MIPS Quality Measures

Quality Measures for Mental and Behavioral Health

2020 MIPS Quality Measures & QCDR Measures for Psychologists

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Quality IdMeasure NameHigh PriorityMeasure TypeDetailsMeasure DescriptionFull Specifications
047Care PlanYesProcessPercentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan
110Preventive Care and Screening: Influenza ImmunizationNoProcessPercentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization
111Pneumococcal Vaccination Status for Older AdultsNoProcessPercentage of patients 65 years of age and older who have ever received a pneumococcal vaccine
128Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up PlanNoProcessPercentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous twelve months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous twelve months of the current encounter.
130Documentation of Current Medications in the Medical RecordYesProcessPercentage of visits for patients aged 18 years and older for which the eligible professional or eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications name, dosage, frequency and route of administration.
131Pain Assessment and Follow-UpYesProcessPercentage of visits for patients aged 18 years and older with documentation of a pain assessment using a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present
134Preventive Care and Screening: Screening for Depression and Follow-Up PlanNoProcessPercentage of patients aged 12 years and older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen
181Elder Maltreatment Screen and Follow-Up PlanYesProcessPercentage of patients aged 65 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening Tool on the date of encounter AND a documented follow-up plan on the date of the positive screen
226Preventive Care and Screening: Tobacco Use: Screening and Cessation InterventionNoProcessPercentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received tobacco cessation intervention if identified as a tobacco user
282Dementia: Functional Status AssessmentNoProcessPercentage of patients with dementia for whom an assessment of functional status* was performed at least once in the last 12 months
283Dementia Associated Behavioral and Psychiatric Symptoms Screening and ManagementNoProcessPercentage of patients with dementia for whom there was a documented symptoms screening* for behavioral and psychiatric symptoms, including depression, AND for whom, if symptoms screening was positive, there was also documentation of recommendations for symptoms management in the last 12 months
286Dementia: Safety Concerns Screening and Mitigation Recommendations or Referral for Patients with DementiaYesProcessPercentage of patients with dementia or their caregiver(s) for whom there was a documented safety concerns screening * in two domains of risk: 1) dangerousness to self or others and 2) environmental risks; and if safety concerns screening was positive in the last 12 months, there was documentation of mitigation recommendations, including but not limited to referral to other resources or orders for home safety evaluation
288Dementia: Caregiver Education and SupportYesProcessPercentage of patients with dementia whose caregiver(s)* were provided with education** on dementia disease management and health behavior changes AND were referred to additional resources*** for support in the last 12 months
317Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up DocumentedNoProcessPercentage of patients aged 18 years and older seen during the submitting 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 indicated
325Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid ConditionsYesProcessPercentage of medical records of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) and a specific diagnosed comorbid condition (diabetes, coronary artery disease, ischemic stroke, intracranial hemorrhage, chronic kidney disease [stages 4 or 5], End Stage Renal Disease [ESRD] or congestive heart failure) being treated by another clinician with communication to the clinician treating the comorbid condition
342Pain Brought Under Control Within 48 HoursYesOutcomePatients aged 18 and older who report being uncomfortable because of pain at the initial assessment (after admission to palliative care services) who report pain was brought to a comfortable level within 48 hours
370Depression Remission at Twelve MonthsYesOutcomeThe percentage of patients 18 years of age and or older with major depression or dysthymia who reached remission 12 months (+/- 30 days) after an index visit
391Follow-Up After Hospitalization for Mental Illness (FUH)YesProcessThe percentage of discharges for patients 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses and who had a follow-up visit with a mental health practitioner. Two rates are submitted: - 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.
402Tobacco Use and Help with Quitting Among AdolescentsNoProcessThe 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 user
411Depression Remission at Six MonthsYesOutcomeThe percentage of patients 18 years of age or older with major depression or dysthymia who reached remission six months (+/- 30 days) after an index visit
431Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief CounselingNoProcessPercentage of patients 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 user
MBHR1Anxiety Utilization of the GAD-7 ToolNoProcessThe percentage of adult patients (18 years and older) with an anxiety disorder diagnosis (generalized anxiety disorder, social anxiety disorder, post-traumatic stress disorder, or panic disorder) who have completed GAD-7 tool during measurement period
MBHR2Anxiety Response at 6-monthsYesPatient Reported Outcome (PRO)The percentage of adult patients (18 years of age or older) with an anxiety disorder (generalized anxiety disorder, social anxiety disorder, post-traumatic stress disorder, or panic disorder) who demonstrated a response to treatment at six months (+/- 60 days) after an index visit
383Adherence to Antipsychotic Medications For Individuals with SchizophreniaYesIntermediate OutcomePercentage 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 prescriptions filled for any antipsychotic medication and who had a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic medications during the measurement period (12 consecutive months)
046Medication Reconciliation Post-DischargeYesProcessThe percentage of discharges from any inpatient facility (e.g. hospital, skilled nursing facility, or rehabilitation facility) for patients 18 years and older 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 for whom the discharge medication list was reconciled with the current medication list in the outpatient medical record.
This measure is reported as three rates stratified by age group:
Submission Criteria 1: 18-64 years of age
Submission Criteria 2: 65 years and older
Total Rate: All patients 18 years of age and older
154Falls: Risk AssessmentYesProcessPercentage of patients aged 65 years and older with a history of falls that had a risk assessment for falls completed within 12 months
155Falls: Plan of CareYesProcessPercentage of patients aged 65 years and older with a history of falls that had a plan of care for falls documented within 12 months
374Closing the Referral Loop: Receipt of Specialist ReportYesProcessPercentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred
MBHR6Sleep Quality Screening and Sleep Response at 3-monthsYesPatient Reported Outcome (PRO)Percentage of patients 18 years and older who reported sleep quality concerns (e.g., insomnia) with documentation of a standardized tool AND demonstrated a response to treatment at three months (+/- 60 days) after index visit
MBHR3Pain Interference Response utilizing PROMISYesPatient Reported Outcome (PRO)The percentage of adult patients (18 years of age or older) who report pain issues and demonstrated a response to treatment at one month from the index score
MBHR4Social Role Functioning Outcome utilizing PROMISYesPatient Reported Outcome (PRO)The percentage of adult patients (18 years of age or older) with a mood or anxiety disorder who report concerns related to their psychosocial function and demonstrated a response to treatment two months (+/- 30 days) after the index visit
MBHR5Screening and monitoring for psychosocial problems among children and youthYesPatient Reported Outcome (PRO)Percentage of children from 3.00 to 17.99 years of age who are administered a parent-report, standardized and validated screening tool to assess broad-band psychosocial problems during an intake visit AND who demonstrated a reliable change in parent-reported problem behaviors 2 to 6 months after initial positive screen for externalizing and internalizing behavior problems.
474 Zoster (Shingles) VaccinationNoProcessThe percentage of patients 50 years of age and older who have a Varicella Zoster (shingles) vaccination.
182Functional Outcome AssessmentYesProcessPercentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies.
414Evaluation or Interview for Risk of Opioid MisuseYesProcessAll patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAPP-R) or patient interview documented at least once during Opioid Therapy in the medical record.

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