 month(s) starts after end of First: $DepressionIndexNumerator Exclusions (Performance Not Met)Remission at twelve months not demonstrated by a twelve month (+/-30 days) PHQ-9 score of less than five. Either PHQ-9 score was not assessed or is greater than or equal to 5 (G9510 or equivelant record of score)DSRIP Specific ModificationsMeasure was specified to include primary care clinic level. To be consistent with the SAMHSA CCBHC specifications for the 12 month remission level, the word "patient" has been replaced with "consumer."Additional InformationMeasure is a clinic-reported measure for Certified Community Behavioral Health Clinics (CCBHCs) as part of the Demonstration Program to Improve Community Mental Health Services, found in Section 223 of the federal Protecting Access to Medicare Act of 2014 (PAMA). For DSRIP reporting purposes, measure has been specified using the same source measure used for CCBHC reporting requirements. Standard Baseline Measurement Period: Measurement Period Index Period: December 2, 2015 through November 30, 2016Assessment Period: November 1, 2016 through December 31, 2017 PY1 Measurement Period: Measurement Period Index Period: December 2, 2016 through November 30, 2017Assessment Period: November 1, 2017 through December 31, 2018 PY2 Measurement Period: Measurement Period Index Period: December 2, 2017 through November 30, 2018Assessment Period: November 1, 2018 through December 31, 2019 PY3 Measurement Period: Measurement Period Index Period: December 2, 2018 through November 30, 2019Assessment Period: November 1, 2019 through December 31, 2020 Follow the steps below to identify the eligible population:Step 1: Identify consumers seen at the provider entity at least once during the measurement year.Step 2: Identify consumers from step 1 who have a diagnosis of Major Depression or Dysthymia during an Outpatient encounter during the measurement year. Note: For behavioral health providers, the Depression or dysthymia diagnosis codes must be listed as the primary diagnosis. This excludes consumers with other psychiatric diagnoses with a secondary component of Depression. If the provider is primary care, the diagnosis codes can be in any position (this might occur if the Consumer was diagnosed by a primary care provider and subsequently seen by the CMHC). This distinction between behavioral health providers and other providers is only meaningful for CMHCs that include non-behavioral health healthcare providers who may screen for depression as a part of providing general health care.Step 3: Identify consumers from step 2 who have an index date PHQ-9 score greater than 9 documented during the twelve-month denominator identification period (code G9511).Step 4: Identify consumers from step 3 who are aged 18 years and older at the index date.Note: To be considered denominator eligible for this measure, the consumer must have both the diagnosis of Major Depression or Dysthymia and an index date PHQ-9 score greater than 9 documented at the same encounter during the dates of denominator identification measurement period. E.H.R. Additional Information:Data Criteria (QDM Variables):? $DepressionIndex = o "Assessment, Performed: PHQ-9 Tool (result > 9 )" during Union of: $DepressionEncounter $DepressionEncounterBH $DepressionF2FSnomed? $DepressionEncounter = o "Encounter, Performed: Office Visit" satisfies all: < 13 month(s) ends before start of "Measurement Period" > 0 month(s) ends before start of "Measurement Period" satisfies any: overlaps "Diagnosis: Major Depression Including Remission" overlaps "Diagnosis: Dysthymia"? $DepressionEncounterBH = o "Encounter, Performed: Psych Visit" satisfies all: < 13 month(s) ends before start of "Measurement Period" > 0 month(s) ends before start of "Measurement Period" satisfies any: (principal diagnosis: Major Depression Including Remission) (principal diagnosis: Dysthymia)? $DepressionF2FSnomed = o "Encounter, Performed: Face to Face Interaction - No ED" satisfies all: < 13 month(s) ends before start of "Measurement Period" > 0 month(s) ends before start of "Measurement Period" satisfies any: overlaps "Diagnosis: Major Depression Including Remission" overlaps "Diagnosis: Dysthymia" Data Criteria (QDM Data Elements):? "Assessment, Performed: PHQ-9 Tool" using "PHQ-9 Tool Grouping Value Set (2.16.840.1.113883.3.67.1.101.11.723)"? "Diagnosis: Bipolar Disorder" using "Bipolar Disorder Grouping Value Set (2.16.840.1.113883.3.67.1.101.1.128)"? "Diagnosis: Dysthymia" using "Dysthymia Grouping Value Set (2.16.840.1.113883.3.67.1.101.1.254)"? "Diagnosis: Major Depression Including Remission" using "Major Depression Including Remission Grouping Value Set (2.16.840.113883.3.67.1.101.3.2444)"? "Diagnosis: Personality Disorder" using "Personality Disorder Grouping Value Set (2.16.840.1.113883.3.67.1.101.1.246)"? "Encounter, Performed: Care Services in Long-Term Residential Facility" using "Care Services in Long-Term Residential Facility Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1014)"? "Encounter, Performed: Face to Face Interaction - No ED" using "Face to Face Interaction - No ED SNOMEDCT Value Set (2.16.840.1.113762.1.4.1080.1)"? "Encounter, Performed: Office Visit" using "Office Visit Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1001)"? "Encounter, Performed: Palliative care encounter" using "Palliative care encounter ICD10CM Value Set (2.16.840.1.113883.3.600.1.1575)"? "Encounter, Performed: Psych Visit" using "Psych Visit Grouping Value Set (2.16.840.113883.3.67.1.101.3.2445)"? "Intervention, Order: Palliative Care" using "Palliative Care Grouping Value Set (2.16.840.1.113883.3.600.1.1579)"? Attribute: "Principal diagnosis: Dysthymia" using "Dysthymia Grouping Value Set (2.16.840.1.113883.3.67.1.101.1.254)"? Attribute: "Principal diagnosis: Major Depression Including Remission" using "Major Depression Including Remission Grouping Value Set (2.16.840.113883.3.67.1.101.3.2444)"M1-180: Adherence to Antipsychotics for Individuals with Schizophrenia (SAA-AD)Measure Description:Percentage of individuals at least 18 years of age as of the beginning of the measurement period with schizophrenia or schizoaffective disorder who had at least two prescription drug claims for antipsychotic medications and had a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic medications during the measurement period (12 consecutive months).M1-180: Adherence to Antipsychotics for Individuals with Schizophrenia (SAA-AD)DY7/DY8 Program IDM1-180Measure DetailsSteward: CMSNQF #: 1879Source: CMS MIPS #383 (Claims/Registry)Data SourceClaimsRequired StatusOptionalMeasure ClassificationType: Clinical OutcomeMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: QISMCHPL: 0.7092MPL: 0.528National Quality Compass 2016 - All LOBs: Average (90th and 25th percentiles)Directionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsMeasure is NOT eligible for a shortened baseline measurement period.Measure is not eligible for a baseline of 0.Denominator DescriptionIndividuals at least 18 years of age as of the beginning of the measurement period with schizophrenia or schizoaffective disorder and at least two prescriptions filled for any antipsychotic medication during the measurement period (12 consecutive months) DENOMINATOR NOTE: The following are the oral antipsychotic medications by class for the denominator. The route of administration includes all oral formulations of the medications listed below. TYPICAL ANTIPSYCHOTIC MEDICATIONS:? chlorpromazine? fluphenazine? haloperidol? loxapine? molindone? perphenazine? pimozide? prochlorperazine? thioridazine? thiothixene? trifluoperazine ATYPICAL ANTIPSYCHOTIC MEDICATIONS:? aripiprazole? asenapine? clozapine? olanzapine? iloperidone? lurasidone? paliperidone? quetiapine? risperidone? ziprasidone ANTIPSYCHOTIC COMBINATIONS:? olanzapine-fluoxetine? perphenazine-amitriptyline ATYPICAL ANTIPSYCHOTIC MEDICATIONS:NOTE: The following are the long-acting (depot) injectable antipsychotic medications by class for the denominator. The route of administration includes all injectable and intramuscular formulations of the medications listed below. TYPICAL ANTIPSYCHOTIC MEDICATIONS:? fluphenazine decanoate (J2680)? haloperidol decanoate (J1631) ATYPICAL ANTIPSYCHOTIC MEDICATIONS:? olanzapine pamoate (J2358)? paliperidone palmitate (J2426)? risperidone microspheres (J2794)? aripiprazole (J0401) NOTE: Since the days’ supply variable is not reliable for long-acting injections in administrative data, the days’ supply is imputed as listed below for the long-acting (depot) injectable antipsychotic medications billed under Part D and Part B:? fluphenazine decanoate (J2680) – 28 days’ supply? haloperidol decanoate (J1631) – 28 days’ supply? olanzapine pamoate (J2358) – 28 days’ supply? paliperidone palmitate (J2426) – 28 days’ supply? aripiprazole (J0401) – 28 days’ supply? risperidone microspheres (J2794) – 14 days’ supplyDenominator InclusionsPatients aged ≥ 18 years at the beginning of the measurement periodANDDiagnosis for schizophrenia or schizoaffective disorder (ICD-10-CM): F20.0, F20.1, F20.2, F20.3, F20.5, F20.81, F20.89, F20.9, F25.0, F25.1, F25.8, F25.9AND At least two encounters** with a diagnosis of schizophrenia or schizoaffective disorder (see code set below) with different dates of service in an outpatient setting, emergency department setting, or non-acute inpatient setting during the measurement period OR At least one encounter** with a diagnosis of schizophrenia or schizoaffective disorder (see code set below) in an acute inpatient setting during the measurement period AND**Patient encounter during the performance period determination Outpatient Setting Option 1 (CPT or HCPCS): 98960, 98961, 98962, 99078, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99281, 99282, 99283, 99284, 99285, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0155, G0176, G0177, G0409, G0410, G0411, G0463, H0002, H0004, H0031, H0034, H0035, H0036, H0037, H0039, H0040, H2000, H2001, H2010, H2011, H2012, H2013, H2014, H2015, H2016, H2017, H2018, H2019, H2020, M0064, S0201, S9480, S9484, S9485, T1015 OR Outpatient Setting Option 2 (CPT): 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90847, 90849, 90853, 90863, 90867, 90868, 90869, 90870, 90875, 90876, 90880, 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99251, 99255, 99291WITH Place of Service (POS): 03, 05, 07, 09, 11, 12, 13, 14, 15, 20, 22, 24, 33, 49, 50, 52, 53, 71, 72 OR Emergency Department Setting Option 1 (CPT): 99281, 99282, 99283, 99284, 99285 OR Emergency Department Setting Option 2 (CPT): 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90847, 90849, 90853, 90863, 90867, 90868, 90869, 90870, 90875, 90876, 99291WITHPlace of Service (POS): 23 OR Non-Acute Inpatient Setting Option 1 (CPT): 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337 OR Non-Acute Inpatient Setting Option 2 (CPT): 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90847, 90849, 90853, 90863, 90867, 90868, 90869, 90870, 90875, 90876, 99291WITHPlace of Service (POS): 31, 32, 56 OR Acute Inpatient Setting (CPT): 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90847, 90849, 90853, 90863, 90867, 90868, 90869, 90870, 90875, 90876, 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99251, 99252, 99253, 99254, 99255, 99291WITHPlace of Service (POS): 21, 51Denominator ExclusionsDiagnosis for dementia (ICD-10-CM): E75.00, E75.01, E75.02, E75.09, E75.10, E75.11, E75.19, E75.4, F01.50, F01.51, F02.80, F02.81, F03.90, F03.91, F05, F10.27, F13.27, F13.97, F18.17, F18.27, F18.97, F19.17, F19.27, F19.97, G30.0, G30.1, G30.8, G30.9, G31.09, G31.83Numerator DescriptionIndividuals in the denominator who have a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic medications NUMERATOR NOTE: The PDC is calculated as follows: PDC NUMERATOR:The PDC numerator is the sum of the days covered by the days’ supply of all antipsychotic prescriptions. The period covered by the PDC starts on the day the first prescription is filled (index date) and lasts through the end of the measurement period, or death, whichever comes first. For prescriptions with a days’ supply that extends beyond the end of the measurement period, count only the days for which the drug was available to the individual during the measurement period. If there are prescriptions for the same drug (generic name) on the same date of service, keep the prescription with the largest days’ supply. If prescriptions for the same drug (generic name) overlap, then adjust the prescription start date to be the day after the previous fill has ended. PDC DENOMINATOR:The PDC denominator is the number of days from the first prescription date through the end of the measurement period, or death date, whichever comes first.Numerator Inclusions (Performance Met)Individual had a PDC of 0.8 or greater (G9512)Numerator Exclusions (Performance Not Met)Individual did not have a PDC of 0.8 or greater (G9513)DSRIP Specific ModificationsRemoved Medicare specific clarifications regarding non-covered services under Medicare Part B.Additional InformationThis measure is a state-reported measure under the SAMHSA Certified Community Behavioral Health Clinics. Measure specifications have been re-formatted for DSRIP reporting purposes from the CMS MACRA MIPS measure which is specified at the clinic level, rather than the state/health-plan level.M1-181: Depression Response at Twelve Months- Progress Towards RemissionMeasure Description:The percentage of patients 18 years of age or older with Major Depression or Dysthymia who demonstrated a response to treatment 12 months (+/- 30 days) after an index visit.M1-181: Depression Response at Twelve Months- Progress Towards RemissionDY7/DY8 Program IDM1-181Measure DetailsSteward: MN Community MeasurementNQF #: 1885Source: SourceE.H.R.Required StatusOptionalMeasure ClassificationType: Clinical OutcomeMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionConsumers age 18 and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 score greater than nine during the index visit. Definition:An index visit occurs when ALL of the following criteria are met during a face-to-face visit or contact with an eligible provider in an eligible specialty:? A PHQ-9 result greater than nine? An active diagnosis of Major Depression or Dysthymia** (Major Depression or Dysthymia Value Set)The patient is NOT in a prior index period" from the denominator descriptionAn index period begins with an index visit and is 13 months in duration.** For psychiatry providers and behavioral health providers with a psychiatrist on site: the diagnosis of Major Depression or Dysthymia must be the primary diagnosis.Denominator InclusionsConsumers aged ≥ 18 years ANDDiagnosis for MDD (ICD-10-CM): F32.0, F32.1, F32.2, F32.3, F32.4, F32.5, F32.9, F33.0, F33.1, F33.2, F33.3, F33.40, F33.41, F33.42, F33.9, F34.1 AND Patient encounter during the performance period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, G0402, G0438, G0439 ANDIndex Date PHQ-9 Score greater than 9 documented during the twelve month denominator identification period: G9511Denominator ExclusionsRequired Exclusions: Consumers with a diagnosis of bipolar disorder ICD10-CM: F30.10, F30.11, F30.12, F30.13, F30.2, F30.3, F30.4, F30.8, F30.9, F31.0, F31.10, F31.11, F31.12, F31.13, F31.2, F31.30, F31.31, F31.32, F31.4, F31.5, F31.60, F31.61, F31.62, F31.63, F31.64, F31.70, F31.71, F31.72, F31.73, F31.74, F31.75, F31.76, F31.77, F31.78, F31.81, F31.89, F31.9ICD-9-CM: 296.00, 296.01, 296.02, 296.03, 296.04, 296.05, 296.06, 296.10, 296.11, 296.12, 296.13, 296.14, 296.15, 296.16, 296.40, 296.41, 296.42, 296.43, 296.44, 296.45, 296.46, 296.50, 296.51, 296.52, 296.53, 296.54, 296.55, 296.56, 296.60, 296.61, 296.62, 296.63, 296.64, 296.65, 296.66, 296.7, 296.80, 296.81, 296.82, 296.89ORConsumers with a diagnosis of personality disorder:ICD-10-CM: F21, F34.0, F60.0, F60.1, F60.2, F60.3, F60.4, F60.5, F60.6, F60.7, F60.81, F60.89, F60.9, F68.10, F68.11, F68.12, F68.13ICD-9-CM: 301.0, 301.10, 301.11, 301.12, 301.13, 301.20, 301.21, 301.22, 301.3, 301.4, 301.50, 301.51, 301.59, 301.6, 301.7, 301.81, 301.82, 301.83, 301.84, 301.89, 301.9Optional Exclusions: Consumers who diedORConsumers who received hospice or palliative care serviceORConsumers who were permanent nursing home residentsNumerator DescriptionConsumers in the denominator who demonstrated a response to treatment, with a PHQ-9 result that is reduced by at least 50 percent since the index PHQ-9 result, 12 months (+/- 30 days) after an index visit. Definitions:Twelve Months - the point in time from the index date extending out twelve months (+/- 30 days). The most recent PHQ-9 score that is reduced by at least 50 percent obtained during this two month period is deemed as progress towards remission at twelve months, values obtained prior to or after this period are not counted as numerator compliant.Numerator Inclusions (Performance Met)Progress towards remission at twelve months as demonstrated by a twelve month (+/-30 days) PHQ-9 score that is reduceed by at least 50%Numerator Exclusions (Performance Not Met)Progress towards remission at twelve months not demonstrated by a twelve month (+/-30 days) PHQ-9 score that is reduceed by at least 50%. Either PHQ-9 score was not assessed, has increased, or is reduced by less than 50%DSRIP Specific ModificationsMeasure was specified to include primary care clinic level. To be consistent with the SAMHSA CCBHC specifications for the 12 month remission level, the word "patient" has been replaced with "consumer."Additional InformationStandard Baseline Measurement Period: Index Period: December 2, 2015 through November 30, 2016Assessment Period: November 1, 2016 through December 31, 2017 PY1 Measurement Period: Index Period: December 2, 2016 through November 30, 2017Assessment Period: November 1, 2017 through December 31, 2018 PY2 Measurement Period: Index Period: December 2, 2017 through November 30, 2018Assessment Period: November 1, 2018 through December 31, 2019 PY3 Measurement Period: Index Period: December 2, 2018 through November 30, 2019Assessment Period: November 1, 2019 through December 31, 2020 Follow the steps below to identify the eligible population:Step 1: Identify consumers seen at the provider entity at least once during the measurement year.Step 2: Identify consumers from step 1 who have a diagnosis of Major Depression or Dysthymia during an outpatient encounter during the measurement year. Note: For behavioral health providers, the Depression or dysthymia diagnosis codes must be listed as the primary diagnosis. This excludes consumers with other psychiatric diagnoses with a secondary component of Depression. If the provider is primary care, the diagnosis codes can be in any position (this might occur if the patient was diagnosed by a primary care provider and subsequently seen by the CMHC). This distinction between behavioral health providers and other providers is only meaningful for CMHCs that include non-behavioral health healthcare providers who may screen for depression as a part of providing general health care.Step 3: Identify consumers from step 2 who have an index date PHQ-9 score greater than 9 documented during the twelve-month denominator identification period (code G9511).Step 4: Identify consumers from step 3 who are aged 18 years and older at the index date.Note: To be considered denominator eligible for this measure, the consumer must have both the diagnosis of Major Depression or Dysthymia and an index date PHQ-9 score greater than 9 documented at the same encounter during the dates of denominator identification measurement period. Example of how to calculate percent reduction in PHQ-9 score for DSRIP reporting purposes:(Initial Score -12 Month Follow-up score)/Initial ScoreA. Initial PHQ-9 score of 18, follow-up PHQ-9 score of 9 = (18-9)/18 = 50% = PERFORMANCE METB. Initial PHQ-9 score of 14, follow-up PHQ-9 score of 9 = (14-9)/14 = 35.7% = PERFORMANCE NOT METC. Initial PHQ-9 Score of 16, follow-up PHQ-9 score of 7 = (16-7)/16 = 56.25% = PERFORMANCE METFor DSRIP reporting purposes, a percent reduction equal to or greater than 50% is performance met. No rounding will be acceptedM1-182: Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (SSD-AD)Measure Description:The percentage of patients 18 – 64 years of age with schizophrenia or bipolar disorder, who were prescribed an antipsychotic medication and had a diabetes screening test during the measurement year.M1-182: Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (SSD-AD)DY7/DY8 Program IDM1-182Measure DetailsSteward: NCQANQF #: 1932Source: CMS Adult Core SetData SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusOptionalMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: QISMCHPL: 0.8717MPL: 0.7737National Quality Compass 2016 - All LOBs: Average (90th and 25th percentiles)Directionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is eligible for a baseline numerator of 0 per PFM Section VI.22.b.i (page 24). If approved for a baseline of zero, the DY7 goal will be 84.01% and DY8 goal of 84.33%.Denominator DescriptionPatients ages 18 to 64 years of age as of the end of the measurement year (e.g., December 31) with a schizophrenia or bipolar disorder diagnosis and who were prescribed an antipsychotic medication.Denominator InclusionsAges 18 to 64 as of December 31 of the measurement year.ANDAt least one of the following criteria during the mesaurement year: - At least one acute inpatient encounter with any diagnosis of schizophrenia or bipolar disorder. Any of the following code combinations meet criteria: - BH Stand Alone Acute Inpatient Value Set with Schizophrenia Value Set - BH Stand Alone Acute Inpatient Value Set with Bipolar Disorder Value Set - BH Stand Alone Acute Inpatient Value Set with Other Bipolar Disorder Value Set - BH Acute Inpatient Value Set with BH Acute Inpatient POS Value Set and Schizophrenia Value Set - BH Acute Inpatient Value Set with BH Acute Inpatient POS Value Set and Bipolar Disorder Value Set - BH Acute Inpatient Value Set with BH Acute Inpatient POS Value Set and Other Bipolar Disorder Value Set- At least two visits in an outpatient, intensive outpatient, partial hospitalization, ED, or nonacute inpatient setting, on different dates of service, with any diagnosis of schizophrenia. Any two of the following code combinations meet criteria: - BH Stand Alone Outpatient/PH/IOP Value Set with Schizophrenia Value Set - BH Outpatient/PH/IOP Value Set with BH Outpatient/PH/IOP POS Value Set and Schizophrenia Value Set - ED Value Set with Schizophrenia Value Set - BH ED Value Set with ED POS Value Set and Schizophrenia Value Set - BH Stand Alone Nonacute Inpatient Value Set with Schizophrenia Value Set - BH Nonacute Inpatient Value Set with BH Nonacute Inpatient POS Value Set and Schizophrenia Value Set- At least two visits in an outpatient, intensive outpatient, partial hospitalization, ED, or nonacute inpatient setting, on different dates of service, with any diagnosis of bipolar disorder. Any two of the following code combinations meet criteria: - BH Stand Alone Outpatient/PH/IOP Value Set with Bipolar Disorder Value Set - BH Stand Alone Outpatient/PH/IOP Value Set with Other Bipolar Disorder Value Set - BH Outpatient/PH/IOP Value Set with BH Outpatient/PH/IOP POS Value Set and Bipolar Disorder Value Set - BH Outpatient/PH/IOP Value Set with BH Outpatient/PH/IOP POS Value Set and Other Bipolar Disorder Value Set - ED Value Set with Bipolar Disorder Value Set - ED Value Set with Other Bipolar Disorder Value Set - BH ED Value Set with ED POS Value Set and Bipolar Disorder Value Set - BH ED Value Set with ED POS Value Set and Other Bipolar Disorder Value Set - BH Stand Alone Nonacute Inpatient Value Set with Bipolar Disorder Value Set - BH Stand Alone Nonacute Inpatient Value Set with Other Bipolar Disorder Value Set - BH Nonacute Inpatient Value Set with BH Nonacute Inpatient POS Value Set and Bipolar Disorder Value Set - BH Nonacute Inpatient Value Set with BH Nonacute Inpatient POS Value Set and Other Bipolar Disorder Value Set AbilifyAbilify DiscmeltAbilify MaintenaAripiprazoleAristadaChlorpromazine HydrochlorideClozapineClozarilCompazineFanaptFazaCloFluoxetine Hydrochloride-OlanzapineFluphenazine DecanoateFluphenazine HydrochlorideGeodonHaldol DecanoateHaloperidolHaloperidol DecanoateHaloperidol LactateInvegaInvega SustennaInvega TrinzaLatudaLoxapine SuccinateLoxitaneMolindone HydrochlorideOlanzapineOrapPaliperidone ERPermitilPerphenazinePerphenazine-AmitriptylinePimozideProchlorperazine MaleateQuetiapine FumarateRexultiRisperdalRisperdal ConstaRisperdal M-TabRisperidoneSaphrisSaphris Black CherrySeroquelSeroquel XRSymbyaxThioridazine HydrochlorideThiothixeneTrifluoperazine HydrochlorideTrilafonVersaclozVraylarZiprasidone HydrochlorideZyprexaZyprexa RelprevvZyprexa ZydisDenominator ExclusionsStep 2: Required ExclusionsExclude patients who met any of the following criteria: Patients with diabetes:There are two ways to identify beneficiaries with diabetes: (1) by claims/encounter data and (2) by pharmacy data. Providers should use both methods to identify beneficiaries with diabetes, but a beneficiary need only be identified by one method to be excluded from the measure. Patients may be identified as having diabetes during the measurement year or the year prior to the measurement year.1. Claims/encounter data. Beneficiaries who met any of the following criteria during the measurement year or year prior to the measurement year (count services that occur over both years): ? At least two outpatient visits Outpatient Value Set), observation visits (Observation Value Set), ED Visits (ED Value Set), or nonacute inpatient encounters (Nonacute Inpatient Value Set) on different dates of service, with a diagnosis of diabetes (Diabetes Value Set). Visit type need not be the same for the two visits. services that occur over both years): ? At least one acute inpatient encounter (Acute Inpatient Value Set) with a diagnosis of diabetes (Diabetes Value Set).2. Pharmacy data. Beneficiaries who were dispensed insulin or oral hypoglycemics/ antihyperglycemics during the measurement year or the year prior to the measurement year (Table SSD-A)Prescriptions to Identify Beneficiaries with Diabetes:Alpha-glucosidase inhibitors:- Acarbose- MiglitolAmylin analogs: - PramlinitideAntidiabetic combinations:- Alogliptin-metformin- Alogliptin-pioglitazone- Canaglifozin-metformin- Dapagliflozin-metformin- Empaglifozin-linagliptin- Empagliflozin/metformin- Glimepiride-pioglitazone- Glimepiride-rosiglitazone- Glipizide-metformin- Glyburide-metformin- Linagliptin-metformin- Metformin-pioglitazone- Metformin-repaglinide- Metformin-rosiglitazone- Metformin-saxagliptin- Metformin-sitagliptin- Sitagliptin-simvastatinInsulin: - Insulin aspart- Insulin aspart-insulin aspart protamine- Insulin degludec- Insulin detemir- Insulin glargine- Insulin glulisine- Insulin human inhaled- Insulin isophane human- Insulin isophane-insulin regular- Insulin lispro- Insulin lispro-insulin lispro protamine- Insulin regular human- Meglitinides: - Nateglinide- RepaglinideGlucagon-like peptide-1 (GLP1) agonists:- Dulaglutide- Exenatide- Liraglutide- AlbiglutideSodium glucose cotransporter 2 (SGLT2) inhibitor:- Canagliflozin- Dapagliflozin- EmpagliflozinSulfonylureas: - Chlorpropamide- Glimepiride- Glipizide- Glyburide- Tolazamide- TolbutamideThiazolidinediones: - Pioglitazone- RosiglitazoneDipeptidyl peptidase-4 (DDP-4) inhibitors:- Alogliptin- Linagliptin- Saxagliptin- Sitaglipin Beneficiaries who had no antipsychotic medications dispensed during the measurement year:There are two ways to identify dispensing events: (1) by claims/encounter data and (2) by pharmacy data. Both methods must be used to identify dispensing events, but an event need only be identified by one method to be counted.1. Claim/encounter data. An antipsychotic medication (Long-Acting Injections Value Set).2. Pharmacy data. Dispensed an antipsychotic medication (Table SSD-B) on an ambulatory basis:Miscellaneous antipsychotic agents (oral):- Aripiprazole- Asenapine- Brexpiprazole- Cariprazine- Clozapine- Haloperidol- Iloperidone Loxapine- Lurasidone- Molindone- Olanzapine- Paliperidone- Pimozide- Quetiapine- Quetiapinefumarate- Risperidone- Ziprasidone- Phenothiazine antipsychotics (oral):- Chlorpromazine- Fluphenazine- Perphenazine- Perphenazineamitriptyline- Prochlorperazine- Thioridazine- TrifluoperazinePsychotherapeutic combinations (oral):- Fluoxetine-olanzapineThioxanthenes (oral):- ThiothixeneLong-acting injections: - Aripiprazole- Fluphenazine- decanoate- Haloperidol decanoate- Olanzapine- Paliperidone- palmitate- Risperidone Exclude members who use hospice services or elect to use a hospice benefit any time during the measurement year, regardless of when the services began.Numerator DescriptionA glucose test (Glucose Tests Value Set) or an HbA1c test (HbA1c Tests Value Set) performed during the measurement year, as identified by claims/encounter or automated laboratory data.Numerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsSource measure was specified at the health plan level. Measure has been adapted from the 2017 CMS Adult Core Set and has been respecified to refer to patients rather than members, and to refer to medications prescribed rather than medications dispensed.Additional InformationRefer to HEDIS 2017 Value Set Directory for referenced value sets.M1-203: Hepatitis C: One-Time Screening for Hepatitis C Virus (HCV) for Patients at RiskMeasure Description:Percentage of patients aged 18 years and older with one or more of the following: a history of injection drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis, OR birthdate in the years 1945–1965 who received one- time screening for hepatitis C virus (HCV) infectionM1-203: Hepatitis C: One-Time Screening for Hepatitis C Virus (HCV) for Patients at RiskDY7/DY8 Program IDM1-203Measure DetailsSteward: AMA-PCPINQF #: NA / 3059 eMeasureSource: CMS MIPS #400 (Claims/Registry)Data SourceClaimsRequired StatusOptionalMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionAll patients aged 18 years and older who were seen twice for any visit or who had at least one preventive visit within the 12 month reporting period with one or more of the following: a history of injection drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis, OR birthdate in the years 1945–1965 DENOMINATOR NOTE: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for registry-based measures.Denominator InclusionsPatients aged ≥ 18 yearsANDAt least one preventive encounter during the performance period (CPT or HCPCS): 99385*, 99386*, 99387*, 99395*, 99396*, 99397*, G0438, G0439WITHOUT:Telehealth Modifier: GQ, GTORAt least two patient encounters during the performance period (CPT): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99241*, 99242*, 99243*, 99244*, 99245*, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350WITHOUT:Telehealth Modifier: GQ, GTANDPatients who were born in the years 1945 to 1965: G9448ORHistory of receiving blood transfusions prior to 1992: G9449ORReceiving maintenance hemodialysis (CPT): 90951, 90952, 90953, 90954, 90955, 90956, 90957, 90958, 90959, 90960, 90961, 90962, 90963, 90964, 90965, 90966, 90967, 90968, 90969, 90970, 99512*ORHistory of injection drug use: G9450Denominator ExclusionsDiagnosis for Chronic Hepatitis C (ICD-10-CM): B18.2ORDocumentation of medical reason(s) for not receiving one-time screening for HCV infection (e.g., decompensated cirrhosis indicating advanced disease [ie, ascites, esophageal variceal bleeding, hepatic encephalopathy], hepatocellular carcinoma, waitlist for organ transplant, limited life expectancy, other medical reasons) (G9452)ORDocumentation of patient reason(s) for not receiving one-time screening for HCV infection (e.g., patient declined, other patient reasons) (G9453)Numerator DescriptionPatients who received one-time screening for HCV infection Definition:Screening for HCV Infection includes current or prior receipt of:1. HCV antibody test2. HCV RNA test3. Recombinant immunoblot assay (RIBA) test (if performed at any time in the past)Numerator Inclusions (Performance Met)Patient received one-time screening for HCV infection (G9451)Numerator Exclusions (Performance Not Met)One-time screening for HCV infection not received within 12 month reporting period and no documentation of prior screening for HCV infection, reason not given (G9454)DSRIP Specific ModificationsNoneAdditional InformationNoneM1-205: Third next available appointmentMeasure Description:This measure is used to assess the average number of days to the third next available appointment for an office visit* for each clinic and/or department. This measure does not differentiate between "new" and "established" patients.*Office Visit: A patient encounter with a health care provider in an office, clinic, or ambulatory care facility as an outpatient.M1-205: Third next available appointmentDY7/DY8 Program IDM1-205Measure DetailsSteward: Wisconsin Collaborative for Healthcare QualityNQF #: NASource: SourceAnyRequired StatusOptionalMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: NegativeUnit of Measurement for Payer TypeUnit: NAMeasure will be reported as an all-payer rate only.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionThe denominator for this measure should be reported as 1.Denominator InclusionsNot ApplicableDenominator ExclusionsNot applicable.Numerator DescriptionContinuous variable statement: Average number of days to third next available appointment for an office visit for each clinic and/or department The measure will take into account calendar days, including weekends, holidays and clinician days off.Numerator Inclusions (Performance Met)Not ApplicableNumerator Exclusions (Performance Not Met)Not ApplicableDSRIP Specific ModificationsFor DSRIP reporting Purposes, the denominator for this measure is 1 so that the resulting rate is days to third next available appointment. Measure stewards denominator description is included in the measure description.Additional InformationA. All providers are included. Full-time and part-time providers are included, regardless of the number of hours s/he practices per week.- Providers who truly job share are counted as one provider (i.e., they share one schedule, and/or they work separate day and share coverage of one practice).- When measuring a care team, each member of the care team is counted separately (i.e., MD, NP, PA).- If a provider is practicing in a specialty other than the one which s/he is board certified, the provider should be included in the specialty in which s/he is practicing.- For providers practicing at more than 1 location, measure days to third next available for only the provider's primary location as long as the provider is at that location 51%+ of their time.- New providers who started seeing patients during the reporting period and have an active schedule should be included.2. Locums are included in the measure only if they are assigned to a specific site for an extended period of time (greater than 4 weeks) and provide continuity care to a panel of patients.B. Mid-Level providers are included in the measure (NP, PA, CNM).- Mid-Level providers should have continuity practice and their own schedule available to see patients.C. Resident Providers are to be included if they have an active schedule AND are considered a Primary Care Provider within the organization.D. Providers with closed practices should be included. They still have to schedule their current patients. In addition, it may not be clear when they start seeing new patients again.Exclusions: Exclude clinicians who do not practice for an extended period of time (greater than 4 weeks) due to maternity leave, sabbatical, family medical leave.Mid-Level providers who function only as an "extender," overflow to another practice, or urgent care should not be included.Exclude Resident Providers if they are not considered a Primary Care Provider, have an inconsistent schedule, and a restricted patient panel.Time to third next available appointment is a nationally accepted measure of access and is endorsed by the Institute for Healthcare Improvement. This measure is used across the country at most major healthcare institutions. In addition, the members of the Wisconsin Collaborative for Healthcare Quality have undergone a data audit and validation by MetaStar, Inc, an independent third party. The purpose of this process was to audit the systems used to produce the data and to conduct measure determination. Measure determination consists of a series of steps to assure that the denominator is accurate, the sampling process is accurate, the numerator is appropriate, the entity has complied with the algorithm and documentation is appropriate.M1-207: Diabetes care: BP control (<140/90mm Hg)Measure Description:The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) whose most recent blood pressure level taken during the measurement year is <140/90 mm Hg.M1-207: Diabetes care: BP control (<140/90mm Hg)DY7/DY8 Program IDM1-207Measure DetailsSteward: NCQANQF #: 0061Source: See notesData SourceClaimsRequired StatusOptionalMeasure ClassificationType: Clinical OutcomeMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: QISMCHPL: 0.7564MPL: 0.5229National Quality Compass 2016 - All LOBs: Average (90th and 25th percentiles)Directionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionPatients 18 - 75 years of age with diabetes with a visit during the measurement periodDenominator InclusionsPatients aged 18 years to 75 years on date of encounterANDDiagnosis for diabetes (ICD-10-CM): E10.10, E10.11, E10.21, E10.22, E10.29, E10.311, E10.319, E10.3211, E10.3212, E10.3213, E10.3219, E10.3291, E10.3292, E10.3293, E10.3299, E10.3311, E10.3312, E10.3313, E10.3319, E10.3391, E10.3392, E10.3393, E10.3399, E10.3411, E10.3412, E10.3413, E10.3419, E10.3491, E10.3492, E10.3493, E10.3499, E10.3511, E10.3512, E10.3513, E10.3519, E10.3521, E10.3522, E10.3523, E10.3529, E10.3531, E10.3532, E10.3533, E10.3539, E10.3541, E10.3542, E10.3543, E10.3549, E10.3551, E10.3552, E10.3553, E10.3559, E10.3591, E10.3592, E10.3593, E10.3599, E10.36, E10.37X1, E10.37X2, E10.37X3, E10.37X9, E10.39, E10.40, E10.41, E10.42, E10.43, E10.44, E10.49, E10.51, E10.52, E10.59, E10.610, E10.618, E10.620, E10.621, E10.622, E10.628, E10.630, E10.638, E10.641, E10.649, E10.65, E10.69, E10.8, E10.9, E11.00, E11.01, E11.21, E11.22, E11.29, E11.311, E11.319, E11.3211, E11.3212, E11.3213, E11.3219, E11.3291, E11.3292, E11.3293, E11.3299, E11.3311, E11.3312, E11.3313, E11.3319, E11.3391, E11.3392, E11.3393, E11.3399, E11.3411, E11.3412, E11.3413, E11.3419, E11.3491, E11.3492, E11.3493, E11.3499, E11.3511, E11.3512, E11.3513, E11.3519, E11.3521, E11.3522, E11.3523, E11.3529, E11.3531, E11.3532, E11.3533, E11.3539, E11.3541, E11.3542, E11.3543, E11.3549, E11.3551, E11.3552, E11.3553, E11.3559, E11.3591, E11.3592, E11.3593, E11.3599, E11.36, E11.37X1, E11.37X2, E11.37X3, E11.37X9, E11.39, E11.40, E11.41, E11.42, E11.43, E11.44, E11.49, E11.51, E11.52, E11.59, E11.610, E11.618, E11.620, E11.621, E11.622, E11.628, E11.630, E11.638, E11.641, E11.649, E11.65, E11.69, E11.8, E11.9, E13.00, E13.01, E13.10, E13.11, E13.21, E13.22, E13.29, E13.311, E13.319, E13.3211, E13.3212, E13.3213, E13.3219, E13.3291, E13.3292, E13.3293, E13.3299, E13.3311, E13.3312, E13.3313, E13.3319 E13.3391, E13.3392, E13.3393, E13.3399, E13.3411, E13.3412, E13.3413, E13.3419, E13.3491, E13.3492, E13.3493, E13.3499, E13.3511, E13.3512, E13.3513, E13.3519, E13.3521, E13.3522, E13.3523, E13.3529, E13.3531, E13.3532, E13.3533, E13.3539, E13.3541, E13.3542, E13.3543, E13.3549, E13.3551, E13.3552, E13.3553, E13.3559, E13.3591, E13.3592, E13.3593, E13.3599, E13.36, E13.37X1, E13.37X2, E13.37X3, E13.37X9, E13.39, E13.40, E13.41, E13.42, E13.43, E13.44, E13.49, E13.51, E13.52, E13.59, E13.610, E13.618, E13.620, E13.621, E13.622, E13.628, E13.630, E13.638, E13.641, E13.649, E13.65, E13.69, E13.8, E13.9, O24.011, O24.012, O24.013, O24.019, O24.02, O24.03, O24.111, O24.112, O24.113, O24.119, O24.12, O24.13, O24.311, O24.312, O24.313, O24.319, O24.32, O24.33, O24.811, O24.812, O24.813, O24.819, O24.82, O24.83ANDPatient encounter during performance period (CPT or HCPCS): 97802, 97803, 97804, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99281, 99282, 99283, 99284, 99285, 99291, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0270, G0271, G0402, G0438, G0439E.H.R: AND: "Diagnosis: Diabetes" overlaps "Measurement Period" AND: Age>= 18 year(s) at: "Measurement Period" AND: Age< 75 year(s) at: "Measurement Period" AND: Union of: "Encounter, Performed: Office Visit" "Encounter, Performed: Face-to-Face Interaction" "Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up" "Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up" "Encounter, Performed: Home Healthcare Services" "Encounter, Performed: Annual Wellness Visit" during "Measurement Period"@@@For both the Claims and E.H.R. specifications, providers should limit office visit/E&M CPT codes 99201 - 99205 and 99211 - 99219 to primary care, outpatient specialty care where primary care is managed, and specialty care related to diabetes management. Encounters may be limited by clinic, place of service, or physician but not by visit specific services.Denominator ExclusionsCLAIMS:Hospice services provided to patient any time during the measurement period: G9687E.H.R.: OR: "Encounter, Performed: Encounter Inpatient (discharge status: Discharged to Home for Hospice Care)" ends during "Measurement Period" OR: "Encounter, Performed: Encounter Inpatient (discharge status: Discharged to Health Care Facility for Hospice Care)" ends during "Measurement Period" OR: Union of: "Intervention, Order: Hospice care ambulatory" "Intervention, Performed: Hospice care ambulatory" overlaps "Measurement Period"Numerator DescriptionPatients whose blood pressure at the most recent visit is adequately controlled (systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg) during the measurement period Numerator Instructions: To describe both systolic and diastolic blood pressure values, each must be reported separately. If there are multiple blood pressures on the same date of service, use the lowest systolic and lowest diastolic blood pressure on that date as the representative blood pressure. NUMERATOR NOTE: In reference to the numerator element, only blood pressure readings performed by an eligible clinician in the provider office are acceptable for numerator compliance with this measure. Blood pressure readings from the patient's home (including readings directly from monitoring devices) are not acceptable.If no blood pressure is recorded during the measurement period, the patient's blood pressure is assumed "not controlled."If there are multiple blood pressure readings on the same day, use the lowest systolic and the lowest diastolic reading as the most recent blood pressure reading.Numerator Inclusions (Performance Met)Most recent systolic blood pressure < 140 mmHg (G8752)ANDMost recent diastolic blood pressure < 90 mmHg (G8754)E.H.R.: AND: Most Recent: "Occurrence A of Encounter, Performed: Adult Outpatient Visit" satisfies all: during "Measurement Period" overlaps "Physical Exam, Performed: Diastolic Blood Pressure (result)" overlaps "Physical Exam, Performed: Systolic Blood Pressure (result)" overlaps "Occurrence A of Diagnosis: Essential Hypertension" AND: "Physical Exam, Performed: Diastolic Blood Pressure" satisfies all: Most Recent: during "Occurrence A of Encounter, Performed: Adult Outpatient Visit" (result < 90 mmHg) AND: "Physical Exam, Performed: Systolic Blood Pressure" satisfies all: Most Recent: during "Occurrence A of Encounter, Performed: Adult Outpatient Visit" (result < 140 mmHg)Numerator Exclusions (Performance Not Met)Most recent systolic blood pressure ≥ 140 mmHg (G8753)ORMost recent diastolic blood pressure ≥ 90 mmHg (G8755)ORNo documentation of blood pressure measurement, reason not given (G8756)DSRIP Specific ModificationsDenominator has been modified to follow the specifications of measure A1-115 Comprehensive Diabetes Care: HbA1c Poor Control (>9%). Numerator values were specified to follow the specifications of measure A2-103 Controlling High Blood Pressure (excluding the E.H.R. numerator inclusion elements requiring a hypertension diagnosis). Additional InformationNoneM1-210: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up DocumentedMeasure Description:Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicatedM1-210: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up DocumentedDY7/DY8 Program IDM1-210Measure DetailsSteward: CMSNQF #: NASource: CMS MIPS #317 (Claims/Registry) eMeasure: SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusOptionalMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionAll patients aged 18 years and olderDenominator InclusionsCLAIMS/REGISTRY:Patients aged ≥ 18 yearsANDPatient encounter during the performance period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 90839, 90845, 90880, 92002, 92004, 92012, 92014, 96118, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99281, 99282, 99283, 99284, 99285, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, D7140, D7210, G0101, G0402, G0438, G0439WITHOUTTelehealth Modifier: GQ, GT E.H.R.: AND: Age>= 18 year(s) at: "Measurement Period" AND: "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" during "Measurement Period"Denominator ExclusionsCLAIMS/REGISTRY:Patient not eligible due to active diagnosis of hypertension: G9744ORDocumented reason for not screening or recommending a follow-up for high blood pressure (G9745) Not Eligible for High Blood Pressure Screening (Denominator Exclusion)-? Patient has an active diagnosis of hypertension Patients with a Documented Reason for not Screening or Follow-Up Plan for High Blood Pressure (Denominator Exception)-? Patient refuses to participate (either BP measurement or follow-up)? Patient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient’s health status. This may include but is not limited to severely elevated BP when immediate medical treatment is indicated E.H.R.: OR: "Diagnosis: Diagnosis of hypertension" starts before start of "Occurrence A of Encounter, Performed: BP Screening Encounter Codes"Numerator DescriptionPatients who were screened for high blood pressure AND have a recommended follow-up plan documented, as indicated, if the blood pressure is pre-hypertensive or hypertensive NUMERATOR NOTE: Although the recommended screening interval for a normal BP reading is every 2 years, to meet the intent of this measure, BP screening and follow-up must be performed once per measurement period. For patients with Normal blood pressure a follow-up plan is not required. If the blood pressure is pre-hypertensive (SBP > 120 and <139 OR DBP >80 and <89) at a PCP encounter no additional follow-up would be needed, this would meet the intent of the measure (G8783). Definitions:Blood Pressure (BP) Classification - BP is defined by four (4) BP reading classifications: Normal, Pre- Hypertensive, First Hypertensive, and Second Hypertensive ReadingsRecommended BP Follow-Up - The Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) recommends BP screening intervals, lifestyle modifications and interventions based on the current BP reading as listed in the “Recommended Blood Pressure Follow- Up Interventions” listed belowRecommended Lifestyle Modifications - The JNC 7 report outlines lifestyle modifications which must include one or more of the following as indicated:? Weight Reduction? Dietary Approaches to Stop Hypertension (DASH) Eating Plan? Dietary Sodium Restriction? Increased Physical Activity? Moderation in alcohol (ETOH) ConsumptionSecond Hypertensive Reading - Requires a BP reading of Systolic BP ≥ 140 mmHg OR Diastolic BP ≥ 90 mmHg during the current encounter AND a most recent BP reading within the last 12 months Systolic BP ≥ 140 mmHg OR Diastolic BP ≥ 90 mmHgSecond Hypertensive BP Reading Interventions - The JNC 7 report outlines BP follow-up interventions for a second hypertensive BP reading and must include one or more of the following as indicated:? Anti-Hypertensive Pharmacologic Therapy? Laboratory Tests? Electrocardiogram (ECG)Recommended Blood Pressure Follow-up Interventions -? Normal BP: No follow-up required for Systolic BP <120 mmHg AND Diastolic BP < 80 mmHg? Pre-Hypertensive BP: Follow-up with rescreen every year with systolic BP of 120 – 139 mmHg OR diastolic BP of 80 – 89 mmHg AND recommended lifestyle modifications OR referral to Alternate/Primary Care Provider? First Hypertensive BP Reading: Patients with one elevated reading of systolic BP >= 140 mmHg OR diastolic BP >= 90 mmHg:? Follow-up with rescreen > 1 day and < 4 weeks AND recommend lifestyle modifications OR referral to Alternative/Primary Care Provider? Second Hypertensive BP Reading: Patients with second elevated reading of systolic BP >= 140 mmHg OR diastolic BP >= 90 mmHg:? Follow-up with Recommended lifestyle modifications AND one or more of the Second Hypertensive Reading Interventions OR referral to Alternative/Primary Care Provider Recommended Blood Pressure Follow-Up (must include all indicated actions for each BP Classification): A. Normal BP Readiing (Systolic <120 AND Diastolic <80): No follow up required B. Pre-Hypertensive BP Reading (Systolic greater than or equal to 120 and less than or equal to 139, or Diastolic greater than or equal to 80 and less than or equal to 89):Rescreen BP within a minimum of 1 year AND recomemended Lifestyle Modifications OR Referal to Alternative/Primary Care Provider C. First Hypertensive BP Reading (Systolic greater than or equal to 140 or Diastolic greater than or equal to 90): Rescreen BP within a minimum of >1 day and <4 weeks AND recommend Lifestyle ModificationsORReferal to Alternative/Primary Care Provider D. Second Hypertensive BP Reading (Systolic greater than or equal to 140 or Diastolic greater than or equal to 90): Recommend Lifestyle Modifications AND 1 or more of the Second Hypertensive Reading Interventions (see definitions) ORReferral to Alternative/Primary Care ProviderNumerator Inclusions (Performance Met)CLAIMS/REGISTRY:Normal blood pressure reading documented, follow-up not required (G8783)ORPre-Hypertensive or Hypertensive blood pressure reading documented, AND the indicated follow-up is documented (G8950) E.H.R.: AND: Most Recent: "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" satisfies all: overlaps "Physical Exam, Performed: Diastolic Blood Pressure (result)" overlaps "Physical Exam, Performed: Systolic Blood Pressure (result)" AND: OR: AND: "Physical Exam, Performed: Systolic Blood Pressure" satisfies all: Most Recent: during "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" (result < 120 mmHg) AND: "Physical Exam, Performed: Diastolic Blood Pressure" satisfies all: Most Recent: during "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" (result < 80 mmHg) OR: AND: OR: AND: "Physical Exam, Performed: Systolic Blood Pressure" satisfies all: Most Recent: during "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" (result >= 120 mmHg) (result < 140 mmHg) AND: "Physical Exam, Performed: Diastolic Blood Pressure" satisfies all: Most Recent: during "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" (result < 90 mmHg) OR: AND: "Physical Exam, Performed: Diastolic Blood Pressure" satisfies all: Most Recent: during "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" (result >= 80 mmHg) (result < 90 mmHg) AND: "Physical Exam, Performed: Systolic Blood Pressure" satisfies all: Most Recent: during "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" (result < 140 mmHg) AND: OR: "Intervention, Order: Referral to Alternative Provider / Primary Care Provider (reason: Finding of Hypertension)" <= 1 day(s) starts after or concurrent with start of "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" OR: AND: $HypertensionRecommendations <= 1 day(s) starts after or concurrent with start of "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" AND: "Intervention, Order: Followup within one year (reason: Finding of Hypertension)" <= 1 day(s) starts after or concurrent with start of "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" OR: AND: OR: AND NOT: "Physical Exam, Performed: Systolic Blood Pressure (result)" < 1 year(s) starts before start of "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" AND NOT: "Physical Exam, Performed: Diastolic Blood Pressure (result)" < 1 year(s) starts before start of "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" OR: AND: "Physical Exam, Performed: Systolic Blood Pressure" satisfies all: Most Recent: < 1 year(s) starts before start of "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" (result < 140 mmHg) AND: "Physical Exam, Performed: Diastolic Blood Pressure" satisfies all: Most Recent: < 1 year(s) starts before start of "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" (result < 90 mmHg) AND: OR: "Physical Exam, Performed: Systolic Blood Pressure" satisfies all: Most Recent: during "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" (result >= 140 mmHg) OR: "Physical Exam, Performed: Diastolic Blood Pressure" satisfies all: Most Recent: during "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" (result >= 90 mmHg) AND: OR: "Intervention, Order: Referral to Alternative Provider / Primary Care Provider (reason: Finding of Hypertension)" <= 1 day(s) starts after or concurrent with start of "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" OR: AND: $HypertensionRecommendations <= 1 day(s) starts after or concurrent with start of "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" AND: "Intervention, Order: Followup within 4 weeks (reason: Finding of Hypertension)" <= 1 day(s) starts after or concurrent with start of "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" OR: AND: OR: "Physical Exam, Performed: Systolic Blood Pressure" satisfies all: Most Recent: < 1 year(s) starts before start of "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" (result >= 140 mmHg) OR: "Physical Exam, Performed: Diastolic Blood Pressure" satisfies all: Most Recent: < 1 year(s) starts before start of "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" (result >= 90 mmHg) AND: OR: "Physical Exam, Performed: Systolic Blood Pressure" satisfies all: Most Recent: during "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" (result >= 140 mmHg) OR: "Physical Exam, Performed: Diastolic Blood Pressure" satisfies all: Most Recent: during "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" (result >= 90 mmHg) AND: OR: "Intervention, Order: Referral to Alternative Provider / Primary Care Provider (reason: Finding of Hypertension)" <= 1 day(s) starts after or concurrent with start of "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" OR: AND: $HypertensionRecommendations <= 1 day(s) starts after or concurrent with start of "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" AND: Union of: "Medication, Order: Anti-Hypertensive Pharmacologic Therapy" "Laboratory Test, Order: Laboratory Tests for Hypertension" "Diagnostic Study, Order: ECG 12 lead or study order" <= 1 day(s) starts after or concurrent with start of "Occurrence A of Encounter, Performed: BP Screening Encounter Codes"Numerator Exclusions (Performance Not Met)CLAIMS/REGISTRY:Blood pressure reading not documented, reason not given (G8785)ORPre-Hypertensive or Hypertensive blood pressure reading documented, indicated follow-up not documented, reason not given (G8952) E.H.R.:NoneDSRIP Specific ModificationsNoneAdditional InformationE.H.R.:Data Criteria (QDM Variables):? $HypertensionRecommendations = o Union of: "Intervention, Order: Lifestyle Recommendation" "Intervention, Order: Weight Reduction Recommended" "Intervention, Order: Dietary Recommendations" "Intervention, Order: Physical Activity Recommendation" "Intervention, Order: Moderation of ETOH Consumption Recommendation"Data Criteria (QDM Data Elements):? "Diagnosis: Diagnosis of hypertension" using "Diagnosis of hypertension Grouping Value Set (2.16.840.1.113883.3.600.263)"? "Diagnostic Study, Order: ECG 12 lead or study order" using "ECG 12 lead or study order Grouping Value Set (2.16.840.1.113883.3.600.2448)"? "Diagnostic Study, Order not done: Patient Reason refused" using "Patient Reason refused SNOMEDCT Value Set (2.16.840.1.113883.3.600.791)"? "Encounter, Performed: BP Screening Encounter Codes" using "BP Screening Encounter Codes Grouping Value Set (2.16.840.1.113883.3.600.1920)"? "Intervention, Order: Dietary Recommendations" using "Dietary Recommendations Grouping Value Set (2.16.840.1.113883.3.600.1515)"? "Intervention, Order: Followup within 4 weeks" using "Followup within 4 weeks SNOMEDCT Value Set (2.16.840.1.113883.3.600.1537)"? "Intervention, Order: Followup within one year" using "Followup within one year SNOMEDCT Value Set (2.16.840.1.113883.3.600.1474)"? "Intervention, Order: Lifestyle Recommendation" using "Lifestyle Recommendation SNOMEDCT Value Set (2.16.840.1.113883.3.600.1508)"? "Intervention, Order: Moderation of ETOH Consumption Recommendation" using "Moderation of ETOH Consumption Recommendation SNOMEDCT Value Set (2.16.840.1.113883.3.600.823)"? "Intervention, Order: Physical Activity Recommendation" using "Physical Activity Recommendation Grouping Value Set (2.16.840.1.113883.3.600.1518)"? "Intervention, Order: Referral to Alternative Provider / Primary Care Provider" using "Referral to Alternative Provider / Primary Care Provider SNOMEDCT Value Set (2.16.840.1.113883.3.600.1475)"? "Intervention, Order: Weight Reduction Recommended" using "Weight Reduction Recommended Grouping Value Set (2.16.840.1.113883.3.600.1510)"? "Intervention, Order not done: Patient Reason refused" using "Patient Reason refused SNOMEDCT Value Set (2.16.840.1.113883.3.600.791)"? "Laboratory Test, Order: Laboratory Tests for Hypertension" using "Laboratory Tests for Hypertension Grouping Value Set (2.16.840.1.113883.3.600.1482)"? "Laboratory Test, Order not done: Patient Reason refused" using "Patient Reason refused SNOMEDCT Value Set (2.16.840.1.113883.3.600.791)"? "Medication, Order: Anti-Hypertensive Pharmacologic Therapy" using "Anti-Hypertensive Pharmacologic Therapy RXNORM Value Set (2.16.840.1.113883.3.600.1476)"? "Medication, Order not done: Patient Reason refused" using "Patient Reason refused SNOMEDCT Value Set (2.16.840.1.113883.3.600.791)"? "Physical Exam, Performed: Diastolic Blood Pressure" using "Diastolic Blood Pressure Grouping Value Set (2.16.840.1.113883.3.526.3.1033)"? "Physical Exam, Performed: Systolic Blood Pressure" using "Systolic Blood Pressure Grouping Value Set (2.16.840.1.113883.3.526.3.1032)"? "Physical Exam, Performed not done: Medical or Other reason not done" using "Medical or Other reason not done SNOMEDCT Value Set (2.16.840.1.113883.3.600.1.1502)"? "Physical Exam, Performed not done: Patient Reason refused" using "Patient Reason refused SNOMEDCT Value Set (2.16.840.1.113883.3.600.791)"? Attribute: "Reason: Finding of Hypertension" using "Finding of Hypertension SNOMEDCT Value Set (2.16.840.1.113883.3.600.2395)"M1-211: Weight Assessment and Counseling for Nutrition and Physical Activity for Children/ AdolescentsMeasure Description:Percentage of Consumers 3-17 years of age who had an Outpatient visit with a Primary Care Practitioner (PCP) or Obstetrician/Gynecologist (OB/GYN) and who had evidence of the following during the measurement period. Three rates are reported. - Percentage of Consumers with height, weight, and body mass index (BMI) percentile documentation- Percentage of Consumers with counseling for nutrition- Percentage of Consumers with counseling for physical activityM1-211: Weight Assessment and Counseling for Nutrition and Physical Activity for Children/ AdolescentsDY7/DY8 Program IDM1-211Measure DetailsSteward: NCQANQF #: 0024Source: eMeasure: SourceE.H.R.Required StatusOptionalMeasure ClassificationType: ProcessMeasure Parts: 3Achievement CalculationsCategory: P4PGoal Calculation: QISMCHPL: BMI Percentile: 0.8637Counseling for Nutrition: 0.7952 Counseling for Physical Activity: 0.7158MPL: BMI Percentile: 0.545Counseling for Nutrition: 0.5184Counseling for Physical Activity: 0.4509National Quality Compass 2016 - All LOBs: Average (90th and 25th percentiles)Directionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is eligible for a baseline numerator of 0 per PFM Section VI.22.b.i (page 24). If approved for a baseline of zero, the goals for DY7 and DY8 will be as follows for each measure part: - BMI Percentile: DY7 goal is 77.78% and DY8 goal of 78.64%- CDenominator DescriptionConsumers 3-17 years of age with at least one Outpatient visit with a primary care practitioner (PCP) or an obstetrician/gynecologist (OB/GYN) during the measurement period. Exclusions: Consumers who have a diagnosis of pregnancy during the measurement period. Exclude Consumers who were in hospice care during the measurement year.Denominator InclusionsAND: Age >= 3 year(s) at: "Measurement Period" AND: Age < 17 year(s) at: "Measurement Period" AND: $OutpatientVisitsDenominator ExclusionsOR: "Encounter, Performed: Encounter Inpatient (discharge status: Discharged to Home for Hospice Care)" ends during "Measurement Period" OR: "Encounter, Performed: Encounter Inpatient (discharge status: Discharged to Health Care Facility for Hospice Care)" ends during "Measurement Period" OR: Union of: "Intervention, Order: Hospice care ambulatory" "Intervention, Performed: Hospice care ambulatory" overlaps "Measurement Period" OR: "Diagnosis: Pregnancy" overlaps "Measurement Period"Numerator DescriptionRate 1: Consumers who had a height, weight and body mass index (BMI) percentile recorded during the measurement periodRate 2: Consumers who had counseling for nutrition during a visit that occurs during the measurement periodRate 3: Consumers who had counseling for physical activity during a visit that occurs during the measurement periodNumerator Inclusions (Performance Met)Population Criteria 1: AND: "Physical Exam, Performed: BMI percentile (result)" during "Measurement Period" AND: "Physical Exam, Performed: Height (result)" during "Measurement Period" AND: "Physical Exam, Performed: Weight (result)" during "Measurement Period" Population Criteria 2: AND: "Intervention, Performed: Counseling for Nutrition" during $OutpatientVisits Population Criteria 3: AND: "Intervention, Performed: Counseling for Physical Activity" during $OutpatientVisitsNumerator Exclusions (Performance Not Met)NoneDSRIP Specific ModificationsNoneAdditional InformationRate 1 of measure is a clinic-reported measure for Certified Community Behavioral Health Clinics (CCBHCs) as part of the Demonstration Program to Improve Community Mental Health Services, found in Section 223 of the federal Protecting Access to Medicare Act of 2014 (PAMA). For DSRIP reporting purposes, measure has been specified using the same source measure used for administrative specifications for the CCBHC reporting requirements and rates 2 and 3 have been added in accordance with all provider types in DSRIP. The definition of Primary Care Practitioner (PCP) included in the CCBHC program specifications for use in this measure denominator includes the following: ? A physician or nonphysician (e.g., nurse practitioner, physician assistant) who offers primary care medical services? Licensed practical nurses and registered nurses are not considered PCPs.HHHS will update the measure specifications to that this measure references a primary care practitioner for M1-211. E.H.R.Data Criteria (QDM Variables)? $OutpatientVisits = o Union of: "Encounter, Performed: Face-to-Face Interaction" "Encounter, Performed: Office Visit" "Encounter, Performed: Preventive Care Services-Individual Counseling" "Encounter, Performed: Preventive Care- Initial Office Visit, 0 to 17" "Encounter, Performed: Preventive Care - Established Office Visit, 0 to 17" "Encounter, Performed: Preventive Care Services - Group Counseling" "Encounter, Performed: Home Healthcare Services" during "Measurement Period" Data Criteria (QDM Data Elements)? "Diagnosis: Pregnancy" using "Pregnancy Grouping Value Set (2.16.840.1.113883.3.526.3.378)"? "Encounter, Performed: Encounter Inpatient" using "Encounter Inpatient SNOMEDCT Value Set (2.16.840.1.113883.3.666.5.307)"? "Encounter, Performed: Face-to-Face Interaction" using "Face-to-Face Interaction Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1048)"? "Encounter, Performed: Home Healthcare Services" using "Home Healthcare Services Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1016)"? "Encounter, Performed: Office Visit" using "Office Visit Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1001)"? "Encounter, Performed: Preventive Care - Established Office Visit, 0 to 17" using "Preventive Care - Established Office Visit, 0 to 17 Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1024)"? "Encounter, Performed: Preventive Care Services - Group Counseling" using "Preventive Care Services - Group Counseling Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1027)"? "Encounter, Performed: Preventive Care Services-Individual Counseling" using "Preventive Care Services-Individual Counseling Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1026)"? "Encounter, Performed: Preventive Care- Initial Office Visit, 0 to 17" using "Preventive Care- Initial Office Visit, 0 to 17 Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1022)"? "Intervention, Order: Hospice care ambulatory" using "Hospice care ambulatory SNOMEDCT Value Set (2.16.840.1.113762.1.4.1108.15)"? "Intervention, Performed: Counseling for Nutrition" using "Counseling for Nutrition Grouping Value Set (2.16.840.1.113883.3.464.1003.195.12.1003)"? "Intervention, Performed: Counseling for Physical Activity" using "Counseling for Physical Activity Grouping Value Set (2.16.840.1.113883.3.464.1003.118.12.1035)"? "Intervention, Performed: Hospice care ambulatory" using "Hospice care ambulatory SNOMEDCT Value Set (2.16.840.1.113762.1.4.1108.15)"? "Physical Exam, Performed: BMI percentile" using "BMI percentile Grouping Value Set (2.16.840.1.113883.3.464.1003.121.12.1012)"? "Physical Exam, Performed: Height" using "Height Grouping Value Set (2.16.840.1.113883.3.464.1003.121.12.1014)"? "Physical Exam, Performed: Weight" using "Weight Grouping Value Set (2.16.840.1.113883.3.464.1003.121.12.1015)"? Attribute: "Discharge status: Discharged to Health Care Facility for Hospice Care" using "Discharged to Health Care Facility for Hospice Care SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.207)"? Attribute: "Discharge status: Discharged to Home for Hospice Care" using "Discharged to Home for Hospice Care SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.209)"M1-216: Risk Adjusted Behavioral Health/ Substance Abuse 30-Day Readmission RateMeasure Description:Risk adjusted rate of hospital admissions for Behavioral Health /Substance Abuse (BH/SA) that had at least one readmission for any reason within 30 days of discharge for Behavioral Health or Substance abuse patients 18 years of age and older.A readmission is a subsequent hospital admission in the same hospital within 30 days following an original admission. The discharge date for the index admission must occur within the time period defined as one month prior to the beginning of the measurement period and ending one month prior to the end of the measurement year to allow for the 30-day follow-up period for readmissions within the measurement year.M1-216: Risk Adjusted Behavioral Health/ Substance Abuse 30-Day Readmission RateDY7/DY8 Program IDM1-216Measure DetailsSteward: NANQF #: NASource: NAData SourceClaims, otherRequired StatusOptionalMeasure ClassificationType: Clinical OutcomeMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: NegativeUnit of Measurement for Payer TypeUnit: EncountersMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionExpected (risk-adjusted) number of readmissions for all-causes during the measurement year.The Expected number reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected number is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days. Case-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc.Denominator InclusionsNoneDenominator ExclusionsNoneNumerator DescriptionObserved (Actual) number of readmissions within 30 days following an Index Admission for BH/SA during the measurement year.Numerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationSee risk adjusting guidance for additional informationM1-241: Decrease in mental health admissions and readmissions to criminal justice settings such as jails or prisonsMeasure Description:The percentage of individuals receiving the project intervention(s) who had a potentially preventable admission/readmission to a criminal justice setting (e.g. jail, prison, etc.) within the measurement periodM1-241: Decrease in mental health admissions and readmissions to criminal justice settings such as jails or prisonsDY7/DY8 Program IDM1-241Measure DetailsSteward: NANQF #: NASource: NAData SourceAnyRequired StatusOptionalMeasure ClassificationType: Clinical OutcomeMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: NegativeUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionNumber of individuals receiving project intervention(s)Denominator InclusionsDenominator:Number of individuals receiving project intervention(s)Numerator:If an individual has more than one jail booking occurrence within the measurement period, that individual would only be counted once in the numeratorDenominator ExclusionsNone listed by measure steward.Numerator DescriptionThe number of individuals receiving project intervention(s) who had a potentially preventable admission/readmission to a criminal justice setting (e.g. jail, prison, etc.) within the measurement period.Numerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationNoneM1-255: Follow-up Care for Children Prescribed ADHD Medication (ADD)Measure Description:Percentage of children 6-12 years of age and newly dispensed a medication for attention-deficit/hyperactivity disorder (ADHD) who had appropriate follow-up care. Two rates are reported. a. Percentage of children who had one follow-up visit with a practitioner with prescribing authority during the 30-Day Initiation Phase.b. Percentage of children who remained on ADHD medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two additional follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended.M1-255: Follow-up Care for Children Prescribed ADHD Medication (ADD)DY7/DY8 Program IDM1-255Measure DetailsSteward: National Committee for Quality AssuranceNQF #: 0108Source: CMS MIPS #366 eMeasure: SourceE.H.R.Required StatusOptionalMeasure ClassificationType: Clinical OutcomeMeasure Parts: 2Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionInitial Population 1: Children 6-12 years of age who were dispensed an ADHD medication during the Intake Period and who had a visit during the measurement period. Initial Population 2: Children 6-12 years of age who were dispensed an ADHD medication during the Intake Period and who remained on the medication for at least 210 days out of the 300 days following the IPSD, and who had a visit during the measurement period. Exclusions: Denominator Exclusion 1: Exclude patients diagnosed with narcolepsy at any point in their history or during the measurement period. Exclude patients who had an acute inpatient stay with a principal diagnosis of mental health or substance abuse during the 30 days after the IPSD. Exclude patients who were actively on an ADHD medication in the 120 days prior to the Index Prescription Start Date.Denominator Exclusion 2: Exclude patients diagnosed with narcolepsy at any point in their history or during the measurement period.Exclude patients who had an acute inpatient stay with a principal diagnosis of mental health or substance abuse during the 300 days after the IPSD.Exclude patients who were actively on an ADHD medication in the 120 days prior to the Index Prescription Start Date.Denominator InclusionsPopulation Criteria 1: AND: $InitialADHDMedication AND: Age>= 6 year(s) at: "Measurement Period" AND: Age< 12 year(s) at: "Measurement Period" AND: $Encounter Population Criteria 2: AND: $InitialADHDMedication AND: Sum>= 210 day(s): "Medication, Active: ADHD Medications (cumulative medication duration)" <= 300 day(s) starts after or concurrent with start of $InitialADHDMedication AND: Age>= 6 year(s) at: "Measurement Period" AND: Age< 12 year(s) at: "Measurement Period" AND: $EncounterDenominator ExclusionsPopulation Criteria 1: OR: "Diagnosis: Narcolepsy" starts before end of "Measurement Period" OR: Union of: "Encounter, Performed: Inpatient Encounter (principal diagnosis: Mental Health Diagnoses)" <= 30 day(s) starts after end of $InitialADHDMedication "Encounter, Performed: Inpatient Encounter (principal diagnosis: Substance Abuse)" <= 30 day(s) starts after end of $InitialADHDMedication OR: "Medication, Active: ADHD Medications" <= 120 day(s) starts before start of $InitialADHDMedication Population Criteria 2: OR: "Diagnosis: Narcolepsy" starts before end of "Measurement Period" OR: Union of: "Encounter, Performed: Inpatient Encounter (principal diagnosis: Mental Health Diagnoses)" <= 300 day(s) starts after end of $InitialADHDMedication "Encounter, Performed: Inpatient Encounter (principal diagnosis: Substance Abuse)" <= 300 day(s) starts after end of $InitialADHDMedication OR: "Medication, Active: ADHD Medications" <= 120 day(s) starts before start of $InitialADHDMedicationNumerator DescriptionRate 1: Patients who had at least one face-to-face visit with a practitioner with prescribing authority within 30 days after the IPSD. Rate 2: Patients who had at least one face-to-face visit with a practitioner with prescribing authority during the Initiation Phase, and at least two follow-up visits during the Continuation and Maintenance Phase. One of the two visits during the Continuation and Maintenance Phase may be a telephone visit with a practitioner.Numerator Inclusions (Performance Met)Population Criteria 1: AND: $Encounter30DaysAfterInitialADHDMed Population Criteria 2: AND: $Encounter30DaysAfterInitialADHDMed AND: OR: Count>= 2 : $EncounterAfterInitialMedication OR: AND: $EncounterAfterInitialMedication AND: Union of: "Encounter, Performed: Telehealth Services" satisfies all: >= 31 day(s) ends after end of $InitialADHDMedication <= 300 day(s) ends after end of $InitialADHDMedication "Encounter, Performed: Telephone Management" satisfies all: >= 31 day(s) ends after end of $InitialADHDMedication <= 300 day(s) ends after end of $InitialADHDMedicationNumerator Exclusions (Performance Not Met)NoneDSRIP Specific ModificationsProviders that do not have access to pharmacy fill data should interpret specifications as medication prescribed rather than dispensed.Additional InformationDefinitions: - Intake Period: The five-month period starting 90 days prior to the start of the measurement period and ending 60 days after the start of the measurement period. - Index Prescription Start Date (IPSD): The earliest prescription dispensing date for an ADHD medication where the date is in the Intake Period and an ADHD medication was not dispensed during the 120 days prior. - Initiation Phase: The 30 days following the IPSD. - Continuation and Maintenance Phase: The 31-300 days following the IPSD.Guidance:- CUMULATIVE MEDICATION DURATION is an individual's total number of medication days over a specific period; the period counts multiple prescriptions with gaps in between, but does not count the gaps during which a medication was not dispensed.- To determine the cumulative medication duration, determine first the number of the medication Days for each prescription in the period: the number of doses divided by the dose frequency per day. Then add the Medication Days for each prescription without counting any days between the prescriptions.- For example, there is an original prescription for 30 days with 2 refills for thirty days each. After a gap of 3 months, the medication was prescribed again for 60 days with 1 refill for 60 days. The cumulative medication duration is (30 x 3) + (60 x 2) = 210 days over the 10 month period. Data Criteria (QDM Variables):? $Encounter = o Union of: "Encounter, Performed: Office Visit" "Encounter, Performed: Face-to-Face Interaction" "Encounter, Performed: Home Healthcare Services" "Encounter, Performed: Preventive Care - Established Office Visit, 0 to 17" "Encounter, Performed: Preventive Care- Initial Office Visit, 0 to 17" during "Measurement Period"? $Encounter30DaysAfterInitialADHDMed = o Union of: "Encounter, Performed: Office Visit" "Encounter, Performed: Hospital Observation Care - Initial" "Encounter, Performed: Preventive Care Services - Group Counseling" "Encounter, Performed: Behavioral Health Follow-up Visit" "Encounter, Performed: Preventive Care Services-Individual Counseling" "Encounter, Performed: Psychotherapy and Pharmacologic Management (facility location: Ambulatory)" "Encounter, Performed: Face-to-Face Interaction" "Encounter, Performed: Discharge Services- Observation Care" "Encounter, Performed: Outpatient Consultation" "Encounter, Performed: Home Healthcare Services" "Encounter, Performed: Preventive Care- Initial Office Visit, 0 to 17" "Encounter, Performed: Preventive Care - Established Office Visit, 0 to 17" "Encounter, Performed: Psych Visit - Diagnostic Evaluation" "Encounter, Performed: Psych Visit - Psychotherapy" <= 30 day(s) ends after end of $InitialADHDMedication? $EncounterAfterInitialMedication = o Union of: "Encounter, Performed: Office Visit" satisfies all: >= 31 day(s) ends after end of $InitialADHDMedication <= 300 day(s) ends after end of $InitialADHDMedication "Encounter, Performed: Hospital Observation Care - Initial" satisfies all: >= 31 day(s) ends after end of $InitialADHDMedication <= 300 day(s) ends after end of $InitialADHDMedication "Encounter, Performed: Preventive Care Services - Group Counseling" satisfies all: >= 31 day(s) ends after end of $InitialADHDMedication <= 300 day(s) ends after end of $InitialADHDMedication "Encounter, Performed: Behavioral Health Follow-up Visit" satisfies all: >= 31 day(s) ends after end of $InitialADHDMedication <= 300 day(s) ends after end of $InitialADHDMedication "Encounter, Performed: Preventive Care Services-Individual Counseling" satisfies all: >= 31 day(s) ends after end of $InitialADHDMedication <= 300 day(s) ends after end of $InitialADHDMedication "Encounter, Performed: Psychotherapy and Pharmacologic Management" satisfies all: >= 31 day(s) ends after end of $InitialADHDMedication <= 300 day(s) ends after end of $InitialADHDMedication "Encounter, Performed: Face-to-Face Interaction" satisfies all: >= 31 day(s) ends after end of $InitialADHDMedication <= 300 day(s) ends after end of $InitialADHDMedication "Encounter, Performed: Discharge Services- Observation Care" satisfies all: >= 31 day(s) ends after end of $InitialADHDMedication <= 300 day(s) ends after end of $InitialADHDMedication "Encounter, Performed: Outpatient Consultation" satisfies all: >= 31 day(s) ends after end of $InitialADHDMedication <= 300 day(s) ends after end of $InitialADHDMedication "Encounter, Performed: Home Healthcare Services" satisfies all: >= 31 day(s) ends after end of $InitialADHDMedication <= 300 day(s) ends after end of $InitialADHDMedication "Encounter, Performed: Preventive Care- Initial Office Visit, 0 to 17" satisfies all: >= 31 day(s) ends after end of $InitialADHDMedication <= 300 day(s) ends after end of $InitialADHDMedication "Encounter, Performed: Preventive Care - Established Office Visit, 0 to 17" satisfies all: >= 31 day(s) ends after end of $InitialADHDMedication <= 300 day(s) ends after end of $InitialADHDMedication "Encounter, Performed: Psych Visit - Diagnostic Evaluation" satisfies all: >= 31 day(s) ends after end of $InitialADHDMedication <= 300 day(s) ends after end of $InitialADHDMedication "Encounter, Performed: Psych Visit - Psychotherapy" satisfies all: >= 31 day(s) ends after end of $InitialADHDMedication <= 300 day(s) ends after end of $InitialADHDMedication? $InitialADHDMedication = o First: Union of: "Medication, Dispensed: ADHD Medications" <= 60 day(s) starts after start of "Measurement Period" "Medication, Dispensed: ADHD Medications" <= 90 day(s) starts before or concurrent with start of "Measurement Period"Data Criteria (QDM Data Elements):? "Diagnosis: Narcolepsy" using "Narcolepsy Grouping Value Set (2.16.840.1.113883.3.464.1003.114.12.1011)"? "Encounter, Performed: Behavioral Health Follow-up Visit" using "Behavioral Health Follow-up Visit Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1054)"? "Encounter, Performed: Discharge Services- Observation Care" using "Discharge Services- Observation Care Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1039)"? "Encounter, Performed: Face-to-Face Interaction" using "Face-to-Face Interaction Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1048)"? "Encounter, Performed: Home Healthcare Services" using "Home Healthcare Services Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1016)"? "Encounter, Performed: Hospital Observation Care - Initial" using "Hospital Observation Care - Initial Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1002)"? "Encounter, Performed: Inpatient Encounter" using "Inpatient Encounter Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1060)"? "Encounter, Performed: Office Visit" using "Office Visit Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1001)"? "Encounter, Performed: Outpatient Consultation" using "Outpatient Consultation Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1008)"? "Encounter, Performed: Preventive Care - Established Office Visit, 0 to 17" using "Preventive Care - Established Office Visit, 0 to 17 Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1024)"? "Encounter, Performed: Preventive Care Services - Group Counseling" using "Preventive Care Services - Group Counseling Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1027)"? "Encounter, Performed: Preventive Care Services-Individual Counseling" using "Preventive Care Services-Individual Counseling Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1026)"? "Encounter, Performed: Preventive Care- Initial Office Visit, 0 to 17" using "Preventive Care- Initial Office Visit, 0 to 17 Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1022)"? "Encounter, Performed: Psych Visit - Diagnostic Evaluation" using "Psych Visit - Diagnostic Evaluation Grouping Value Set (2.16.840.1.113883.3.526.3.1492)"? "Encounter, Performed: Psych Visit - Psychotherapy" using "Psych Visit - Psychotherapy Grouping Value Set (2.16.840.1.113883.3.526.3.1496)"? "Encounter, Performed: Psychotherapy and Pharmacologic Management" using "Psychotherapy and Pharmacologic Management Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1055)"? "Encounter, Performed: Telehealth Services" using "Telehealth Services Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1031)"? "Encounter, Performed: Telephone Management" using "Telephone Management Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1053)"? "Medication, Active: ADHD Medications" using "ADHD Medications Grouping Value Set (2.16.840.1.113883.3.464.1003.196.12.1171)"? "Medication, Dispensed: ADHD Medications" using "ADHD Medications Grouping Value Set (2.16.840.1.113883.3.464.1003.196.12.1171)"? Attribute: "Principal diagnosis: Substance Abuse" using "Substance Abuse Grouping Value Set (2.16.840.1.113883.3.464.1003.106.12.1004)"? Attribute: "Principal diagnosis: Mental Health Diagnoses" using "Mental Health Diagnoses Grouping Value Set (2.16.840.1.113883.3.464.1003.105.12.1004)"? Attribute: "Facility location: Ambulatory" using "Ambulatory Grouping Value Set (2.16.840.1.113883.3.464.1003.122.12.1003)"M1-256: Initiation of Depression TreatmentMeasure Description:The proportion of individuals diagnosed with major depression that have filled at least one antidepressant prescription or had at least three psychotherapy visits during the 5-month period after diagnosis.M1-256: Initiation of Depression TreatmentDY7/DY8 Program IDM1-256Measure DetailsSteward: Center for Quality Assessment and Improvement in Mental Health (CQAIMH)NQF #: NASource: SourceAnyRequired StatusOptionalMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionAll patients seen in primary care during a specified period who had major depression based on a structured assessment administered independent of the clinical visit.Denominator InclusionsNone listed by measure steward.Denominator ExclusionsNone listed by measure steward.Numerator DescriptionPatients in the denominator who filled at least one antidepressant prescription or had at least three psychotherapy visits during the 5-month period after diagnosis.Numerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationNoneM1-257: Care Planning for Dual DiagnosisMeasure Description:Percentage of patients with dual diagnosis undergoing case management services who have a documented plan to address both conditions.M1-257: Care Planning for Dual DiagnosisDY7/DY8 Program IDM1-257Measure DetailsSteward: Center for Quality Assessment and Improvement in Mental Health (CQAIMH)NQF #: NASource: SourceClaimsRequired StatusOptionalMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionThe number of individuals participating in a case management program who are dually diagnosed with a mental disorder and a substance abuse disorder during a six-month period.Denominator InclusionsNone listed by measure steward.Denominator ExclusionsNone listed by measure steward.Numerator DescriptionThose individuals from the denominator for whom a case manager has documented a plan of care that addresses the consumer's need for treatment of both conditions.Numerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationNoneM1-259: Assignment of Primary Care Physician to Individuals with SchizophreniaMeasure Description:The percentage of individuals with a primary diagnosis of schizophrenia that have been assigned a primary care physician.M1-259: Assignment of Primary Care Physician to Individuals with SchizophreniaDY7/DY8 Program IDM1-259Measure DetailsSteward: Center for Quality Assessment and Improvement in Mental Health (CQAIMH)NQF #: NASource: SourceClaimsRequired StatusOptionalMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionEnrollees who had either one inpatient admission or two outpatient visits with a primary diagnosis of schizophrenia within a 12 month period.Denominator InclusionsNone listed by measure steward.Denominator ExclusionsNone listed by measure steward.Numerator DescriptionThe number of individuals in the denominator who were assigned a primary care physician.Numerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationNoneM1-260: Annual Physical Exam for Persons with Mental IllnessMeasure Description:The percentage of individuals receiving services for a primary psychiatric disorder whose medical records document receipt of a physical exam during the measurement year.M1-260: Annual Physical Exam for Persons with Mental IllnessDY7/DY8 Program IDM1-260Measure DetailsSteward: Center for Quality Assessment and Improvement in Mental Health (CQAIMH)NQF #: NASource: SourceClaimsRequired StatusOptionalMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionThe total number of individuals receiving services for a primary psychiatric disorder during a specified 12- month reporting period.Denominator InclusionsNone listed by measure steward.Denominator ExclusionsNone listed by measure steward.Numerator DescriptionIndividuals from the denominator whose medical record documents receipt of a physical examination within the specified 12-month period.Numerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationNoneM1-261: Assessment for Substance Abuse Problems of Psychiatric PatientsMeasure Description:The percentage of individuals who received an assessment for substance abuse problems.M1-261: Assessment for Substance Abuse Problems of Psychiatric PatientsDY7/DY8 Program IDM1-261Measure DetailsSteward: Center for Quality Assessment and Improvement in Mental Health (CQAIMH)NQF #: NASource: SourceAnyRequired StatusOptionalMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionTotal number of patients in a plan who received psychiatric evaluations within a specified period of time.Denominator InclusionsNone listed by measure steward.Denominator ExclusionsNone listed by measure steward.Numerator DescriptionNumber of patients in the denominator whose medical record indicates explicit evidence of assessment of current and/or past substance use disorders.Numerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationNoneM1-262: Assessment of Risk to Self/ OthersMeasure Description:The percentage of individuals with depression who received an evaluation of suicidal/homicidal ideation (SI/HI) and associated risks.Individuals with major depression are at higher risk for suicide than individuals in the general population.M1-262: Assessment of Risk to Self/ OthersDY7/DY8 Program IDM1-262Measure DetailsSteward: Center for Quality Assessment and Improvement in Mental Health (CQAIMH)NQF #: NASource: SourceClaimsRequired StatusOptionalMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionThe number of patients diagnosed with a depressive disorder during a formal evaluation.Denominator InclusionsNone listed by measure steward.Denominator ExclusionsNone listed by measure steward.Numerator DescriptionPatients from the denominator whose medical record of the formal evaluation contains specific documentation of the patient's potential to harm self or others.Numerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationNoneM1-263: Assessment for Psychosocial Issues of Psychiatric PatientsMeasure Description:The percentage of individuals whose medical record documents a psychosocial/developmental history.M1-263: Assessment for Psychosocial Issues of Psychiatric PatientsDY7/DY8 Program IDM1-263Measure DetailsSteward: Center for Quality Assessment and Improvement in Mental Health (CQAIMH)NQF #: NASource: SourceAnyRequired StatusOptionalMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionAll individuals age 18 and older who undergo a psychiatric evaluation during a specified period.Denominator InclusionsNADenominator ExclusionsNone listed by measure steward.Numerator DescriptionIndividuals in the denominator whose medical record documents a psychosocial/developmental history. [Components include major life events, history of abuse or trauma, levels of functioning in family and social roles.]Numerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)None listed by measure stewardDSRIP Specific ModificationsNoneAdditional InformationClinical practice guidelines recommend that a psychiatric evaluation of a newly presenting patient include an assessment of the individual's psychosocial and developmental history. Such an assessment typically includes information about developmental milestones, family and social relationships, educational and work history, and major life events including a history of trauma. This assessment can inform diagnosis and treatment as well as provide information about patient strengths, vulnerabilities, and potential sources of support. There is little research on the adequacy of assessment of psychosocial issues in psychiatric evaluations or its impact on patient outcome.M1-264: Vocational Rehabilitation for SchizophreniaMeasure Description:The percentage of individuals who received an assessment for Vocational Rehabilitation.M1-264: Vocational Rehabilitation for SchizophreniaDY7/DY8 Program IDM1-264Measure DetailsSteward: Center for Quality Assessment and Improvement in Mental Health (CQAIMH)NQF #: NASource: SourceAnyRequired StatusOptionalMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionIndividuals, 18 years or older, in active treatment for schizophrenia who at a specified point in time:i) Report in a survey that they are currently employed and they have a prior work history or are actively looking for a job; or ii) Are currently employedDenominator InclusionsNone listed by measure steward.Denominator ExclusionsNone listed by measure steward.Numerator DescriptionIndividuals in the denominator who: i) Report participating in a program to help them find a job or vocational rehabilitation is prescribed in their treatment plan; or ii) Report receiving assistance from an employment specialistNumerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationNoneM1-265: Housing Assessment for Individuals with SchizophreniaMeasure Description:The percentage of individuals with Schizophrenia whose housing quality was assessedM1-265: Housing Assessment for Individuals with SchizophreniaDY7/DY8 Program IDM1-265Measure DetailsSteward: Center for Quality Assessment and Improvement in Mental Health (CQAIMH)NQF #: NASource: SourceClaimsRequired StatusOptionalMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionIndividuals who had either one inpatient admission or two outpatient visits with a primary diagnosis of schizophrenia within a 12 month period.Denominator InclusionsNone listed by measure steward.Denominator ExclusionsNone listed by measure steward.Numerator DescriptionThe number of individuals in the denominator whose housing quality was assessed with medical record documentation indicating that a trained professional (e.g., social worker, visiting nurse) saw the quality of the individual's housing and/or made an effort to modify the individual's housing situation.Numerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsChanged "enrollees" to "Individuals"Additional InformationNoneM1-266: Independent Living Skills Assessment for Individuals with SchizophreniaMeasure Description:The percentage of patients who received an assessment of independent living skillsM1-266: Independent Living Skills Assessment for Individuals with SchizophreniaDY7/DY8 Program IDM1-266Measure DetailsSteward: Center for Quality Assessment and Improvement in Mental Health (CQAIMH)NQF #: NASource: SourceClaimsRequired StatusOptionalMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionPatients who had either one inpatient admission or two outpatient visits with a primary diagnosis of schizophrenia within a 12 month period.Denominator InclusionsNone listed by measure steward.Denominator ExclusionsNone listed by measure steward.Numerator DescriptionPatients in the denominator who received an assessment of independent living skills.Numerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationNoneM1-280: Chlamydia Screening in Women (CHL)Measure Description:The percentage of women 16–24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement year.M1-280: Chlamydia Screening in Women (CHL)DY7/DY8 Program IDM1-280Measure DetailsSteward: NCQANQF #: 0033Source: eMeasure: SourceE.H.R.Required StatusOptionalMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: QISMCHPL: 0.6892MPL: 0.4881National Quality Compass 2016 - All LOBs: Average (90th and 25th percentiles)Directionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is eligible for a baseline numerator of 0 per PFM Section VI.22.b.i (page 24). If approved for a baseline of zero, the DY7 goal will be 61.69% and DY8 goal of 62.41%.Denominator DescriptionWomen 16 to 24 years of age who are sexually active and who had a visit in the measurement period Exclusions: Women who are only eligible for the initial population due to a pregnancy test and who had an x-ray or an order for a specified medication within 7 days of the pregnancy test. Exclude patients who were in hospice care during the measurement year.Denominator InclusionsAND: Age>= 16 year(s) at: "Measurement Period" AND: Age< 24 year(s) at: "Measurement Period" AND: "Patient Characteristic Sex: Female" AND: Union of: "Encounter, Performed: Office Visit" "Encounter, Performed: Face-to-Face Interaction" "Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up" "Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up" "Encounter, Performed: Preventive Care - Established Office Visit, 0 to 17" "Encounter, Performed: Preventive Care- Initial Office Visit, 0 to 17" "Encounter, Performed: Home Healthcare Services" during "Measurement Period" AND: OR: "Assessment, Performed: Sexually Active (result: Yes Response)" starts before end of "Measurement Period" OR: Union of: "Diagnosis: Other Female Reproductive Conditions" "Diagnosis: Genital Herpes" "Diagnosis: Gonococcal Infections and Venereal Diseases" "Medication, Active: Contraceptive Medications" "Diagnosis: Inflammatory Diseases of Female Reproductive Organs" "Diagnosis: Chlamydia" "Diagnosis: HIV" "Diagnosis: Syphilis" "Diagnosis: Complications of Pregnancy, Childbirth and the Puerperium" overlaps "Measurement Period" OR: Union of: "Laboratory Test, Order: Pregnancy Test" "Laboratory Test, Order: Pap Test" "Procedure, Performed: Delivery Live Births" "Laboratory Test, Order: Lab Tests During Pregnancy" "Laboratory Test, Order: Lab Tests for Sexually Transmitted Infections" "Medication, Order: Contraceptive Medications" "Diagnostic Study, Order: Diagnostic Studies During Pregnancy" "Procedure, Performed: Procedures During Pregnancy" "Procedure, Performed: Procedures Involving Contraceptive Devices" during "Measurement Period"Denominator ExclusionsOR: "Encounter, Performed: Encounter Inpatient (discharge status: Discharged to Home for Hospice Care)" ends during "Measurement Period" OR: "Encounter, Performed: Encounter Inpatient (discharge status: Discharged to Health Care Facility for Hospice Care)" ends during "Measurement Period" OR: Union of: "Intervention, Order: Hospice care ambulatory" "Intervention, Performed: Hospice care ambulatory" overlaps "Measurement Period" OR: AND: Union of: "Medication, Order: Isotretinoin" "Diagnostic Study, Order: X-Ray Study (all inclusive)" <= 7 day(s) starts after end of ("Laboratory Test, Order: Pregnancy Test" during "Measurement Period" ) AND NOT: Union of: Union of: "Diagnosis: Other Female Reproductive Conditions" "Diagnosis: Genital Herpes" "Diagnosis: Gonococcal Infections and Venereal Diseases" "Medication, Active: Contraceptive Medications" "Diagnosis: Inflammatory Diseases of Female Reproductive Organs" "Diagnosis: Chlamydia" "Diagnosis: HIV" "Diagnosis: Syphilis" "Diagnosis: Complications of Pregnancy, Childbirth and the Puerperium" overlaps "Measurement Period" Union of: "Laboratory Test, Order: Pap Test" "Procedure, Performed: Delivery Live Births" "Laboratory Test, Order: Lab Tests During Pregnancy" "Laboratory Test, Order: Lab Tests for Sexually Transmitted Infections" "Medication, Order: Contraceptive Medications" "Diagnostic Study, Order: Diagnostic Studies During Pregnancy" "Procedure, Performed: Procedures During Pregnancy" "Procedure, Performed: Procedures Involving Contraceptive Devices" during "Measurement Period"Numerator DescriptionWomen with at least one chlamydia test during the measurement periodNumerator Inclusions (Performance Met)AND: "Laboratory Test, Performed: Chlamydia Screening (result)" during "Measurement Period"Numerator Exclusions (Performance Not Met)NoneDSRIP Specific ModificationsNoneAdditional InformationGuidance:- Codes to identify sexually active women include codes for: pregnancy, sexually transmitted infections, contraceptives or contraceptive devices, and infertility treatments.- The denominator exclusion does not apply to patients who qualify for the initial population (IP) based on services other than the pregnancy test alone. These other services include services for sexually transmitted infections, contraceptives or contraceptive devices and infertility treatments. For example, a patient who has both a pregnancy test and a chlamydia diagnosis, either of which would qualify them for the IP, would not be eligible for this denominator exclusion.- Patient self-report for procedures as well as diagnostic studies should be recorded in 'Procedure, Performed' template or 'Diagnostic Study, Performed' template in QRDA-1. Patient self-report is not allowed for laboratory tests. Data Criteria (QDM Data Elements):? "Assessment, Performed: Sexually Active" using "Sexually Active Grouping Value Set (2.16.840.1.113883.3.464.1003.121.12.1040)"? "Diagnosis: Chlamydia" using "Chlamydia Grouping Value Set (2.16.840.1.113883.3.464.1003.112.12.1003)"? "Diagnosis: Complications of Pregnancy, Childbirth and the Puerperium" using "Complications of Pregnancy, Childbirth and the Puerperium Grouping Value Set (2.16.840.1.113883.3.464.1003.111.12.1012)"? "Diagnosis: Genital Herpes" using "Genital Herpes Grouping Value Set (2.16.840.1.113883.3.464.1003.110.12.1049)"? "Diagnosis: Gonococcal Infections and Venereal Diseases" using "Gonococcal Infections and Venereal Diseases Grouping Value Set (2.16.840.1.113883.3.464.1003.112.12.1001)"? "Diagnosis: HIV" using "HIV Grouping Value Set (2.16.840.1.113883.3.464.1003.120.12.1003)"? "Diagnosis: Inflammatory Diseases of Female Reproductive Organs" using "Inflammatory Diseases of Female Reproductive Organs Grouping Value Set (2.16.840.1.113883.3.464.1003.112.12.1004)"? "Diagnosis: Other Female Reproductive Conditions" using "Other Female Reproductive Conditions Grouping Value Set (2.16.840.1.113883.3.464.1003.111.12.1006)"? "Diagnosis: Syphilis" using "Syphilis Grouping Value Set (2.16.840.1.113883.3.464.1003.112.12.1002)"? "Diagnostic Study, Order: Diagnostic Studies During Pregnancy" using "Diagnostic Studies During Pregnancy Grouping Value Set (2.16.840.1.113883.3.464.1003.111.12.1008)"? "Diagnostic Study, Order: X-Ray Study (all inclusive)" using "X-Ray Study (all inclusive) Grouping Value Set (2.16.840.1.113883.3.464.1003.198.12.1034)"? "Encounter, Performed: Encounter Inpatient" using "Encounter Inpatient SNOMEDCT Value Set (2.16.840.1.113883.3.666.5.307)"? "Encounter, Performed: Face-to-Face Interaction" using "Face-to-Face Interaction Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1048)"? "Encounter, Performed: Home Healthcare Services" using "Home Healthcare Services Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1016)"? "Encounter, Performed: Office Visit" using "Office Visit Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1001)"? "Encounter, Performed: Preventive Care - Established Office Visit, 0 to 17" using "Preventive Care - Established Office Visit, 0 to 17 Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1024)"? "Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up" using "Preventive Care Services - Established Office Visit, 18 and Up Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1025)"? "Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up" using "Preventive Care Services-Initial Office Visit, 18 and Up Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1023)"? "Encounter, Performed: Preventive Care- Initial Office Visit, 0 to 17" using "Preventive Care- Initial Office Visit, 0 to 17 Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1022)"? "Intervention, Order: Hospice care ambulatory" using "Hospice care ambulatory SNOMEDCT Value Set (2.16.840.1.113762.1.4.1108.15)"? "Intervention, Performed: Hospice care ambulatory" using "Hospice care ambulatory SNOMEDCT Value Set (2.16.840.1.113762.1.4.1108.15)"? "Laboratory Test, Order: Lab Tests During Pregnancy" using "Lab Tests During Pregnancy Grouping Value Set (2.16.840.1.113883.3.464.1003.111.12.1007)"? "Laboratory Test, Order: Lab Tests for Sexually Transmitted Infections" using "Lab Tests for Sexually Transmitted Infections Grouping Value Set (2.16.840.1.113883.3.464.1003.110.12.1051)"? "Laboratory Test, Order: Pap Test" using "Pap Test Grouping Value Set (2.16.840.1.113883.3.464.1003.108.12.1017)"? "Laboratory Test, Order: Pregnancy Test" using "Pregnancy Test Grouping Value Set (2.16.840.1.113883.3.464.1003.111.12.1011)"? "Laboratory Test, Performed: Chlamydia Screening" using "Chlamydia Screening Grouping Value Set (2.16.840.1.113883.3.464.1003.110.12.1052)"? "Medication, Active: Contraceptive Medications" using "Contraceptive Medications Grouping Value Set (2.16.840.1.113883.3.464.1003.196.12.1080)"? "Medication, Order: Contraceptive Medications" using "Contraceptive Medications Grouping Value Set (2.16.840.1.113883.3.464.1003.196.12.1080)"? "Medication, Order: Isotretinoin" using "Isotretinoin Grouping Value Set (2.16.840.1.113883.3.464.1003.196.12.1143)"? "Patient Characteristic Sex: Female" using "Female AdministrativeGender Value Set (2.16.840.1.113883.3.560.100.2)"? "Procedure, Performed: Delivery Live Births" using "Delivery Live Births Grouping Value Set (2.16.840.1.113883.3.464.1003.111.12.1015)"? "Procedure, Performed: Procedures During Pregnancy" using "Procedures During Pregnancy Grouping Value Set (2.16.840.1.113883.3.464.1003.111.12.1009)"? "Procedure, Performed: Procedures Involving Contraceptive Devices" using "Procedures Involving Contraceptive Devices Grouping Value Set (2.16.840.1.113883.3.464.1003.111.12.1010)"? Attribute: "Result: Yes Response" using "Yes Response Grouping Value Set (2.16.840.1.113883.3.464.1003.122.12.1050)"? Attribute: "Discharge status: Discharged to Health Care Facility for Hospice Care" using "Discharged to Health Care Facility for Hospice Care SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.207)"? Attribute: "Discharge status: Discharged to Home for Hospice Care" using "Discharged to Home for Hospice Care SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.209)"M1-286: Depression Remission at Six MonthsMeasure Description:Adult patients age 18 and older with major depression or dysthymia and an initial PHQ-9 score > 9 who demonstrate remission at six months defined as a PHQ-9 score less than 5. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment. This measure additionally promotes ongoing contact between the patient and provider as patients who do not have a follow-up PHQ-9 score at six months (+/- 30 days) are also included in the denominator.M1-286: Depression Remission at Six MonthsDY7/DY8 Program IDM1-286Measure DetailsSteward: MN Community MeasurementNQF #: 0711Source: CMS MIPS #411 (Claims/Registry)Data SourceE.H.R.Required StatusOptionalMeasure ClassificationType: Clinical OutcomeMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionAdults age 18 and older with a diagnosis of major depression or dysthymia and an initial (index) PHQ-9 score greater than nineIndex Date - The first instance of elevated PHQ-9 greater than 9 and diagnosis of depression or dysthymiaNOTE: To be considered denominator eligible for this measure, the patient must have both the diagnosis of depression or dysthymia and an index date PHQ-9 Score greater than 9 documented during the denominator identification measurement period. Encounters in a Psychiatric, Behavioral, or Mental Health Setting require the diagnosis of depression or dysthymia to be a primary diagnosis.Denominator InclusionsDenominator Criteria (Eligible Cases):Patients aged ≥ 18 yearsANDDiagnosis for MDD (ICD-10-CM): F32.0, F32.1, F32.2, F32.3, F32.4, F32.5, F32.9, F33.0, F33.1, F33.2,F33.3, F33.40, F33.41, F33.42, F33.9, F34.1ANDPatient encounter during the performance period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837,99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, G0402, G0438, G0439ANDIndex date PHQ-9 Score greater than 9 documented during the twelve month denominatoridentification period: G9511Denominator ExclusionsPatients with a diagnosis of bipolar disorder ICD10-CM: F30.10, F30.11, F30.12, F30.13, F30.2, F30.3, F30.4, F30.8, F30.9, F31.0, F31.10, F31.11, F31.12, F31.13, F31.2, F31.30, F31.31, F31.32, F31.4, F31.5, F31.60, F31.61, F31.62, F31.63, F31.64, F31.70, F31.71, F31.72, F31.73, F31.74, F31.75, F31.76, F31.77, F31.78, F31.81, F31.89, F31.9ICD-9-CM: 296.00, 296.01, 296.02, 296.03, 296.04, 296.05, 296.06, 296.10, 296.11, 296.12, 296.13, 296.14, 296.15, 296.16, 296.40, 296.41, 296.42, 296.43, 296.44, 296.45, 296.46, 296.50, 296.51, 296.52, 296.53, 296.54, 296.55, 296.56, 296.60, 296.61, 296.62, 296.63, 296.64, 296.65, 296.66, 296.7, 296.80, 296.81, 296.82, 296.89ORPatients with a diagnosis of personality disorder:ICD-10-CM: F21, F34.0, F60.0, F60.1, F60.2, F60.3, F60.4, F60.5, F60.6, F60.7, F60.81, F60.89, F60.9, F68.10, F68.11, F68.12, F68.13ICD-9-CM: 301.0, 301.10, 301.11, 301.12, 301.13, 301.20, 301.21, 301.22, 301.3, 301.4, 301.50, 301.51, 301.59, 301.6, 301.7, 301.81, 301.82, 301.83, 301.84, 301.89, 301.9ORPatients who diedORPatients who received hospice or palliative care serviceORPatients who were permanent nursing home residentsNumerator DescriptionAdults age 18 and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 score greater than nine who achieve remission at six months as demonstrated by a six month (+/- 30 days) PHQ-9 score of less than five Definitions:Remission - a PHQ-9 score less than five.Six Months - the point in time from the index date extending out six months (+/- 30 days). Any PHQ-9 score less than five obtained during this two month period is deemed as remission at six months, values obtained prior to or after this period are not counted as numerator compliant (remission).Numerator Inclusions (Performance Met)Remission at six months as demonstrated by a six month (+/-30 days) PHQ-9 score of less than five (G9573)Numerator Exclusions (Performance Not Met)Remission at six months not demonstrated by a six month (+/-30 days) PHQ-9 score of less than five. Either PHQ-9 score was not assessed or is greater than or equal to five (G9574)DSRIP Specific ModificationsNoneAdditional InformationStandard Baseline Measurement Period: Measurement Period Index Period: June 3, 2016 through June 2, 2017Assessment Period: November 1, 2016 through December 31, 2017 PY1 Measurement Period: Measurement Period Index Period: June 3, 2017 through June 2, 2018Assessment Period: November 1, 2017 through December 31, 2018 PY2 Measurement Period: Measurement Period Index Period: June 3, 2018 through June 2, 2019Assessment Period: November 1, 2018 through December 31, 2019 PY3 Measurement Period: Measurement Period Index Period: June 3, 2019 through June 2, 2020Assessment Period: November 1, 2019 through December 31, 2020M1-287: Documentation of Current Medications in the Medical RecordMeasure Description:Percentage of visits for Consumers aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administrationM1-287: Documentation of Current Medications in the Medical RecordDY7/DY8 Program IDM1-287Measure DetailsSteward: CMSNQF #: 0419Source: CMS MIPS #130 (Claims/Registry) eMeasure: SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusOptionalMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: PositiveUnit of Measurement for Payer TypeUnit: EncountersMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionAll visits for Consumers aged 18 years and olderDenominator InclusionsCLAIMS/REGISTRY:Denominator Criteria (Eligible Cases): Consumers aged ≥ 18 years on date of encounter AND Consumer encounter during the performance period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 90839, 92002, 92004, 92012, 92014, 92507, 92508, 92526, 92537, 92538, 92540, 92541, 92542, 92544, 92545, 92547, 92548, 92550, 92557, 92567, 92568, 92570, 92585, 92588, 92626, 96116, 96150, 96151, 96152, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97532, 97802, 97803, 97804, 98960, 98961, 98962, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99221, 99222, 99223, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99495, 99496, G0101, G0108, G0270, G0402, G0438, G0439 E.H.R.: AND: Age>= 18 year(s) at: "Measurement Period" AND: "Occurrence A of Encounter, Performed: Medications Encounter Code Set" during "Measurement Period"Denominator ExclusionsCLAIMS, REGISTRY:Eligible clinician attests to documenting in the medical record the Consumer is not eligible for a current list of medications being obtained, updated, or reviewed by the eligible clinician (G8430) E.H.R.:NoneNumerator DescriptionEligible clinician attests to documenting, updating or reviewing a Consumer’s current medications using all resources available on the date of encounter. This list must include ALL known prescriptions, over-the counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosages, frequency and route of administration Definitions:Current Medications – Medications the Consumer is presently taking including all prescriptions, over-the- counters, herbals and vitamin/mineral/dietary (nutritional) supplements with each medication’s name, dosage, frequency and administered route.Route – Documentation of the way the medication enters the body (some examples include but are not limited to: oral, sublingual, subcutaneous injections, and/or topical)Not Eligible (Denominator Exception) – A Consumer is not eligible if the following reason is documented:? Consumer is in an urgent or emergent medical situation where time is of the essence and to delaytreatment would jeopardize the Consumer’s health status NUMERATOR NOTE: The eligible clinician must document in the medical record they obtained, updated, or reviewed a medication list on the date of the encounter. Eligible clinicians reporting this measure may document medication information received from the Consumer, authorized representative(s), caregiver(s) or other available healthcare resources. G8427 should be reported if the eligible clinician documented that the Consumer is not currently taking any medicationsNumerator Inclusions (Performance Met)CLAIMS, REGISTRY:Eligible clinician attests to documenting in the medical record they obtained, updated, or reviewed the Consumer’s current medications (G8427) E.H.R.: AND: "Procedure, Performed: Current Medications Documented SNMD" during "Occurrence A of Encounter, Performed: Medications Encounter Code Set"Numerator Exclusions (Performance Not Met)CLAIMS/REGISTRY:Current list of medications not documented as obtained, updated, or reviewed by the eligible clinician, reason not given (G8428) E.H.R.NADSRIP Specific ModificationsFor DSRIP reporting purposes, HHSC replaced the word "Patients" with "consumers"Additional InformationMeasure is a clinic-reported measure for Certified Community Behavioral Health Clinics (CCBHCs) as part of the Demonstration Program to Improve Community Mental Health Services, found in Section 223 of the federal Protecting Access to Medicare Act of 2014 (PAMA). For DSRIP reporting purposes, measure has been specified using the same source measure used for CCBHC reporting requirements. E.H.R.Data Criteria (QDM Data Elements):? "Encounter, Performed: Medications Encounter Code Set" using "Medications Encounter Code Set Grouping Value Set (2.16.840.1.113883.3.600.1.1834)"? "Procedure, Performed: Current Medications Documented SNMD" using "Current Medications Documented SNMD SNOMEDCT Value Set (2.16.840.1.113883.3.600.1.462)"? "Procedure, Performed not done: Medical or Other reason not done" using "Medical or Other reason not done SNOMEDCT Value Set (2.16.840.1.113883.3.600.1.1502)"M1-305: Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment (SRA-CH)Measure Description:Percentage of Consumer visits for those Consumers aged 6 through 17 years with a diagnosis of major depressive disorder with an assessment for suicide riskM1-305: Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment (SRA-CH)DY7/DY8 Program IDM1-305Measure DetailsSteward: AMA-convened Physician Consortium for Performance ImprovementNQF #: 1365Source: eMeasure: SourceE.H.R.Required StatusOptionalMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: PositiveUnit of Measurement for Payer TypeUnit: EncountersMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionAll Consumer visits for those Consumers aged 6 through 17 years with a diagnosis of major depressive disorderDenominator InclusionsAND: Age>= 6 year(s) at: "Measurement Period" AND: Age< 17 year(s) at: "Measurement Period" AND: Occurrence A of $MDDEncounters177Denominator ExclusionsNoneNumerator DescriptionConsumer visits with an assessment for suicide riskNumerator Inclusions (Performance Met)AND: "Intervention, Performed: Suicide Risk Assessment" during Occurrence A of $MDDEncounters177Numerator Exclusions (Performance Not Met)NoneDSRIP Specific ModificationsNoneAdditional InformationMeasure is a clinic-reported measure for Certified Community Behavioral Health Clinics (CCBHCs) as part of the Demonstration Program to Improve Community Mental Health Services, found in Section 223 of the federal Protecting Access to Medicare Act of 2014 (PAMA). For DSRIP reporting purposes, measure has been specified using the same source measure used for CCBHC reporting requirements. Definitions:E.H.R.Data Criteria (QDM Variables)? $MDDEncounters177 = o Union of: "Encounter, Performed: Office Visit (diagnosis: Major Depressive Disorder-Active)" "Encounter, Performed: Outpatient Consultation (diagnosis: Major Depressive Disorder-Active)" "Encounter, Performed: Face-to-Face Interaction (diagnosis: Major Depressive Disorder-Active)" "Encounter, Performed: Psych Visit - Diagnostic Evaluation (diagnosis: Major Depressive Disorder-Active)" "Encounter, Performed: Psych Visit - Family Psychotherapy (diagnosis: Major Depressive Disorder-Active)" "Encounter, Performed: Psychoanalysis (diagnosis: Major Depressive Disorder-Active)" "Encounter, Performed: Group Psychotherapy (diagnosis: Major Depressive Disorder-Active)" "Encounter, Performed: Psych Visit - Psychotherapy (diagnosis: Major Depressive Disorder-Active)" during "Measurement Period"Data Criteria (QDM Data Elements):? "Encounter, Performed: Face-to-Face Interaction" using "Face-to-Face Interaction Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1048)"? "Encounter, Performed: Group Psychotherapy" using "Group Psychotherapy Grouping Value Set (2.16.840.1.113883.3.526.3.1187)"? "Encounter, Performed: Office Visit" using "Office Visit Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1001)"? "Encounter, Performed: Outpatient Consultation" using "Outpatient Consultation Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1008)"? "Encounter, Performed: Psych Visit - Diagnostic Evaluation" using "Psych Visit - Diagnostic Evaluation Grouping Value Set (2.16.840.1.113883.3.526.3.1492)"? "Encounter, Performed: Psych Visit - Family Psychotherapy" using "Psych Visit - Family Psychotherapy Grouping Value Set (2.16.840.1.113883.3.526.3.1018)"? "Encounter, Performed: Psych Visit - Psychotherapy" using "Psych Visit - Psychotherapy Grouping Value Set (2.16.840.1.113883.3.526.3.1496)"? "Encounter, Performed: Psychoanalysis" using "Psychoanalysis Grouping Value Set (2.16.840.1.113883.3.526.3.1141)"? "Intervention, Performed: Suicide Risk Assessment" using "Suicide Risk Assessment Grouping Value Set (2.16.840.1.113883.3.526.3.1484)"? Attribute: "Diagnosis: Major Depressive Disorder-Active" using "Major Depressive Disorder-Active Grouping Value Set (2.16.840.1.113883.3.526.3.1491)"M1-306: Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP-CH)*Measure Description:Percentage of children and adolescents 1–17 years of age with a new prescription for an antipsychotic, but no indication for antipsychotics, who had documentation of psychosocial care as first-line treatment.M1-306: Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP-CH)*DY7/DY8 Program IDM1-306Measure DetailsSteward: NCQANQF #: 2801Source: CMS Child Core SetData SourceClaimsRequired StatusOptionalMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionChildren and adolescents who had a new prescription of an antipsychotic medication for which they do not have a U.S Food and Drug Administration primary indication.Denominator InclusionsFollow the steps below to determine the eligible population.Step 1Identify all patients in the specified age range who were prescribed an antipsychotic medication (see list below) during the Intake Period.Step 2Test for Negative Medication History. For each patient identified in step 1, test each antipsychotic prescription for a Negative Medication History. The IPSD is the dispensing/perscription date of the earliest antipsychotic prescription in the Intake Period with a Negative Medication History.Step 3: (NOT APPLICABLE TO DSRIP PROVIDERS)Step 4Exclude patients 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, bipolar disorder or other psychotic disorder during the measurement year. Any of the following code combinations meet criteria:- BH Stand Alone Acute Inpatient Value Set with Schizophrenia Value Set- BH Stand Alone Acute Inpatient Value Set with Bipolar Disorder Value Set- BH Stand Alone Acute Inpatient Value Set with Other Psychotic Disorders Value Set- BH Acute Inpatient Value Set with BH Acute Inpatient POS Value Set and Schizophrenia Value Set- BH Acute Inpatient Value Set with BH Acute Inpatient POS Value Set and Bipolar Disorder Value Set- BH Acute Inpatient Value Set with BH Acute Inpatient POS Value Set and Other Psychotic Disorders Value Set? At least two visits in an outpatient, intensive outpatient, or partial hospitalization setting, on different dates of service, with a diagnosis of schizophrenia, bipolar disorder, or other psychotic disorder during the measurement year. Any of the following code combinations meet criteria:- BH Stand Alone Outpatient/PH/IOP Value Set with Schizophrenia Value Set- BH Outpatient/PH/IOP Value Set with BH Outpatient/PH/IOP POS Value Set and Schizophrenia Value Set- BH Stand Alone Outpatient/PH/IOP Value Set with Bipolar Disorder Value Set- BH Outpatient/PH/IOP Value Set with BH Outpatient/PH/IOP POS Value Set and Bipolar Disorder Value Set- BH Stand Alone Outpatient/PH/IOP Value Set with Other Psychotic Disorders Value Set- BH Outpatient/PH/IOP Value Set with BH Outpatient/PH/IOP POS Value Set and Other Psychotic Disorders Value Set List of Antipsychotic Medications:First Generation Antipsychotic Medications:- Chlorpromazine HCL- Fluphenazine HCL- Fluphenazine decanoate- Haloperidol- Haloperidol decanoate- Molindone HCL- Perphenazine- Pimozide- Haloperidol lactate- Loxapine HCL- Loxapine succinate- Thioridazine HCL- Thiothixene- Trifluoperazine HCLSecond Generation Antipsychotic Medications:- Aripiprazole- Asenapine- Brexpiprazole- Cariprazine- Clozapine- Iloperidone- Lurasidone- Olanzapine- Olanzapine pamoate- Paliperidone- Paliperidone palmitate- Quetiapine fumarate- Risperidone- Risperidone microspheres- Ziprasidone HCL- Ziprasidone mesylateCombinations - Olanzapine-fluoxetine HCL (Symbyax)- Perphenazine-amitriptyline HCL (Etrafon, Triavil [various])Denominator ExclusionsExclude children and adolescents with a diagnosis of a condition for which antipsychotic medications have a U.S. Food and Drug Administration indication and are thus clinically appropriate: schizophrenia, bipolar disorder, psychotic disorder, autism, tic disorders.Numerator DescriptionChildren and adolescents from the denominator who had psychosocial care as first-line treatment prior to (or immediately following) a new prescription of an antipsychotic.Numerator Inclusions (Performance Met)Documentation of psychosocial care (Psychosocial Care Value Set) in the 121-day period from 90 days before the IPSD through 30 days after the IPSD."2.16.840.1.113883.3.464.1004.1316" CPT: 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90846, 90847, 90849, 90853, 90875, 90876, 90880 HCPS: G0176 Activity therapy, such as music, dance, art or play therapies not for recreation, related to the care and treatment of patient's disabling mental health problems, per session (45 minutes or more) (G0176)G0177 Training and educational services related to the care and treatment of patient's disabling mental health problems per session (45 minutes or more) (G0177)G0409 Social work and psychological services, directly relating to and/or furthering the patient's rehabilitation goals, each 15 minutes, face-to-face; individual (services provided by a corf-qualified social worker or psychologist in a corf) (G0409)G0410 Group psychotherapy other than of a multiple-family group, in a partial hospitalization setting, approximately 45 to 50 minutes (G0410)G0411 Interactive group psychotherapy, in a partial hospitalization setting, approximately 45 to 50 minutes (G0411)H0004 Behavioral health counseling and therapy, per 15 minutes (H0004)H0035 Mental health partial hospitalization, treatment, less than 24 hours (H0035)H0036 Community psychiatric supportive treatment, face-to-face, per 15 minutes (H0036)H0037 Community psychiatric supportive treatment program, per diem (H0037)H0038 Self-help/peer services, per 15 minutes (H0038)H0039 Assertive community treatment, face-to-face, per 15 minutes (H0039)H0040 Assertive community treatment program, per diem (H0040)H2000 Comprehensive multidisciplinary evaluation (H2000)H2001 Rehabilitation program, per 1/2 day (H2001)H2011 Crisis intervention service, per 15 minutes (H2011)H2012 Behavioral health day treatment, per hour (H2012)H2013 Psychiatric health facility service, per diem (H2013)H2014 Skills training and development, per 15 minutes (H2014)H2017 Psychosocial rehabilitation services, per 15 minutes (H2017)H2018 Psychosocial rehabilitation services, per diem (H2018)H2019 Therapeutic behavioral services, per 15 minutes (H2019)H2020 Therapeutic behavioral services, per diem (H2020)S0201 Partial hospitalization services, less than 24 hours, per diem (S0201)S9480 Intensive outpatient psychiatric services, per diem (S9480)S9484 Crisis intervention mental health services, per hour (S9484)S9485 Crisis intervention mental health services, per diem (S9485)Numerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsMeasure was specified at the health plan level. Measure has been respecified from the CMS 2017 Child Core Set to replace "beneficiary" with "patient" and replaced "dispense" with "prescribed" and removed requirements for continuous plan enrollment. HHSC rAdditional Information? This measure intends to assess use of psychosocial care as a first-line treatment for conditions for which antipsychotic medications are not indicated. The 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. DEFINITIONS:IPDS: Index Prescription Start Date. The earliest prescription 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.M1-317: Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief CounselingMeasure Description:Percentage of Consumers aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol userM1-317: Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief CounselingDY7/DY8 Program IDM1-317Measure DetailsSteward: AMA-convened Physician Consortium for Performance ImprovementNQF #: 2152Source: CMS MIPS #431 (Claims/Registry)Data SourceE.H.R.Required StatusOptionalMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionAll Consumers aged 18 years and older seen for at least two visits or at least one preventive visit during the measurement periodDenominator InclusionsConsumers aged ≥ 18 yearsANDAt least two Consumer encounters during the performance period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 90845, 96150, 96151, 96152, 97165, 97166, 97167, 97168, 97802, 97803, 97804, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, G0270, G0271WITHOUTTelehealth Modifier: GQ, GTORAt Least One Preventive Visit during the performance period (CPT or HCPCS): 96160, 96161, 99385, 99386, 99387, 99395, 99396, 99397, 99401, 99402, 99403, 99404, 99411, 99412, 99429, G0438, G0439WITHOUTTelehealth Modifier: GQ, GTDenominator ExclusionsDocumentation of medical reason(s) for not screening for unhealthy alcohol use (e.g., limited life expectancy, other medical reasons) (G9623)Numerator DescriptionConsumers who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol userDefinitions:Systematic screening method - For purposes of this measure, one of the following systematic methods toassess unhealthy alcohol use must be utilized. Systematic screening methods and thresholds for definingunhealthy alcohol use include:? AUDIT Screening Instrument (score ≥ 8)? AUDIT-C Screening Instrument (score ≥ 4 for men; score ≥ 3 for women)? Single Question Screening - How many times in the past year have you had 5 (for men) or 4 (forwomen and all adults older than 65 years) or more drinks in a day? (response ≥ 2) Brief counseling - Brief counseling for unhealthy alcohol use refers to one or more counseling sessions, aminimum of 5-15 minutes, which may include: feedback on alcohol use and harms; identification of high risksituations for drinking and coping strategies; increased motivation and the development of a personal plan toreduce drinking.NUMERATOR NOTE: In the event that a Consumer is screened for unhealthy alcohol use and identified as a userbut did not receive brief alcohol cessation counseling report G9624.Numerator Inclusions (Performance Met)Consumer identified as an unhealthy alcohol user when screened for unhealthy alcohol use using a systematic screening method and received brief counseling (G9621)ORConsumer not identified as an unhealthy alcohol user when screened for unhealthy alcohol use using a systematic screening method (G9622)Numerator Exclusions (Performance Not Met)Consumer not screened for unhealthy alcohol screening using a systematic screening method OR Consumer did not receive brief counseling, reason not given (G9624)DSRIP Specific ModificationsRemoved Medicare specific clarifications regarding non-covered services under Medicare Part B.Additional InformationMeasure is a clinic-reported measure for Certified Community Behavioral Health Clinics (CCBHCs) as part of the Demonstration Program to Improve Community Mental Health Services, found in Section 223 of the federal Protecting Access to Medicare Act of 2014 (PAMA). For DSRIP reporting purposes, measure has been specified using the same source measure used for CCBHC reporting requirements.M1-319: Adult Major Depressive Disorder (MDD): Suicide Risk Assessment (eMeasure)Measure Description:Percentage of Consumers aged 18 years and older with a diagnosis of major depressive disorder (MDD) with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identifiedM1-319: Adult Major Depressive Disorder (MDD): Suicide Risk Assessment (eMeasure)DY7/DY8 Program IDM1-319Measure DetailsSteward: AMA and PCPI(R) Foundation (PCPI[R])NQF #: 0104Source: eMeasure: SourceE.H.R.Required StatusOptionalMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: PositiveUnit of Measurement for Payer TypeUnit: EncountersMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionAll Consumers aged 18 years and older with a diagnosis of major depressive disorder (MDD)Denominator InclusionsMedical Records:Follow the steps below to identify the eligible population:Step 1: Identify consumers seen at the provider entity at least once during the measurement year.Step 2: Identify consumers from step 1 aged 18 and older at the time of the first encounter identified in step 3.Step 3: Identify consumers from step 2 with a new diagnosis or recurrent episode of MDD identified by the provider entity during the measurement year. Step 4: Identify the number of times, for the consumers in step 3, there was a new diagnosis or recurrent episode of MDD identified by the clinic during the measurement year.Note: It is expected that a suicide risk assessment will be completed at the visit during which a new diagnosis is made or at the visit during which a recurrent episode is first identified. This is an episode-of-care measure and should be reported for each instance of a new or recurrent episode of MDD; every new or recurrent episode will count separately in the Eligible Population. Age >= 18 yearsANDDiagnosis for Major Depressive Disorder (ICD-9-CM) [reportable through9/30/2015]: 296.20, 296.21, 296.22, 296.23, 296.24, 296.30, 296.31, 296.32,296.33, 296.34Diagnosis for Major Depressive Disorder (ICD-10-CM) [reportable beginning10/1/2015]: F32.0, F32.1, F32.2, F32.3, F32.9, F33.0, F33.1, F33.2, F33.3, F33.9ANDCPT? Code for Encounter: 90791, 90792, 90832, 90834, 90837, 90845, 99201,99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99241, 99242, 99243,99244, 99245, 99281, 99282, 99283, 99284, 99285 E.H.R.: AND: Age>= 17 year(s) at: "Measurement Period" AND: Occurrence A of $MDDEncounters161 AND NOT: $MDDEncounters161 < 105 day(s) ends before start of Occurrence A of $MDDEncounters161Denominator ExclusionsNoneNumerator DescriptionConsumers with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identifiedNumerator Inclusions (Performance Met)Medical Records:Patients with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified (Report G Code: G8932: Suicide risk assessed at the initial evaluation) E.H.R. AND: "Intervention, Performed: Suicide Risk Assessment" during Occurrence A of $MDDEncounters161Numerator Exclusions (Performance Not Met)NoneDSRIP Specific ModificationsNoneAdditional InformationMeasure is a clinic-reported measure for Certified Community Behavioral Health Clinics (CCBHCs) as part of the Demonstration Program to Improve Community Mental Health Services, found in Section 223 of the federal Protecting Access to Medicare Act of 2014 (PAMA). For DSRIP reporting purposes, measure has been specified using the same source measure used for CCBHC reporting requirements. DEFINITIONS: Suicide Risk Assessment: A suicide risk assessment must include questions about the following: 1. Suicidal ideation 2. Consumer’s intent of initiating a suicide attempt AND, if either is present: 3. Consumer plans for a suicide attempt 4. Whether the consumer has means for completing suicide E.H.R.Data Criteria (QDM Variables):? $MDDEncounters161 = o Union of: "Encounter, Performed: Psych Visit - Diagnostic Evaluation (diagnosis: Major Depressive Disorder-Active)" "Encounter, Performed: Psych Visit - Psychotherapy (diagnosis: Major Depressive Disorder-Active)" "Encounter, Performed: Emergency Department Visit (diagnosis: Major Depressive Disorder-Active)" "Encounter, Performed: Office Visit (diagnosis: Major Depressive Disorder-Active)" "Encounter, Performed: outpatient Consultation (diagnosis: Major Depressive Disorder-Active)" "Encounter, Performed: Psychoanalysis (diagnosis: Major Depressive Disorder-Active)" "Encounter, Performed: Face-to-Face Interaction (diagnosis: Major Depressive Disorder-Active)" during "Measurement Period"Data Criteria (QDM Data Elements):? "Encounter, Performed: Emergency Department Visit" using "Emergency Department Visit Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1010)"? "Encounter, Performed: Face-to-Face Interaction" using "Face-to-Face Interaction Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1048)"? "Encounter, Performed: Office Visit" using "Office Visit Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1001)"? "Encounter, Performed: outpatient Consultation" using "outpatient Consultation Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1008)"? "Encounter, Performed: Psych Visit - Diagnostic Evaluation" using "Psych Visit - Diagnostic Evaluation Grouping Value Set (2.16.840.1.113883.3.526.3.1492)"? "Encounter, Performed: Psych Visit - Psychotherapy" using "Psych Visit - Psychotherapy Grouping Value Set (2.16.840.1.113883.3.526.3.1496)"? "Encounter, Performed: Psychoanalysis" using "Psychoanalysis Grouping Value Set (2.16.840.1.113883.3.526.3.1141)"? "Intervention, Performed: Suicide Risk Assessment" using "Suicide Risk Assessment Grouping Value Set (2.16.840.1.113883.3.526.3.1484)"? Attribute: "Diagnosis: Major Depressive Disorder-Active" using "Major Depressive Disorder-Active Grouping Value Set (2.16.840.1.113883.3.526.3.1491)"M1-339: Alcohol & Other Drug Use Disorder Treatment Provided or Offered at Discharge SUB-3 / Alcohol and Other Drug Use Disorder Treatment at Discharge SUB-3aMeasure Description:Rate 1: SUB-3 Patients who are identified with alcohol or drug use disorder who receive or refuse at discharge a prescription for FDA-approved medications for alcohol or drug use disorder, OR who receive or refuse a referral for addictions treatment.Rate 2: SUB-3a Patients who are identified with alcohol or drug disorder who receive a prescription for FDA-approved medications for alcohol or drug use disorder OR a referral for addictions treatment. The measure is reported as an overall rate which includes all patients to whom alcohol or drug use disorder treatment was provided, or offered and refused, at the time of hospital discharge, and a second rate, a subset of the first, which includes only those patients who received alcohol or drug use disorder treatment at discharge. The Provided or Offered rate (SUB-3) describes patients who are identified with alcohol or drug use disorder who receive or refuse at discharge a prescription for FDA-approved medications for alcohol or drug use disorder, OR who receive or refuse a referral for addictions treatment. The Alcohol and Other Drug Disorder Treatment at Discharge (SUB-3a) rate describes only those who receive a prescription for FDA-approved medications for alcohol or drug use disorder OR a referral for addictions treatment. Those who refused are not included.M1-339: Alcohol & Other Drug Use Disorder Treatment Provided or Offered at Discharge SUB-3 / Alcohol and Other Drug Use Disorder Treatment at Discharge SUB-3aDY7/DY8 Program IDM1-339Measure DetailsSteward: The Joint CommissionNQF #: 1664Source: SourceE.H.R.Required StatusOptionalMeasure ClassificationType: ProcessMeasure Parts: 2Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionThe number of hospitalized inpatients 18 years of age and older identified with an alcohol or drug use disorderDenominator InclusionsPatients with ICD-10-CM Principal or Other Diagnosis Code for alcohol or drug use disorder listed on Table 13.1 and 13.2- TJC Table 13.1: Alcohol DependenceF10121, F10221, F10231, F10921, F1026, F1096, F1097, F1027, F10151, F10251, F10951, F10920, F10929, F10150, F10250, F10950, F10230, F10232, F10239, F10182, F10282, F10982, F1014, F10159, F10180, F10181, F10188, F1024, F10259, F10280, F10281, F10288, F10959, F10980, F10981, F10988, F1019, F1029, F1094, F1099, F10220, F10229, F1020, F1010, F10120, F10129, T510X1A, T510X2A, T510X3A, T510X4A, T5191XA, T5192XA, T5193XA, T5194XA - TJC Table 13.2: Drug DependenceF1123, F1193, F13230, F13231, F13232, F13239, F13930, F13931, F13932, F13939, F1423, F1523, F1593, F19230, F19231, F19232, F19239, F19930, F19931, F19932, F19939, F11150, F11250, F11950, F12150, F12250, F12950, F13150, F13250, F13950, F14150, F14250, F14950, F15150, F15250, F15950, F16150, F16250, F16950, F18150, F18250, F18950, F19150, F19250, F19950, F11151, F11251, F11951, F12151, F12251, F12951, F13151, F13251, F13951, F14151, F14251, F14951, F15151, F15251, F15951, F16151, F16251, F16951, F18151, F18251, F18951, F19151, F19251, F19951, F11121, F11221, F11921, F12121, F12221, F12921, F13121, F13221, F13921, F14121, F14221, F14921, F15121, F15221, F15921, F16121, F16221, F16921, F18121, F18221, F18921, F19121, F19221, F19921, F11122, F1327, F1397, F1817, F1827, F1897, F1917, F1927, F1997, F1326, F1396, F1916, F1926, F1996, F1114, F1124, F1194, F1314, F1324, F1394, F1414, F1424, F1494, F1514, F1524, F1594, F1614, F1624, F1694, F1814, F1824, F1894, F1914, F1924, F1994, F11182, F11282, F11982, F13182, F13282, F13982, F14182, F14282, F14982, F15182, F15282, F15982, F19182, F19282, F19982, F11159, F11181, F11188, F11222, F11259, F11281, F11288, F11922, F11959, F11981, F11988, F12122, F12159, F12180, F12188, F12222, F12259, F12280, F12288, F12922, F12959, F12980, F12988, F13159, F13180, F13181, F13188, F13259, F13280, F13281, F13288, F13959, F13980, F13981, F13988, F14122, F14159, F14180, F14181, F14188, F14222, F14259, F14280, F14281, F14288, F14922, F14959, F14980, F14981, F14988, F15122, F15159, F15180, F15181, F15188, F15222, F15259, F15280, F15281, F15288, F15922, F15959, F15980, F15981, F15988, F16122, F16159, F16180, F16183, F16188, F16259, F16280, F16283, F16288, F16959, F16980, F16983, F16988, F18159, F18180, F18188, F18259, F18280, F18288, F18959, F18980, F18988, F19122, F19159, F19180, F19181, F19188, F19222, F19259, F19280, F19281, F19288, F19922, F19959, F19980, F19981, F19988, F1119, F1129, F1199, F1219, F1229, F1299, F1319, F1329, F1399, F1419, F1429, F1499, F1519, F1529, F1599, F1619, F1629, F1699, F1819, F1829, F1899, F19129, F1919, F1929, F1999, F1120, F11220, F11229, F1320, F13220, F13229, F1420, F14220, F14229, F1220, F12220, F12229, F1520, F15220, F15229, F1620, F16220, F16229, F1820, F18220, F18229, F1920, F19220, F19229, F1210, F1290, F1610, F16120, F1690, F1310, F13120, F1390, F1110, F11120, F11129, F1190, F1410, F14120, F1490, F1510, F15120, F1590, F1910, F19120, F1990, O99320, O99321, O99322, O99323, O99324, O99325 Patients with a Principal or Other ICD-10-PCS Procedure Code listed on Table 13.3- TJC Table 13.3: Alcohol and Drug Treatment Procedures:HZ30ZZZ, HZ31ZZZ, HZ32ZZZ, HZ33ZZZ, HZ34ZZZ, HZ35ZZZ, HZ36ZZZ, HZ37ZZZ, HZ38ZZZ, HZ39ZZZ, HZ3BZZZ, HZ40ZZZ, HZ41ZZZ, HZ42ZZZ, HZ43ZZZ, HZ44ZZZ, HZ45ZZZ, HZ46ZZZ, HZ47ZZZ, HZ48ZZZ, HZ49ZZZ, HZ4BZZZ, HZ50ZZZ, HZ51ZZZ, HZ52ZZZ, HZ53ZZZ, HZ54ZZZ, HZ55ZZZ, HZ56ZZZ, HZ57ZZZ, HZ58ZZZ, HZ59ZZZ, HZ5BZZZ, HZ5CZZZ, HZ5DZZZ, HZ63ZZZ, HZ81ZZZ, HZ82ZZZ, HZ83ZZZ, HZ84ZZZ, HZ85ZZZ, HZ86ZZZ, HZ87ZZZ, HZ88ZZZ, HZ89ZZZ, HZ91ZZZ, HZ92ZZZ, HZ93ZZZ, HZ94ZZZ, HZ95ZZZ, HZ96ZZZ, HZ97ZZZ, HZ98ZZZ, HZ99ZZZ, HZ2ZZZZDenominator ExclusionsThere are 11 exclusions to the denominator as follows:? Patients less than 18 years of age? Patient drinking at unhealthy levels who do not meet criteria for an alcohol use disorder? Patients who are cognitively impaired? Patients who expire ? Patients discharged to another hospital ? Patients who left against medical advice? Patients discharged to another healthcare facility? Patients discharged to home or another healthcare facility for hospice care? Patients who have a length of stay less than or equal to one day or greater than 120 days? Patients who do not reside in the United States? Patients receiving Comfort Measures Only documentedNumerator DescriptionSUB-3: The number of patients who received or refused at discharge a prescription for medication for treatment of alcohol or drug use disorder OR received or refused a referral for addictions treatment.SUB-3a: The number of patients who received a prescription at discharge for medication for treatment of alcohol or drug use disorder OR a referral for addictions treatment.Numerator Inclusions (Performance Met)SUB-3: The number of patients who received or refused at discharge a prescription for medication for treatment of alcohol or drug use disorder OR received or refused a referral for addictions treatment. SUB-3a: The number of patients who received a prescription at discharge for medication for treatment of alcohol or drug use disorder OR a referral for addictions treatment.TJC Table 9.2: FDA-Approved Medications for Alcohol and Drug DependenceAcamprosateAntabuseBuprenorphineCampralDisulfiramMethadoneNaltrexoneRevia oralSuboxoneVivitrol injection *See "Additional Information" section for definitions related to "Referral for Addictions Treatment"Numerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationSampling: Refer to the measure set specific sampling requirements and for additional information see the Population and Sampling Specifications section. Data Elements:Data Element Name: Alcohol Use StatusDefinition: Documentation of the adult patient’s alcohol use status using a validated screening questionnaire for unhealthy alcohol use within the first day of admission. A validated screening questionnaire is an instrument that has been psychometrically tested for reliability (the ability of the instrument to produce consistent results), validity (the ability of the instrument to produce true results), and sensitivity (the probability of correctly identifying a patient with the condition). Validated screening questionnaires can be administered by pencil and paper, by computer or verbally. The screening questionnaire should be at a comprehension level or reading level appropriate for the patient population and in the appropriate language for non-English speaking patients.An example of a validated questionnaire for alcohol screening is the 10 item Alcohol Use Disorder Identification Tests (AUDIT). The first three questions of the AUDIT, the AUDIT-C, ask about alcohol consumption, and can be used reliably and validly to identify unhealthy alcohol use. The four-item CAGE questionnaire is generally inappropriate for screening general populations, as it aims to identify only severely alcohol dependent patients.Suggested Data Collection Question: What is the patient’s alcohol use status?Allowable Values:- 1 The patient is screened with a validated tool within the first day of admission and the score on the alcohol screen indicates no or low risk of alcohol related problems.- 2 The patient was screened with a validated tool within the first day of admission and the score on the alcohol screen indicates unhealthy alcohol use (moderate or high risk) benefiting from brief intervention.- 3 The patient was screened with a non-validated tool within the first day of admission and the score on the alcohol screen indicates no or low risk of alcohol related problems.- 4 The patient was screened with a non-validated tool within the first day of admission and the score on the alcohol screen indicates unhealthy alcohol use (moderate or high risk) benefiting from brief intervention.- 5 The patient refused the screen for alcohol use within the first day of admission.- 6 The patient was not screened for alcohol use during the first day of admission or unable to determine from medical record documentation.- 7 The patient was not screened for alcohol use during the first day of admission because of cognitive impairment.Notes for Abstraction:? If patient has a blood alcohol test with a result of .08 or greater or the clinician documents the patient was acutely intoxicated per blood alcohol test results select Value “2.”? Screening may be done with a “validated” Single Alcohol Screening Question (SASQ) in order to identify those patients with no risk or low risk or who do not drink. Further screening should be done with a validated tool for those patients with a positive result to determine if there is need for a brief intervention.Examples of SASQs include: o “On any single occasion during the past 3 months, have you had more than 5 drinks containing alcohol?” (Yes response is considered positive.) o "When was the last time you had more than X drinks in 1 day?" (X = 4 for women and 5 for men) (Within the last 3 months is considered positive.) o “How many times in the past year have you had X or more drinks in a day?" (X = 5 men and 4 women) (Response of >1 is considered positive.) o How often have you had 6 or more drinks on one occasion in the past year? (Ever in the past year considered positive.) o How often do you have X or more drinks on one occasion? (X = 4 for women and 5 for men) (Ever in the past year considered positive.)? Refer to the Inclusion Guidelines for examples of commonly used validated screening tools; note that the CAGE, although a validated tool, is not recommended for this measure set.? The alcohol use status screening timeframe must have occurred within the first day of admission. The day after admission is defined as the first day. EXCEPTION:If the screening was performed prior to admission to the psychiatric unit, i.e., at the transferring facility, in another inpatient hospital unit, emergency department or observation unit, the screening documentation must be present in the psychiatric unit medical record.? Cognition refers to mental activities associated with thinking, learning, and memory. Cognitive impairment for the purposes of this measure set is related to documentation that the patient cannot be screened for alcohol use due to the impairment (e.g., comatose, obtunded, confused, memory loss) within the first day of admission.? If there is documentation that the patient has temporary cognitive impairment due to acute substance use (e.g., overdose or acute intoxication), Value “7” cannot be selected.? If there is documentation within the first day of admission that the patient was psychotic with documented symptoms, e.g., hallucinating, non-communicative, catatonic, etc., which prevented them from answering questions reliably, they would be considered cognitively impaired.? If there is documentation that the patient was intubated the entire first day of admission, select allowable value “7” as the patient is unable to answer.? If there is documentation in the medical record indicating the patient drinks alcohol and conflicting documentation indicating the patient does not drink alcohol, select Value “6” since alcohol use status is unable to be determined.When there is conflicting information in the record with regard to risk, for instance, the results from a validated screening tool are documented as both low AND moderate/high risk, select Value “2” indicating the highest risk.? Documentation of cognitive impairment overrides documentation of an alcohol use screen and therefore would not be considered "conflicting documentation." Even if the family or others tell staff the patient uses alcohol, the patient could not be counseled due to cognitive impairment. Select Value “7.”? If there is documentation within the first day of admission of any of the examples below, select Value “7” regardless of conflicting documentation.? When there is conflicting information in the record with regard to risk, for instance, the results from a validated screening tool are documented as both low AND moderate/high risk, select Value “2” indicating the highest risk.? Documentation of cognitive impairment overrides documentation of an alcohol use screen and therefore would not be considered "conflicting documentation." Even if the family or others tell staff the patient uses alcohol, the patient could not be counseled due to cognitive impairment. Select Value “7.”? If there is documentation within the first day of admission of any of the examples below, select Value “7” regardless of conflicting documentation.Examples of cognitive impairment include: Altered Level of Consciousness (LOC), Altered Mental Status, Cognitive impairment, Cognitively impaired, Dementia, Confused, Memory loss, Mentally retarded, Obtunded, Psychotic/psychosisSuggested Data Sources: Consultation notes, Emergency Department record, History and physical, Nursing admission assessment, Nursing admission notes, Physician progress notesInclusion Guidelines for Abstraction: - Validated Screening Tools for Unhealthy Alcohol Use: (This list is not ALL Inclusive) AUDIT, AUDIT-C, ASSIST, CRAFFT, G-MAST, MAST, TWEAK - Exclusion Guidelines for Abstraction: Any tool which specifically screens for alcohol use disorder, alcohol dependency or alcohol abuse. Examples include, but are not limited to: CAGE, SASSI, S2BI Data Element Name: Comfort Measures OnlyDefinition: Comfort Measures Only refers to medical treatment of a dying person where the natural dying process is permitted to occur while assuring maximum comfort. It includes attention to the psychological and spiritual needs of the patient and support for both the dying patient and the patient's family. Comfort Measures Only is commonly referred to as “comfort care” by the general public. It is not equivalent to a physician order to withhold emergency resuscitative measures such as Do Not Resuscitate (DNR).Suggested Data Collection Question: When is the earliest physician/APN/PA documentation of comfort measures only?Allowable Values:1 - Day 0 or 1: The earliest day the physician/APN/PA documented comfort measures only was the day of arrival (Day 0) or day after arrival (Day 1).2 - Day 2 or after: The earliest day the physician/APN/PA documented comfort measures only was two or more days after arrival day (Day 2+).3 - Timing unclear: There is physician/APN/PA documentation of comfort measures only during this hospital stay, but whether the earliest documentation of comfort measures only was on day 0 or 1 OR after day 1 is unclear.4 - Not Documented/UTD: There is no physician/APN/PA documentation of comfort measures only, or unable to determine from medical record documentation.Notes for Abstraction:? Only accept terms identified in the list of inclusions. No other terminology will be accepted.? Physician/APN/PA documentation of comfort measures only (hospice, comfort care, etc.) mentioned in the following contexts suffices: o Comfort measures only recommendation o Order for consultation or evaluation by a hospice care service o Patient or family request for comfort measures only o Plan for comfort measures only o Referral to hospice care service o Discussion of comfort measures? Determine the earliest day comfort measures only (CMO) was DOCUMENTED by the physician/APN/PA. If any of the inclusion terms are documented by the physician/APN/PA, select Value “1,” “2,” or “3” accordingly.Example: “Discussed comfort care with family on arrival” noted in day 2 progress note – Select “2.”? State-authorized portable orders (SAPOs): o SAPOs are specialized forms or identifiers authorized by state law that translate a patient’s preferences about specific end-of-life treatment decisions into portable medical orders. Examples: DNR-Comfort Care form, MOLST (Medical Orders for Life-Sustaining Treatment), POLST (Physician Orders for Life-Sustaining Treatment), Out-of-Hospital DNR (OOH DNR) o If there is a SAPO in the record that is dated and signed prior to arrival with an option in which an inclusion term is found that is checked, select Value “1.” o If a SAPO lists different options for CMO and any CMO option is checked, select Value “1,” “2,” or “3” as applicable. o If one or more dated SAPOs are included in the record (and signed by the physician/APN/PA), use only the most recent one. Disregard undated SAPOs. o For cases where there is a SAPO in the record with a CMO option selected: If the SAPO is dated prior to arrival and there is documentation on the day of arrival or the day after arrival that the patient does not want CMO, and there is no other documentation regarding CMO found in the record, disregard the SAPO. Example: Patient has a POLST dated prior to arrival in his chart and ED physician states in current record “Patient is refusing comfort measures, wants to receive full treatment and be a full code.”? Documentation of an inclusion term in the following situations should be disregarded. Continue to review the remaining physician/APN/PA documentation for acceptable inclusion terms. If the ONLY documentation found is an inclusion term in the following situations, select Value “4.” o Documentation (other than SAPOs) that is dated prior to arrival or documentation which refers to the pre-arrival time period. Examples: Comfort measures only order in previous hospitalization record.; “Pt. on hospice at home” in MD ED note. o Inclusion term clearly described as negative or conditional. Examples: “No comfort care"; "Not appropriate for hospice care"; “Comfort care would also be reasonable - defer decision for now”; “DNRCCA” (Do Not Resuscitate – Comfort Care Arrest); “Family requests comfort measures only should the patient arrest.” o Documentation of “CMO” should be disregarded if documentation makes clear it is not being used as an acronym for Comfort Measures Only (e.g., “hx dilated CMO” – Cardiomyopathy context).? If there is physician/APN/PA documentation of an inclusion term in one source that indicates the patient is Comfort Measures Only, AND there is physician/APN/PA documentation of an inclusion term in another source that indicates the patient is NOT CMO, the source that indicates the patient is CMO would be used to select Value “1,” “2,” or “3” for this data element. Examples: - Physician documents in progress note on day 1 “The patient has refused Comfort Measures” AND then on day 2 the physician writes an order for a Hospice referral. Select Value “2.” - ED physician documents in a note on day of arrival “Patient states they want to be enrolled in Hospice” AND then on day 2 there is a physician progress note with documentation of “Patient is not a Hospice candidate.” Select Value “1.”Suggested Data Sources: PHYSICIAN/APN/PA DOCUMENTATION ONLY Consultation notes, Discharge summary, DNR/MOLST/POLST forms, Emergency Department record, History and physical, Physician orders, Progress notesExcluded Data Sources: Restraint order sheetInclusion Guidelines for Abstraction: Brain dead, Brain death, Comfort care, Comfort measures, Comfort measures only (CMO), Comfort only, DNR-CC, End of life care, Hospice, Hospice care, Organ harvest, Terminal care, Terminal extubation Data Element Name: Discharge DispositionDefinition: The final place or setting to which the patient was discharged on the day of discharge.Suggested Data Collection Question: What was the patient’s discharge disposition on the day of discharge?Allowable Values:1 - Home2 - Hospice - Home3 - Hospice – Health Care Facility4 - Acute Care Facility5 - Other Health Care Facility6 - Expired7 - Left Against Medical Advice/AMA8 - Not Documented or Unable to Determine (UTD)Notes for Abstraction:? Only use documentation written on the day prior to discharge through 30 days after discharge when abstracting this data element. Example: Documentation in the Discharge Planning notes on 04-01-20xx state that the patient will be discharged back home. On 04-06-20xx the physician orders and nursing discharge notes on the day of discharge reflect that the patient was being transferred to skilled care. The documentation from 04-06-20xx would be used to select Value “5” (Other Health Care Facility).? The medical record must be abstracted as documented (taken at “face value”). Inferences should not be made based on internal knowledge.? If there is documentation that further clarifies the level of care that documentation should be used to determine the correct value to abstract. If documentation is contradictory, use the latest documentation. Examples: o Discharge summary dictated 2 days after discharge states patient went “home.” Physician note on day of discharge further clarifies that the patient will be going "home with hospice.” Select Value “2” (“Hospice - Home”). o Discharge planner note from day before discharge states “XYZ Nursing Home.” Discharge order from day of discharge states “Discharge home.” Contradictory documentation, use latest. Select Value “1” (“Home”). o Physician order on discharge states “Discharge to ALF.” Discharge instruction sheet completed after the physician order states patient discharged to “SNF.” Contradictory documentation, use latest. Select Value “5” (“Other Health Care Facility”).? If documentation is contradictory, and you are unable to determine the latest documentation, select the disposition ranked highest (top to bottom) in the following list. See Inclusion lists for examples. o Acute Care Facility o Hospice – Health Care Facility o Hospice – Home o Other Health Care Facility o Home? Hospice (Values “2” and “3”) includes discharges with hospice referrals and evaluations.? If the medical record states only that the patient is being discharged to another hospital and does not reflect the level of care that the patient will be receiving, select Value “4” (“Acute Care Facility”).? If the medical record states the patient is being discharged to assisted living care or an assisted living facility (ALF) and the documentation also includes nursing home, intermediate care or skilled nursing facility, select Value “1” (“Home”).? If the medical record states the patient is being discharged to nursing home, intermediate care or skilled nursing facility without mention of assisted living care or assisted living facility (ALF), select Value “5” (“Other Health Care Facility”).? If the medical record identifies the facility the patient is being discharged to by name only (e.g., “Park Meadows”), and does not reflect the type of facility or level of care, select Value “5” (“Other Health Care Facility”).? If the medical record states only that the patient is being “discharged” and does not address the place or setting to which the patient was discharged, select Value “1” (“Home”).? When determining whether to select Value “7” (“Left Against Medical Advice/AMA”): o Explicit “left against medical advice” documentation is not required. E.g., “Patient is refusing to stay for continued care” – Select Value “7.” o Documentation suggesting that the patient left before discharge instructions could be given does not count. o A signed AMA form is not required, for the purposes of this data element. o Do not consider AMA documentation and other disposition documentation as “contradictory.” If any source states the patient left against medical advice, select Value “7,” regardless of whether the AMA documentation was written last. E.g., AMA form signed and discharge instruction sheet states “Discharged home with belongings” – Select “7.”Suggested Data Sources: Discharge instruction sheet, Discharge planning notes, Discharge summary, Nursing discharge notes, Physician orders, Progress notes, Social service notes, Transfer recordExcluded Data Sources: Any documentation prior to the last two days of hospitalization, Coding documents, UB-04Inclusion Guidelines for Abstraction:Home (Value 1):? Assisted Living Facilities (ALFs) – Includes ALFs and assisted living care at: nursing home, intermediate care, and skilled nursing facilities? Court/Law Enforcement – includes detention facilities, jails, and prison? Home – includes board and care, foster or residential care, group or personal care homes, retirement communities, and homeless shelters? Home with Home Health Services? Outpatient Services including outpatient procedures at another hospital, Outpatient Chemical Dependency Programs and Partial HospitalizationHospice – Home (Value 2):? Hospice in the home (or other “Home” setting as above in Value 1)Hospice – Health Care Facility (Value 3):? Hospice - General Inpatient and Respite? Hospice - Residential and Skilled Facilities? Hospice - Other Health Care FacilitiesAcute Care Facility (Value 4):? Acute Short Term General and Critical Access Hospitals? Cancer and Children’s Hospitals? Department of Defense and Veteran’s Administration HospitalsOther Health Care Facility (Value 5):? Extended or Intermediate Care Facility (ECF/ICF)? Long Term Acute Care Hospital (LTACH)? Nursing Home or Facility including Veteran’s Administration Nursing Facility? Psychiatric Hospital or Psychiatric Unit of a Hospital? Rehabilitation Facility including Inpatient Rehabilitation Facility/Hospital or Rehabilitation Unit of a Hospital? Skilled Nursing Facility (SNF), Sub-Acute Care or Swing Bed? Transitional Care Unit (TCU)? Veterans Home Data Element Name: Prescription for Alcohol or Drug Disorder MedicationDefinition: Documentation that an FDA-approved medication for alcohol or drug disorder was prescribed at hospital discharge.Suggested Data Collection Question: Was one of the FDA-approved medications for alcohol or drug disorder prescribed at discharge?Allowable Values:1 - A prescription for an FDA-approved medication for alcohol or drug disorder was given to the patient at discharge.2 - A prescription for an FDA-approved medication for alcohol or drug disorder was offered at discharge and the patient refused.3 - The patient’s residence is not in the USA.4 - A prescription for an FDA-approved medication for alcohol or drug disorder was not offered at discharge, or unable to determine from medical record documentation.Notes for Abstraction? In determining whether a medication for alcohol or drug disorder was prescribed at discharge, it is not uncommon to see conflicting documentation among different medical record sources. For example, the discharge summary may list Disulfiram but this is not included in any of the other discharge medications sources, e.g., discharge orders. All discharge medication documentation available in the chart should be reviewed and taken into account by the abstractor.? In cases where there is a medication for alcohol or drug disorder in one source and it is not mentioned on other sources, it should be interpreted as a discharge medication, select Value “1” unless documentation elsewhere in the medical record suggests that it was not prescribed at discharge.? If documentation is contradictory (physician noted “d/c Antabuse” or “hold Antabuse” in the discharge orders, but Antabuse is listed in the discharge summary’s discharge medication list), or after careful examination of circumstances, context, timing, etc., documentation raises enough questions, the case should be deemed unable to determine, select Value “4.”? If the patient does not have a residence in the USA, Value “3” must be selected.Suggested Data Sources: Discharge Instruction Sheet, Discharge summary, Medication Reconciliation Form, Nursing Discharge notes, Physician Orders Sheet, Transfer sheet,Inclusion Guidelines for Abstraction:Refer to TJC Table 9.2 for a comprehensive list of FDA-approved medications for alcohol and drug dependence Data Element Name: Referral for Addictions TreatmentDefinition: Documentation that a referral was made at discharge for addictions treatment by a physician or non-physician (such as nurse, psychologist, or counselor). A referral may be defined as an appointment made by the provider either through telephone contact, fax or e-mail. The referral may be to an addictions treatment program, to a mental health program or mental health specialist for follow-up for substance use or addiction treatment, or to a medical or health professional for follow-up for substance use or addiction.Suggested Data Collection Question: Was a referral for addictions treatment made for the patient prior to discharge?Allowable Values:1 - The referral to addictions treatment was made by the healthcare provider or health care organization at any time prior to discharge.2 - Referral information was given to the patient at discharge but the appointment was not made by the provider or health care organization prior to discharge.3 - The patient refused the referral for addictions treatment and the referral was not made.4 - The patient’s residence is not in the USA.5 - The referral for addictions treatment was not offered at discharge or unable to determine from the medical record documentation.Notes for Abstraction:? A referral to Alcoholics Anonymous (AA) or similar mutual support groups does not meet the intent of the measure, select Value “3” if such a referral is given to the patient.? If the patient does not have a residence in the USA, Value “4” must be selected.Suggested Data Sources: Discharge instruction sheet, Discharge summary, Nursing discharge notes, Physician order sheet, Transfer sheetInclusion Guidelines for Abstraction:? Group counseling? Individual counseling o Addictions counselor o Personal physician o Psychiatrist o PsychologistExclusion Guidelines for Abstraction:? Self-help interventions (brochures, videotapes, audiotapes, reactive hotlines/help lines)? Support groups that are not considered treatment such as Alcoholics Anonymous (AA) Refer to measure stewards data dictionary for additional definitions of Data Elements "Admission Date", "Birthdate", and "Discharge Date"M1-340: Substance use disorders: Percentage of patients aged 18 years and older with a diagnosis of current opioid addiction who were counseled regarding psychosocial AND pharmacologic treatment options for opioid addiction within the 12 month reporting periodMeasure Description:This measure is used to assess the percentage of patients aged 18 years and older with a diagnosis of current opioid addiction who were counseled regarding psychosocial and pharmacologic treatment options for opioid addiction within the 12 month reporting period.M1-340: Substance use disorders: Percentage of patients aged 18 years and older with a diagnosis of current opioid addiction who were counseled regarding psychosocial AND pharmacologic treatment options for opioid addiction within the 12 month reporting periodDY7/DY8 Program IDM1-340Measure DetailsSteward: APA/NCQA/PCPINQF #: NASource: SourceAnyRequired StatusOptionalMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionAll patients aged 18 years and older with a diagnosis of current opioid addictionDenominator InclusionsNone listed by measure steward.Denominator ExclusionsNone listed by measure steward.Numerator DescriptionPatients who were counseled regarding psychosocial AND pharmacologic treatment options for opioid addiction within the 12 month reporting periodNumerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationNoneM1-341: Substance use disorders: Percentage of patients aged 18 years and older with a diagnosis of current alcohol dependence who were counseled regarding psychosocial AND pharmacologic treatment options for alcohol dependence within the 12 month reporting periodMeasure Description:This measure is used to assess the percentage of patients aged 18 years and older with a diagnosis of current alcohol dependence who were counseled regarding psychosocial AND pharmacologic treatment options for alcohol dependence within the 12 month reporting period.M1-341: Substance use disorders: Percentage of patients aged 18 years and older with a diagnosis of current alcohol dependence who were counseled regarding psychosocial AND pharmacologic treatment options for alcohol dependence within the 12 month reporting periodDY7/DY8 Program IDM1-341Measure DetailsSteward: APA/NCQA/PCPINQF #: NASource: SourceAnyRequired StatusOptionalMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionAll patients aged 18 years and older with a diagnosis of current alcohol dependenceDenominator InclusionsNone listed by measure steward.Denominator ExclusionsNone listed by measure steward.Numerator DescriptionPatients who were counseled regarding psychosocial AND pharmacologic treatment options for alcohol dependence within the 12 month reporting periodNumerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationNoneM1-342: Time to Initial Evaluation: Evaluation within 10 Business DaysMeasure Description:The percentage of new consumers with initial evaluation provided within 10 business days of first contactM1-342: Time to Initial Evaluation: Evaluation within 10 Business DaysDY7/DY8 Program IDM1-342Measure DetailsSteward: SAMHSA/CCBHCNQF #: NASource: SourceE.H.R., otherRequired StatusOptionalMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionThe number of consumers in the eligible population.Denominator InclusionsNew consumers who contacted the provider entity seeking services during the measurement year.ANDConsumers 12 years and older as of the end of the measurement year Note: The measurement period for the baseline measurement period denominator is the measurement year excluding the last 30 days of the measurement year and including the 6 months preceding the measurement year. The measurement period for performance measurement periods PY1, PY2, and PY3 is the measurement year excluding the last 30 days of the measurement year and including the 30 days preceding the measurement year.Denominator ExclusionsNone listed by measure steward.Numerator DescriptionConsumers who received an initial evaluation within 10 business days of the first contact with the provider entity.Numerator Inclusions (Performance Met)The number of consumers in the eligible population who received an initial evaluation within 10 business days of the first contact with the provider entity during the measurement year. Note: The measurement period for the numerator is the measurement year.Numerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsThe original measure is specified to be reported with two age stratifications (12 - 17 and 18 and older) and a total rate. For DSRIP reporting purposes, specifications have been modified so that providers are reporting the total rate only.For DSRIP reporting purposes, measurement periods for DSRIP performance years PY1, PY2, and PY3 have been defined as the measurement year excluding the last 30 days of the measurement year and including the 30 days preceding the measurement year, so that performance years data for PY1, PY2, and PY3 does not overlap with baseline or the prior reporting year measurement. The SAMSHA CCBHC developed specifications published in the Metric and Quality Measure for Behavioral Health Clinics Technical Specifications and Resource Manual Volume 1 April 2016 specify that the measurement period is the measurement year excluding the last 30 days of the measurement year and including the 6 months preceding the measurement year.Additional InformationProvider entities will rely on medical records to compile this information. There are several potential sources of information that may be used individually or together:o Electronic health records (including billing records)o Paper health recordso A registryo An electronic scheduling system that is separate from the medical record and that is used to schedule and monitor appointments and critical time frameso A system similar to one developed by NIATx (the NIATx outpatient Spreadsheet) DEFINITIONS: Business Days: Monday through Friday, excluding state and federal holidays (regardless of days of operation)Initial Evaluation: Some certification standards, such as the CCBHC certification criteria, require that an initial evaluation be carried out for new consumers within a specified time frame based on the acuity of needs. In the case of a CCBHC, the initial evaluation is due within 10 business days of first contact for those who present with “routine” non-emergency or non-urgent needs. That standard is used in this specification. Other standards may exist for other entities and this specification can be adapted accordingly.New Consumer: An individual not seen at the clinic in the past 6 monthsProvided: As used in the context of the initial evaluation being “provided” by the clinic, the word “provided” means “received.” The clinic is to record the number of business days from initial contact until the initial evaluation was received by or completed for the consumer.Provider Entity: The provider entity that is being measured ADDITIONAL NOTES: This measure is designed to require provider-level reporting but is not tested at the provider level. It is likely that some new consumers will not have an appointment within 10 days because of their own schedules and non-urgent need. This situation is a recognized limitation of this measure that will affect all clinics. Trying to adjust for non-consumers who are offered but do not accept an appointment within 10 business days complicates the calculation unnecessarily.M1-385: Assessment of Functional Status or QoL (Modified from NQF# 0260/2624)Measure Description:Percent of eligible patients who completed a health-related quality of life assessment or functional assessment using a standardized tool at least once during the measurement period.M1-385: Assessment of Functional Status or QoL (Modified from NQF# 0260/2624)DY7/DY8 Program IDM1-385Measure DetailsSteward: NANQF #: NASource: NAData SourceAnyRequired StatusOptionalMeasure ClassificationType: Quality of LifeMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionNumber of eligible individuals receiving specialty care services during the measurement periodDenominator InclusionsNADenominator ExclusionsNANumerator DescriptionNumber of eligible patients who completed a health-related quality of life assessment or functional assessment using a standardized tool at least once during the measurement period.Numerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationIf 385 and 386 are selected, the same tools must be used in both measures. Provider to specify Functional Status or QoL instrument during RHP plan submission. Instrument must be externally validated and tested for reliability and used for assessment of improvements status. Approvable instruments include (not exhaustive):- AQoL-4D, 6D, 7D, and 8D- PedsQL, including disease specific modules- SF-12, SF-36- Palliative Care Outcome Scale- Fact G- BDI-2- PAID Excluded instruments include:- ANSA- CANS- HRQoL- ABCM1-386: Improvement in Functional Status or QoL (Modified from PQRS #435)Measure Description:Percent of patients who had a follow up health-related quality of life or functional status assessed during the measurement period whose score stayed the same or improved.M1-386: Improvement in Functional Status or QoL (Modified from PQRS #435)DY7/DY8 Program IDM1-386Measure DetailsSteward: NANQF #: NASource: NAData SourceAnyRequired StatusOptionalMeasure ClassificationType: Quality of LifeMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionPatients who had a follow up health-related quality of life or functional status assessed during the measurement periodDenominator InclusionsNADenominator ExclusionsNANumerator DescriptionPatients whose score stayed the same or improved.Numerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationIf 385 and 386 are selected, the same tools must be used in both measures. Provider to specify Functional Status or QoL instrument during RHP plan submission. Instrument must be externally validated and tested for reliability and used for assessment of improvements status. Approvable instruments include (not exhaustive):- AQoL-4D, 6D, 7D, and 8D- PedsQL, including disease specific modules- SF-12, SF-36- Palliative Care Outcome Scale- Fact G- BDI-2- PAID Excluded instruments include:- ANSA- CANS- HRQoL- ABCM1-387: Reduce Emergency Department visits for Behavioral Health and Substance Abuse (Reported as two rates)Measure Description:Rate of ED utilization for behavioral health and substance abuse conditionsM1-387: Reduce Emergency Department visits for Behavioral Health and Substance Abuse (Reported as two rates)DY7/DY8 Program IDM1-387Measure DetailsSteward: NANQF #: NASource: NAData SourceAnyRequired StatusOptionalMeasure ClassificationType: Clinical OutcomeMeasure Parts: 2Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: NegativeUnit of Measurement for Payer TypeUnit: EncountersMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionCMHCs may report the denominator as either the total number of ED visits for individuals 18 years or older during the measurement period OR The DSRIP Attributed Target PopulationDenominator InclusionsNADenominator ExclusionsNANumerator DescriptionRate 1: Total number of ED Visits with a primary or secondary diagnosis of behavioral health conditionsRate 2: Total number of ED Visits with a primary or secondary diagnosis of substance abuseNumerator Inclusions (Performance Met)Rate 1:- Behavioral Health (primary and secondary diagnosis): F20-F29 Schizophrenia, schizotypal, delusional, and other non-mood psychotic disorders F30-F39 Mood [affective] disorders F40-F48 Anxiety, dissociative, stress-related, somatoform and other nonpsychotic mental disorders F60-F69 Disorders of adult personality and behavior Rate 2:- Substance Abuse (primary and secondary diagnosis): F10-F16, F18 - F19 Mental and behavioral disorders due to psychoactive substance use, excluding NicotineNumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationWhere only two digits are listed, all diagnoses at the 3rd, 4th, and 5th digit should be included (e.g., asthma is listed as J45, but you should include J45.20, J45.21, J45.22…J45.991, J45.998). Where only three digits are listed, all diagnoses at the 4th, and 5th digit should also be included etc., etc.M1-390: Time to Initial Evaluation: Mean Days to EvaluationMeasure Description:The mean number of days until initial evaluation for new consumersM1-390: Time to Initial Evaluation: Mean Days to EvaluationDY7/DY8 Program IDM1-390Measure DetailsSteward: SAMHSA/CCBHCNQF #: NASource: SourceE.H.R., otherRequired StatusOptionalMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: NegativeUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionThe number of consumers in the eligible population.Denominator InclusionsNew consumers who contacted the provider entity seeking services during the measurement year.ANDConsumers 12 years and older as of the end of the measurement year Note: The measurement period for the baseline measurement period denominator is the measurement year excluding the last 30 days of the measurement year and including the 6 months preceding the measurement year. The measurement period for performance measurement periods PY1, PY2, and PY3 is the measurement year excluding the last 30 days of the measurement year and including the 30 days preceding the measurement year. Denominator ExclusionsNone listed by measure steward.Numerator DescriptionTotal number of days to initial evaluation for new consumers.Numerator Inclusions (Performance Met)The total number of days between first contact and initial evaluation for all members of the eligible population seen at the provider entity during the measurement yearNote: The measurement period for the numerator is the measurement year. Any who received an initial evaluation after the last day of the measurement year are treated as having been evaluated 31 days after initial contact.Numerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsThe original measure is specified to be reported with two age stratifications (12 - 17 and 18 and older) and a total rate. For DSRIP reporting purposes, specifications have been modified so that providers are reporting the total rate only.For DSRIP reporting purposes, measurement periods for DSRIP performance years PY1, PY2, and PY3 have been defined as the measurement year excluding the last 30 days of the measurement year and including the 30 days preceding the measurement year, so that performance years data for PY1, PY2, and PY3 does not overlap with baseline or the prior reporting year measurement. The SAMSHA CCBHC developed specifications published in the Metric and Quality Measure for Behavioral Health Clinics Technical Specifications and Resource Manual Volume 1 April 2016 specify that the measurement period is the measurement year excluding the last 30 days of the measurement year and including the 6 months preceding the measurement year.Additional InformationProvider entities will rely on medical records to compile this information. There are several potential sources of information that may be used individually or together:o Electronic health records (including billing records)o Paper health recordso A registryo An electronic scheduling system that is separate from the medical record and that is used to schedule and monitor appointments and critical time frameso A system similar to one developed by NIATx (the NIATx Outpatient Spreadsheet) DEFINITIONS: Business Days: Monday through Friday, excluding state and federal holidays (regardless of days of operation)Initial Evaluation: Some certification standards, such as the CCBHC certification criteria, require that an initial evaluation be carried out for new consumers within a specified time frame based on the acuity of needs. In the case of a CCBHC, the initial evaluation is due within 10 business days of first contact for those who present with “routine” non-emergency or non-urgent needs. That standard is used in this specification. Other standards may exist for other entities and this specification can be adapted accordingly.New Consumer: An individual not seen at the clinic in the past 6 monthsProvided: As used in the context of the initial evaluation being “provided” by the clinic, the word “provided” means “received.” The clinic is to record the number of business days from initial contact until the initial evaluation was received by or completed for the consumer.Provider Entity: The provider entity that is being measured ADDITIONAL NOTES: This measure is designed to require provider-level reporting but is not tested at the provider level. It is likely that some new consumers will not have an appointment within 10 days because of their own schedules and non-urgent need. This situation is a recognized limitation of this measure that will affect all clinics. Trying to adjust for non-consumers who are offered but do not accept an appointment within 10 business days complicates the calculation unnecessarily.M1-400: Tobacco Use and Help with Quitting Among AdolescentsMeasure Description:The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco userM1-400: Tobacco Use and Help with Quitting Among AdolescentsDY7/DY8 Program IDM1-400Measure DetailsSteward: NCQANQF #: 2803Source: CMS MIPS #402 (Claims/Registry)Data SourceClaimsRequired StatusOptionalMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionAll patients aged 12-20 years with a visit during the measurement periodDenominator InclusionsPatients aged 12-20 years on date of encounter AND Patient encounter during the performance period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 90839, 90845, 92002, 92004, 92012, 92014, 96150, 96151, 96152, 97165, 97166, 97167, 97168, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99406, 99407, G0438, G0439, 99383, 99384, 99385, 99393, 99394, 99395Denominator ExclusionsNoneNumerator DescriptionPatients who were screened for tobacco use at least once within 18 months (during the measurement period or the six months prior to the measurement period) AND who received tobacco cessation counseling intervention if identified as a tobacco user Definitions:Tobacco Use Status – Any documentation of smoking or tobacco use status, including ‘never’ or ‘non-use’.Tobacco User – Any documentation of active or current use of tobacco products, including smoking. NUMERATOR NOTE: In the event that a patient is screened for tobacco use and identified as a user but did not receive tobacco cessation counseling report G9460.Numerator Inclusions (Performance Met)Patient documented as tobacco user AND received tobacco cessation intervention (must include at least one of the following: advice given to quit smoking or tobacco use, counseling on the benefits of quitting smoking or tobacco use, assistance with or referral to external smoking or tobacco cessation support programs, or current enrollment in smoking or tobacco use cessation program) if identified as a tobacco user (G9458)ORCurrently a tobacco non-user (G9459)Numerator Exclusions (Performance Not Met)Tobacco assessment OR tobacco cessation intervention not performed, reason not given (G9460)DSRIP Specific ModificationsFor DSRIP reporting purpose, HHSC has added CPT values for preventive visits 99383 (Prev visit new age 5 - 11), 99384 (Prev visit new age 12 - 17), 99385 (Prev visit new age 18 - 39), 99393 (Prev visit est age 5 -11), 99394 (Prev visit est age 12 - 17), 99395 (Prev visit est age 18 - 39) to the specifications.Additional InformationNoneM1-405: Bipolar Disorder and Major Depression: Appraisal for alcohol or chemical substance useMeasure Description:Percentage of patients with depression or bipolar disorder with evidence of an initial assessment that includes an appraisal for alcohol or chemical substance useM1-405: Bipolar Disorder and Major Depression: Appraisal for alcohol or chemical substance useDY7/DY8 Program IDM1-405Measure DetailsSteward: CMS/Center for Quality Assessment and Improvement in Mental HealthNQF #: NASource: eMeasure: SourceE.H.R.Required StatusOptionalMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionPatients 18 years of age or older at the start of the measurement period with a new diagnosis of unipolar depression or bipolar disorder during the first 323 days of the measurement period, and evidence of treatment for unipolar depression or bipolar disorder within 42 days of diagnosis. The existence of a 'new diagnosis' is established by the absence of diagnoses and treatments of unipolar depression or bipolar disorder during the 180 days prior to the diagnosis.Denominator InclusionsInitial Population = AND: Age>= 18 year(s) at: "Measurement Period" AND: Union of: - $Treatments - "Encounter, Performed: BH Outpatient Psychotherapy" - <= 42 day(s) starts after start of Union of: Occurrence A of $BHEncounter Occurrence A of $BHOutptPsychotherapy AND NOT: Occurrence A of $BHEncounter < 180 day(s) starts after start of Union of: "Encounter, Performed: BH Outpatient encounter" satisfies any: - during "Diagnosis: BH Condition Involving Bipolar Disorder" - during "Diagnosis: BH Condition Involving Unipolar Depression" - during "Medication, Active: BH Antidepressant Medication" - during "Medication, Active: BH Mood Stabilizer Medication" "Encounter, Performed: BH Outpatient Psychotherapy" satisfies any: - during "Diagnosis: BH Condition Involving Bipolar Disorder" - during "Diagnosis: BH Condition Involving Unipolar Depression" Union of: - "Diagnosis: BH Condition Involving Unipolar Depression" - "Diagnosis: BH Condition Involving Bipolar Disorder" - starts during Union of: - "Encounter, Performed: BH Outpatient encounter" - "Encounter, Performed: BH Outpatient Psychotherapy" $Treatments AND NOT: Occurrence A of $BHOutptPsychotherapy < 180 day(s) starts after start of Union of: "Encounter, Performed: BH Outpatient encounter" satisfies any: - during "Diagnosis: BH Condition Involving Bipolar Disorder" - during "Diagnosis: BH Condition Involving Unipolar Depression" - during "Medication, Active: BH Antidepressant Medication" - during "Medication, Active: BH Mood Stabilizer Medication" "Encounter, Performed: BH Outpatient Psychotherapy" satisfies any: - during "Diagnosis: BH Condition Involving Bipolar Disorder" - during "Diagnosis: BH Condition Involving Unipolar Depression" Union of: - "Diagnosis: BH Condition Involving Unipolar Depression" - "Diagnosis: BH Condition Involving Bipolar Disorder" - starts during Union of: - "Encounter, Performed: BH Outpatient encounter" - "Encounter, Performed: BH Outpatient Psychotherapy" $TreatmentsDenominator = AND: Initial PopulationDenominator ExclusionsNoneNumerator DescriptionPatients in the denominator with evidence of an assessment for alcohol or other substance use following or concurrent with the new diagnosis, and prior to or concurrent with the initiation of treatment for that diagnosisNumerator Inclusions (Performance Met)Numerator = AND: "Procedure, Performed: BH Assessment for Alcohol or Other Drugs" satisfies all: starts after or concurrent with start of Union of: - Occurrence A of $BHEncounter - Occurrence A of $BHOutptPsychotherapy ends before or concurrent with start of (Union of: - First: $Treatments - "Encounter, Performed: BH Outpatient Psychotherapy" - <= 42 day(s) starts after start of Union of: - Occurrence A of $BHEncounter - Occurrence A of $BHOutptPsychotherapy )Numerator Exclusions (Performance Not Met)NoneDSRIP Specific ModificationsNoneAdditional InformationGUIDANCE: The intent of the measure is that the assessment be performed for a single episode for each patient. Due to current limitations of the eMeasure specification system, it is possible for there to be up to two treatment episodes per patient, identified through up to two index episodes. As a result, the numerator criteria of this measure can be satisfied if a substance use assessment is performed within either treatment episode. Future versions of the measure should address this issue. A BH Outpatient Psychotherapy encounter meets the intent of both an encounter and a treatment.Data Criteria (QDM Variables) $BHEncounter = "Encounter, Performed: BH Outpatient encounter" satisfies all: - >= 42 day(s) starts before end of "Measurement Period" - starts after start of "Measurement Period" - satisfies any: satisfies all: - starts before or concurrent with start of "Diagnosis: BH Condition Involving Unipolar Depression" - overlaps "Diagnosis: BH Condition Involving Unipolar Depression" satisfies all: - starts before or concurrent with start of "Diagnosis: BH Condition Involving Bipolar Disorder" - overlaps "Diagnosis: BH Condition Involving Bipolar Disorder" $BHOutptPsychotherapy = "Encounter, Performed: BH Outpatient Psychotherapy" satisfies all: - >= 42 day(s) starts before end of "Measurement Period" - starts after start of "Measurement Period" - satisfies any: satisfies all: - starts before or concurrent with start of "Diagnosis: BH Condition Involving Unipolar Depression" - overlaps "Diagnosis: BH Condition Involving Unipolar Depression" satisfies all: - starts before or concurrent with start of "Diagnosis: BH Condition Involving Bipolar Disorder" - overlaps "Diagnosis: BH Condition Involving Bipolar Disorder" $Treatments = Union of: - "Procedure, Performed: BH Electroconvulsive Therapy" - "Procedure, Order: BH Electroconvulsive Therapy" - "Medication, Order: BH Antidepressant Medication" - "Medication, Order: BH Mood Stabilizer Medication" - "Procedure, Performed: BH Counseling for Depression" - "Procedure, Order: BH Counseling for Depression" Data Criteria (QDM Data Elements):- "Diagnosis: BH Condition Involving Bipolar Disorder" using "BH Condition Involving Bipolar Disorder Grouping Value Set (2.16.840.1.113883.3.1257.1.1504)"- "Diagnosis: BH Condition Involving Unipolar Depression" using "BH Condition Involving Unipolar Depression Grouping Value Set (2.16.840.1.113883.3.1257.1.1505)"- "Encounter, Performed: BH Outpatient encounter" using "BH Outpatient encounter Grouping Value Set (2.16.840.1.113883.3.464.1.49)"- "Encounter, Performed: BH Outpatient Psychotherapy" using "BH Outpatient Psychotherapy Grouping Value Set (2.16.840.1.113883.3.1257.1.973)"- "Medication, Active: BH Antidepressant Medication" using "BH Antidepressant Medication Grouping Value Set (2.16.840.1.113883.3.1257.1.972)"- "Medication, Active: BH Mood Stabilizer Medication" using "BH Mood Stabilizer Medication Grouping Value Set (2.16.840.1.113883.3.1257.1.950)"- "Medication, Order: BH Antidepressant Medication" using "BH Antidepressant Medication Grouping Value Set (2.16.840.1.113883.3.1257.1.972)"- "Medication, Order: BH Mood Stabilizer Medication" using "BH Mood Stabilizer Medication Grouping Value Set (2.16.840.1.113883.3.1257.1.950)"- "Procedure, Order: BH Counseling for Depression" using "BH Counseling for Depression Grouping Value Set (2.16.840.1.113883.3.1257.1.1616)"- "Procedure, Order: BH Electroconvulsive Therapy" using "BH Electroconvulsive Therapy Grouping Value Set (2.16.840.1.113883.3.1257.1.1533)"- "Procedure, Performed: BH Assessment for Alcohol or Other Drugs" using "BH Assessment for Alcohol or Other Drugs Grouping Value Set (2.16.840.1.113883.3.1257.1.1604)"- "Procedure, Performed: BH Counseling for Depression" using "BH Counseling for Depression Grouping Value Set (2.16.840.1.113883.3.1257.1.1616)"- "Procedure, Performed: BH Electroconvulsive Therapy" using "BH Electroconvulsive Therapy Grouping Value Set (2.16.840.1.113883.3.1257.1.1533)" Supplemental Data Elements:- "Patient Characteristic Ethnicity: Ethnicity" using "Ethnicity CDCREC Value Set (2.16.840.1.114222.4.11.837)"- "Patient Characteristic Payer: Payer" using "Payer SOP Value Set (2.16.840.1.114222.4.11.3591)"- "Patient Characteristic Race: Race" using "Race CDCREC Value Set (2.16.840.1.114222.4.11.836)"- "Patient Characteristic Sex: ONC Administrative Sex" using "ONC Administrative Sex AdministrativeGender Value Set (2.16.840.1.113762.1.4.1)" ................
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