2021 MBHR Measure: Outcome monitoring of ADHD functional impairment in children and youth

QCDR Name: MBHR Mental and Behavioral Health Registry

Measure Title Outcome monitoring of ADHD functional impairment in children and youth
NQS Domain Effective Clinical Care
Measure ID MBHR9
Measure Type Patient Reported Outcome (PRO)
High Priority? Yes
Description 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. To see additional details, please view the workflow diagram for this measure: View diagram
Denominator Denominator (Submission Criteria 1):
All patients aged 4 to 18 years receiving a psychiatric or behavioral intake visit during the measurement period and have a diagnosis of ADHD.Denominator Criteria (Eligible cases):
Patients aged 4 to 18 years


Diagnosis for ADHD (ICD-10-CM): all ADHD diagnostic codes:
• F90 Attention-deficit hyperactivity disorders
• F90.0 Attention-deficit hyperactivity disorder, predominantly inattentive type
• F90.1 Attention-deficit hyperactivity disorder, predominantly hyperactive type
• F90.2 Attention-deficit hyperactivity disorder, combined type
• F90.8 Attention-deficit hyperactivity disorder, other type
• F90.9 Attention-deficit hyperactivity disorder, unspecified type


Patient encounter during the performance period (CPT): 0362T, 0373T, 90785, 90791, 90792, 90832,90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90846, 90847, 90849, 90853, 90863, 90875, 90876, 96110, 96112, 96113, 96116, 96121, 96127, 96130, 96131, 96132, 96133, 96136, 96137, 96138, 96139, 96146, 96156, 96158, 96159, 96164, 96165, 96167, 96170, 96171, 96178, 97129, 97130, 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 98966, 98967, 98968, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215,99354, 99355, 99406, 99407, 99408, 99409, 99446, 99447, 99448, 99449, 99484, 99492, 99493, 99494, G2011, G2061, G2062, G2063, G0396, G0397, G0402, G0438, G0439 Denominator (Submission Criteria 2):
All patients aged 4 to 18 years receiving a psychiatric or behavioral intake visit with a WFIRS-P total mean score of 0.65 or greater during the measurement period.
Denominator Criteria (Eligible cases):
Patients aged 4 to 18 years


Diagnosis for ADHD (ICD-10-CM): all ADHD diagnostic codes


Patient encounter during the performance period (CPT): 90785; 90791; 90832; 90834; 90837; 90845; 90846; 90847; 90849; 90853; 96130; 96131; 96137; 96136; 96138; 96139; 96146; 96116; 96121; 96132; 96133; 96146; 96156; 96158; 96164; 96167 90839; 90840; 90863; 99201; 99202; 99203; 99204; 99205; 99212; 99213; 99214; 99215; 99492; 99493; 99494; 99484; G0402; G0438; G0439


Weiss Functional Impairment Rating Scale – Parent Report (WFIRS-P) (total mean score of 0.65 or greater)


Denominator Exclusion Death
Denominator Exception Patient refuses to participate or is unable to complete the questionnaire.
Numerator Numerator (Submission Criteria 1)
Patients who were administered a validated ADHD functional impairment assessmentNumerator (Submission Criteria 2)
Patients who demonstrated a positive improvement of 0.25 or more points on the total mean score of the WFIRS-P assessment taken 2 to 10 months later.
Data Source Claims, EHR, Paper Medical Record, Registry
Meaningful Measure Area Functional Outcomes
Meaningful Measure Rationale Assessing and monitoring functioning for ADHD in children and adolescents will promote interventions and best practices that are effective at reducing symptoms and improve functional status and quality of life by identifying and addressing appropriate treatment needs. This provides a standardized way to communicate status which will improve both quality of treatment and efficient use of resources
Inverse Measure? No
Proportional Measure? Yes
Continuous Variable Measure? No
Ratio Measure No
Number of Performance Rates 2
Risk Adjusted No
Preferred Specialty mental and behavioral health
Applicable Specialties Family Practice, Internal Medicine, Geriatric Medicine, Psychiatry, Behavioral Health
Care Settings Ambulatory Care: Hospital; Inpatient; Rehabilitation Facility; Nursing Home; Outpatient Services; Long Term Care

Clinical Recommendation Statement

Numerous organizations have issued guidelines for the assessment and treatment of attention deficit/hyperactivity disorder (American Academy of Pediatrics1; American Academy of Child and Adolescent Psychiatry2; National Institute for Health and Care Excellence3; Canadian ADHD Resource Alliance4). A majority of individuals diagnosed with ADHD suffer at least one other comorbid behavioral or psychiatric disorder and experience significant impairments affecting one or more functional domains including academic performance, family relations, peer relations, and adaptive skills. Evidence supports use of a variety of psychosocial and psychopharmacological treatments, and a number of professional organization guidelines recommend use of these therapies. The American Academy of Pediatrics Clinical Practice Guideline1 strongly recommends the use of an evidence-based parent and/or teacher administered therapy as the first line of treatment for preschoolers (ages 4-5 years), any U.S. Food and Drug Administration-approved medication and/or evidenced-based behavioral therapy for elementary school children (ages 6-11 years), and any FDA-approved medication for adolescents (ages 12-18 years). The AAP also recommends, albeit less strongly, concomitant use of FDA-approved medications for preschoolers and concomitant evidence-based behavioral therapy for adolescents. Common approaches and criteria for evaluating effective behavioral therapies as well as lists of FDA-approved medications (at the time of publication) are provided within this Guideline1 and its supplemental materials.

Measure Rationale

Attention deficit/hyperactivity disorder (ADHD) is among the most common neurodevelopmental disorders in children and adolescents with typical prevalence estimates ranging between 5 and 10%.5-9 The disorder is also associated with significant functional impairments as evidenced by the high comorbidity with disruptive behavioral disorders (oppositional defiant and conduct disorder)10,11 and findings of increased rates of learning difficulties, risk-taking behaviors, criminality, substance use, injury, suicide, and other psychiatric illnesses.12-18 Researchers estimate that U.S. educational and judicial system responses to functional problems cost society an additional $15.5 to $25.5 billion annually (in 2010 dollars).19 Longitudinal cohort data can now begin framing the public health implications for these problems in terms of early mortality risks with new findings citing an absolute 4.4% increase in mid-life fatalities20 and an 8.4 year reduction in estimated life expectancy21 among adults characterized with select ADHD profiles in childhood. Annual excess healthcare costs for children and adults with ADHD exceed $35 and $100 billion, respectively,19 and when differentiated, a significant portion of these expenses are dedicated to non-treatment related care (e.g., inpatient, emergency department, etc.).22 Several evidence-based behavioral and pharmacological treatment options are available,1,23,24 but low accession and lack of sustained utilization currently limit the public health impact of interventions.20,21 Higher quality care, marked by routine outcome monitoring and adaptive treatment response,1,25 is a best practice model proposed by many to combat these costly trends.21,22,26,27

Presence of functional impairment is most often the cause for seeking initial medical attention; yet, historically, care providers tend to focus on symptom reduction as the primary emphasis of treatment.28 The distinction between symptoms and function can be murky.29 Symptoms tend to be more general, less context dependent and are traditionally viewed as proxies for more specific functional outcomes that reflect “real-world consequences of the disorder.”28 While symptom reduction is a worthy goal of treatment, when unaccompanied by significant functional improvement, lower symptom scores are unlikely to be perceived as successful treatment outcomes in the eyes of a patient or patient’s family. The need to align improvements in functional problems and symptoms has begun to receive recognition among diagnostic classification systems30-32 and treatment guideline developers.1,33 The measure proposed herein takes this a step further, with an exclusive focus on function for ADHD treatment monitoring. In line with goals of the Mental and Behavioral Health Registry of the American Psychological Association, this function measure intends to capture a treatment outcome that is most meaningful to both practitioners and patients. A single instrument for measuring ADHD function is selected for this purpose, the Weiss Functional Impairment Rating Scale (WFIRS). The WFIRS is chosen because it includes wide coverage of functioning, is freely reproducible, and demonstrates psychometric support for validity and reliability.34,35 A minimal important difference (MID) is also established for the parent report version (WFIRS-P) and can be used as a change sensitivity indicator for treatment monitoring.36 Interestingly, this MID is virtually identical to the calculated reliable change index from the same study.

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