Mental/Behavioral Health MIPS Quality Measures and Improvement Activities – 2021

Mental/Behavioral Health professionals have their own QCDR

How to Select MIPS Quality Measures

Step 1 : Select At Least 1 Outcome Measure

For the MIPS Quality Performance Category, you must report at least one outcome measure. If no outcome measures are applicable to your patient population, then you must select at least one high-priority measure (see Step 2). The outcome measures you report count towards the six measure requirement for the Quality Performance Category. Reporting additional outcome measures beyond the required one will award two (2) bonus points to your Quality Performance Category Score.

Step 2 : Select Applicable High-Priority Measures

If you were able to select an outcome measure in Step 1, this step is optional. Non-outcome high-priority measures are worth one (1) bonus point for the Quality Performance Category. This makes it a smart idea to include as many outcome and/or high-priority measures as possible in your six Quality Performance Category Measures.

Step 3 : Make Sure You Have 6 Measures Selected

If you have not yet selected six measures and are aiming for a positive MIPS Payment Adjustment, select from the other recommended measures. If you report over six measures, CMS will calculate your MIPS Quality Performance Score using your top performing quality measures.


Recommended Quality Measures

Quality IdMeasure NameHigh PriorityMeasure TypeMeasure Description
MBHR012021 MBHR Measure: Anxiety ScreeningYESProcessThe 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 a standardized tool (e.g., GAD-7, GAD-2, BAI) during measurement period.View
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
MBHR032021 MBHR Measure: Pain 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 scoreView
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 two months (+/- 30 days) after the index visitView
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
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
MBHR072021 MBHR Measure: Posttraumatic Stress Disorder (PTSD) Screening and Outcome AssessmentYESPatient 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 three months (+/- 60 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.
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
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 6 months after an initial positive finding of functional impairment.View
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 (25%) on the Adult ADHD Self-Report Scale (ASRS-v1.1 - referred to as ASRS) 18 item self-report scale of ADHD symptoms within 2 to 6 months after initially reporting significant symptomsView
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

Normal Parameters: Age 18 years and older BMI => 18.5 and < 25 kg/m2
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 administrationView
134Preventive Care and Screening: Screening for Depression and Follow-Up PlannoeCQM/CQMPercentage 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 deficienciesView
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.View
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 screening for behavioral and psychiatric symptoms, including depression, and for whom, if symptoms screening was positive, there was also documentation of recommendations for management in the last 12 monthsView
286Dementia: Safety Concern Screening and Follow-Up 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 resourcesView
288Dementia: Education and Support of Caregivers for Patients with DementiayesProcessPercentage 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 reporting 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 adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event date.View
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 or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner.View
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 userView
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
MBHR112021 MBHR Measure: Cognitive 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
MBHR122021 MBHR Measure: Patient Feedback of Test Results Following Cognitive or Mental Status AssessmentYESPatient Experience – ProcessPercentage 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

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How to Select MIPS Improvement Activities

Step 1 : Determine how many points are needed for successful reporting

  • 40 points: The standard number of required points and the maximum score for this Performance Category.
  • 20 points: For small or rural practices, HPSAs, or non-patient facing clinicians/groups.
  • 0 points: Certified Patient Centered Medical Homes receive full credit. A Patient Centered Medical Home must be attested to and will not automatically be classified by CMS as such.

Step 2 : Select Improvement Activities

High-weighted activities are worth 20 points, while medium-weight activities are worth 10 points. Participants can select any combination of activities to meet the requirement.


Recommended Improvement Activities

Activity IdActivity NameActivity WeightingActivity Description
IA_EPA_3Collection and use of patient experience and satisfaction data on accessMediumCollection of patient experience and satisfaction data on access to care and development of an improvement plan, such as outlining steps for improving communications with patients to help understanding of urgent access needs.View
IA_CC_2-2021Implementation of improvements that contribute to more timely communication of test resultsMediumTimely communication of test results defined as timely identification of abnormal test results with timely follow-up.View
IA_CC_8Implementation of documentation improvements for practice/process improvementsMediumImplementation of practices/processes that document care coordination activities (e.g., a documented care coordination encounter that tracks all clinical staff involved and communications from date patient is scheduled for outpatient procedure through day of procedure).View
IA_BE_14Engage Patients and Families to Guide Improvement in the System of CareHighEngage patients and families to guide improvement in the system of care by leveraging digital tools for ongoing guidance and assessments outside the encounter, including the collection and use of patient data for return-to-work and patient quality of life improvement. Platforms and devices that collect patient-generated health data (PGHD) must do so with an active feedback loop, either providing PGHD in real or near-real time to the care team, or generating clinically endorsed real or near-real time automated feedback to the patient, including patient reported outcomes (PROs). Examples include patient engagement and outcomes tracking platforms, cellular or web-enabled bi-directional systems, and other devices that transmit clinically valid objective and subjective data back to care teams. Because many consumer-grade devices capture PGHD (for example, wellness devices), platforms or devices eligible for this improvement activity must be, at a minimum, endorsed and offered clinically by care teams to patients to automatically send ongoing guidance (one way). Platforms and devices that additionally collect PGHD must do so with an active feedback loop, either providing PGHD in real or near-real time to the care team, or generating clinically endorsed real or near-real time automated feedback to the patient (e.g. automated patient-facing instructions based on glucometer readings). Therefore, unlike passive platforms or devices that may collect but do not transmit PGHD in real or near-real time to clinical care teams, active devices and platforms can inform the patient or the clinical care team in a timely manner of important parameters regarding a patient’s status, adherence, comprehension, and indicators of clinical concern.View
IA_AHE_1Engagement of New Medicaid Patients and Follow-upHighSeeing new and follow-up Medicaid patients in a timely manner, including individuals dually eligible for Medicaid and Medicare. A timely manner is defined as within 10 business days for this activity.View

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