MIPS Quality Measures 2022

Quality Measures for
Mental and Behavioral Health

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2022 MIPS Quality Measures & QCDR Measures for Psychologists

Quality IdMeasure NameHigh PriorityMeasure TypeMeasure Description
MBHR01Use 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
MBHR02Anxiety Response at 6-monthsYesPatient Reported Outcome (PRO)The percentage of adult patients (18 years of age or older) with an anxiety disorder (e.g., generalized anxiety disorder, social anxiety disorder, or panic disorder) who demonstrated a response to treatment (GAD-7 score at least 25% less than score at index event) at 6-months (+/- 60 days) after an index visit.View
MBHR03Pain 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
MBHR05Monitoring for psychosocial problems among children and youthYesPatient Reported Outcome (PRO)Percentage of children from 3 to 17 years of age who are receiving a psychiatric or behavioral health intake visit AND who demonstrated a reliable change in parent-reported problem behaviors 2 to 10 months after initial positive screen for externalizing and internalizing behavior problems.View
MBHR07Posttraumatic 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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MBHR08Alcohol Use Disorder Outcome ResponseYesPatient Reported Outcome (PRO)The percentage of adult patients (18 years of age or older) who report problems with drinking alcohol (e.g., can be noted through a screening measure such as the AUDIT-C as described in MIPS Clinical Quality Measure Quality ID #431 aka NQF 2152 or other  drug/alcohol screeners such as the DAST and TAPS AND demonstrated a response to treatment at three months (+/- 60 days) after the index visit.View
MBHR09Outcome 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
MBHR10Symptom 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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MBHR11Cognitive Assessment with Counseling on Safety and Potential RiskNoProcessPercentage 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
MBHR12Provision of Feedback Following a Cognitive or Mental Status Assessment with Documentation of Understanding of Test Results and Subsequent Healthcare PlanYesProcessPercentage of patients, regardless of age, who received a standardized cognitive or mental status assessment followed by provision of feedback regarding test results and associated recommendations, who acknowledged understanding of test results and associated recommendations and healthcare plan.View
MBHR13Social Role Functioning Assessment utilizing PROMIS Adult Ability to Participate in Social Roles and ActivitiesYesPatient Reported Outcome (PRO)The percentage of adult patients (18 years of age or older) who report concerns related to their psychosocial function and who have completed a standardized assessment utilizing the PROMIS Adult Ability to Participate in Social Roles and Activities during measurement periodView
MBHR14Sleep Quality 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.View
MBHR15Consideration of Cultural-Linguistic and Demographic Factors in Cognitive AssessmentYesProcessPercentage of patients, regardless of age, referred for evaluation due to concerns for cognitive changes or difficulties for whom 1) a standardized valid assessment of cognition was performed and 2) interpretation of results included consideration of appropriate and relevant cultural-linguistic and demographic factors.View
MBHR16Comprehensive Cognitive Assessment Assists with Differential DiagnosisYesProcessPercentage 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) results of assessment informed determination of diagnosis or further clarified etiological factors of cognitive impairment or complaints.View
MBHR17Improved Efficiency: Time Interval for reporting results of cognitive assessmentYesProcessPercentage of patients, regardless of age, for which the referring provider or patient receives reporting of assessment results within 14 days of the completion of assessment.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
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.View
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
238Use of High-Risk Medications in Older AdultsYesProcessPercentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug classView
290Assessment of Mood Disorders and Psychosis for Patients with Parkinson’s DiseaseNoProcessPercentage of all patients with a diagnosis of Parkinson’s Disease [PD] who were assessed for depression, anxiety, apathy, AND psychosis once during the measurement period.View
291Parkinson’s Disease: Cognitive Impairment or Dysfunction Assessment for Patients with Parkinson's DiseaseNoProcessPercentage of all patients with a diagnosis of Parkinson’s Disease [PD] who were assessed for cognitive impairment or dysfunction once during the measurement period.View

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