Quality Measures for Mental and Behavioral Health
2024 MIPS quality measures and QCDR measures for Psychologists
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| Quality Id | Measure Name | High Priority | Measure Type | Details | Measure Description | Full Specifications |
|---|---|---|---|---|---|---|
| 110 | Preventive Care and Screening: Influenza Immunization | No | Process | Percentage 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 | ||
| 411 | Depression Remission at Six Months | Yes | Outcome | The 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 | ||
| 402 | Tobacco Use and Help with Quitting Among Adolescents | No | Process | 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 user | ||
| 391 | Follow-Up After Hospitalization for Mental Illness (FUH) | Yes | Process | 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 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. | ||
| 370 | Depression Remission at Twelve Months | Yes | Outcome | The 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 | ||
| 342 | Pain Brought Under Control Within 48 Hours | Yes | Outcome | Patients 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 | ||
| 325 | Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions | Yes | Process | Percentage 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 | ||
| 317 | Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | No | Process | Percentage 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 | ||
| 288 | Dementia: Caregiver Education and Support | Yes | Process | Percentage 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 | ||
| 286 | Dementia: Safety Concerns Screening and Mitigation Recommendations or Referral for Patients with Dementia | Yes | Process | Percentage 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 | ||
| 282 | Dementia: Functional Status Assessment | No | Process | Percentage of patients with dementia for whom an assessment of functional status* was performed at least once in the last 12 months | ||
| 226 | Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | No | Process | Percentage 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 | ||
| 181 | Elder Maltreatment Screen and Follow-Up Plan | Yes | Process | Percentage 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 | ||
| 134 | Preventive Care and Screening: Screening for Depression and Follow-Up Plan | No | Process | Percentage 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 | ||
| 131 | Pain Assessment and Follow-Up | Yes | Process | Percentage 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 | ||
| 130 | Documentation of Current Medications in the Medical Record | Yes | Process | Percentage 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. | ||
| 128 | Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan | No | Process | Percentage 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. | ||
| 111 | Pneumococcal Vaccination Status for Older Adults | No | Process | Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine | ||
| 047 | Care Plan | Yes | Process | Percentage 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 | ||
| 283 | Dementia Associated Behavioral and Psychiatric Symptoms Screening and Management | No | Process | Percentage 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 | ||
| MBHR2 | Anxiety Response at 6-months | Yes | Patient 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 | ||
| 374 | Closing the Referral Loop: Receipt of Specialist Report | Yes | Process | Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred | ||
| 155 | Falls: Plan of Care | Yes | Process | Percentage of patients aged 65 years and older with a history of falls that had a plan of care for falls documented within 12 months | ||
| 154 | Falls: Risk Assessment | Yes | Process | Percentage of patients aged 65 years and older with a history of falls that had a risk assessment for falls completed within 12 months | ||
| 046 | Medication Reconciliation Post-Discharge | Yes | Process | The 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 | ||
| 383 | Adherence to Antipsychotic Medications For Individuals with Schizophrenia | Yes | Intermediate Outcome | 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 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) | ||
| MBHR1 | Anxiety Utilization of the GAD-7 Tool | No | Process | The 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 | ||
| 431 | Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling | No | Process | Percentage 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 | ||
| MBHR6 | Sleep Quality Screening and Sleep Response at 3-months | Yes | Patient 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 | ||
| MBHR3 | Pain Interference Response utilizing PROMIS | Yes | Patient 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 | ||
| MBHR4 | Social Role Functioning Outcome utilizing PROMIS | Yes | Patient 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 | ||
| MBHR5 | Screening and monitoring for psychosocial problems among children and youth | Yes | Patient 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) Vaccination | No | Process | The percentage of patients 50 years of age and older who have a Varicella Zoster (shingles) vaccination. | ||
| 182 | Functional Outcome Assessment | Yes | Process | Percentage 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. | ||
| 414 | Evaluation or Interview for Risk of Opioid Misuse | Yes | Process | All 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. |