MIPS Quality Measures 2020

Quality Measures for
Mental and Behavioral Health

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2020 MIPS Quality Measures & QCDR Measures for Psychologists

Note: Measures that have been removed by CMS for 2020 reporting include 46, 131, 325, 411, 474.

Quality IdMeasure NameHigh PriorityMeasure TypeMeasure Description
MBHR102021 MBHR Measure: Symptom Improvement in adults with ADHDYesPatient Reported Outcome (PRO)The percentage of adult patients (18 years of age or older) with a diagnosis of ADHD who show a reduction in symptoms of 25% on the Adult ADHD Self-Report Scale (ASRS-v1.1)- 18 item self-report scale of ADHD symptoms within 2 to 10 months after initially reporting significant symptoms.

There are two aspects to this measure. The first is the assessment of the use of the ASRS v.1. during the denominator identification period (Criteria 1 also referred to as Time 1) and the second is the assessment of improvement in the ASRS v.1.1 from the first administration to the second administration of the ASRS v.1.1 (Criteria 2 also referred to as Time 2).
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MBHR092021 MBHR Measure: Outcome monitoring of ADHD functional impairment in children and youthYesPatient Reported Outcome (PRO)Percentage of children aged 4 through 18 years, with a diagnosis of attention deficit/hyperactivity disorder (ADHD), who demonstrate a change score of 0.25 or greater on the Weiss Functional Impairment Rating Scale – Parent Report (WFIRS-P) within 2 to 10 months after an initial positive finding of functional impairment.View
MBHR082021 MBHR Measure: Alcohol Use Disorder Outcome ResponseYesPatient Reported Outcome (PRO)The percentage of adult patients (18 years of age or older) who report problems with drinking alcohol AND with documentation of a standardized screening tool (e.g., AUDIT, AUDIT-C, DAST, TAPS) AND demonstrated a response to treatment at three months (+/- 60 days) after the index visitView
MBHR072021 MBHR Measure: Posttraumatic Stress Disorder (PTSD) Outcome Assessment for Adults and ChildrenYesPatient Reported Outcome (PRO)The percentage of patients with a history of a traumatic event (i.e., an experience that was unusually or especially frightening, horrible, or traumatic) who report symptoms consistent with PTSD for at least one month following the traumatic event AND with documentation of a standardized symptom monitor (PCL-5 for adults, CATS for child/adolescent) AND demonstrated a response to treatment at six months (+/- 120 days) after the index visit.

This measure is a multi-strata measure, which addresses symptom monitoring for both child and adult patients being treated for post-traumatic stress symptoms. Assessment instruments monitoring severity of symptoms for PTSD are validated either for adult or child populations. Thus, while the measurement structure will be similar for both populations, the specified instruments for symptom monitoring will be different.
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MBHR022021 MBHR Measure: Anxiety 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 visitView
MBHR012021 MBHR Measure: Use of Anxiety Severity MeasureNoProcessThe percentage of adult patients (18 years and older) with an anxiety disorder diagnosis (e.g. generalized anxiety disorder, social anxiety disorder, or panic disorder) who have completed a standardized tool (e.g., GAD-7, BAI) during measurement period.View
MBHR052021 MBHR Measure: Screening 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.View
MBHR042021 MBHR Measure: Social 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 six months (+/- 120 days) after the index visit.View
MBHR032021 MBHR Measure: Pain Interference Response utilizing PROMISYesPatient Reported Outcome (PRO)The percentage of adult patients (18 years of age or older) who report chronic pain issues and demonstrated a response to treatment at one month from the index score. View
MBHR062021 MBHR Measure: Sleep 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 visitView
MBHR112021 MBHR Measure: Cognitive Assessment with Counseling on Safety and Potential RiskYesProcessPercentage of patients, regardless of age, referred for evaluation due to concerns for cognitive impairment for whom 1) a standardized valid assessment of cognition was performed and 2) reporting of results included counseling on safety and potential risks.View
MBHR122021 MBHR Measure: Patient Feedback of Test Results Following Cognitive or Mental Status AssessmentYesProcessPercentage of patients, regardless of age, who received a standardized cognitive or mental status assessment followed by provision of feedback on test results directly to patient and/or their caregiver.View
047Advance Care PlanYesProcessPercentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation 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 planView
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 immunizationView
111Pneumococcal Vaccination Status for Older AdultsNoProcessPercentage of patients 65 years of age and older who have ever received a pneumococcal vaccineView
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.View
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.View
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 screenView
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 monthsView
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 monthsView
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 screenView
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.View
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 userView
282Dementia: Functional Status AssessmentNoProcessPercentage of patients with dementia for whom an assessment of functional status* was performed at least once in the last 12 monthsView
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 monthsView
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 evaluationView
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 monthsView
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 indicatedView
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 hoursView
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 visitView
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 referredView
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)View
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.
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401Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with CirrhosisNoProcessPercentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C cirrhosis who underwent imaging with either ultrasound, contrast enhanced CT or MRI for hepatocellular carcinoma (HCC) at least once within the 12-month submission periodView
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 userView

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