2023 # 383 Adherence to Antipsychotic Medications for Individuals with Schizophrenia

CMS Measure ID: #383

Collection Type: CQM

Reporting Frequency: Once per patient per year

Outcome: No

High Priority: Yes

NQS Domain: Patient Safety

Measure Age: > 2 years

Instructions

This measure is to be submitted a minimum of once per performance period for all patients with a diagnosis of schizophrenia or schizoaffective disorder seen during the performance period. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure for the primary management of patients with schizophrenia or schizoaffective disorder based on the services provided and the measure-specific denominator coding.

NOTE: Patient encounters for this measure conducted via telehealth (e.g., encounters coded with GQ, GT, 95, or POS 02 modifiers) are allowable.

Measure Submission Type:

The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions as allowed by the measure. The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codes may be submitted for those registries that utilize claims data.

Description

Percentage of individuals at least 18 years of age as of the beginning of the performance 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 performance period

2023 Benchmarks (from 2021 CMS data)

Registry

Topped out: No
Capped at 7: No

Decile 0: 0 – 22.72
Decile 1: 22.73 – 81.44
Minimum: 81.45 – 95.74
Decile 3: 95.75 – 99.52
Decile 4: 99.53 – 99.99
Decile 10: 100 – 100

Denominator

Individuals at least 18 years of age as of the beginning of the performance period with schizophrenia or schizoaffective disorder and at least two prescriptions filled for antipsychotic medications during the performance period

DENOMINATOR NOTE: *Signifies that this CPT Category I or HCPCS code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for MIPS CQMs.

The following are the oral antipsychotic medications by class for the denominator. The route of administration includes all oral formulations of the medications listed below.

TYPICAL ANTIPSYCHOTIC MEDICATIONS:

• chlorpromazine
• fluphenazine
• haloperidol
• loxapine
• molindone
• perphenazine
• prochlorperazine
• thioridazine
• thiothixene
• trifluoperazine

ATYPICAL ANTIPSYCHOTIC MEDICATIONS:

• aripiprazole
• asenapine
• brexpiprazole
• cariprazine
• clozapine
• olanzapine
• iloperidone
• lumateperone
• lurasidone
• paliperidone
• quetiapine
• quetiapine fumarate (Seroquel)
• risperidone
• ziprasidone

ANTIPSYCHOTIC COMBINATIONS:

• perphenazine-amitriptyline

LONG-ACTING INJECTABLE ANTIPSYCHOTIC MEDICATIONS:

NOTE: The following are the long-acting (depot) injectable antipsychotic medications by class for the denominator. The route of administration includes all injectable and intramuscular formulations of the medications listed below. Since the days’ supply variable is not reliable for long-acting injections in administrative data, the days’ supply is imputed as listed below for the long-acting (depot) injectable antipsychotic medications billed under Part D and Part B.

TYPICAL ANTIPSYCHOTIC MEDICATIONS:

• fluphenazine decanoate (J2680) – 28 days’ supply
• haloperidol decanoate (J1631) – 28 days’ supply

ATYPICAL ANTIPSYCHOTIC MEDICATIONS:

• aripiprazole (J0401) – 28 days’ supply
• aripiprazole lauroxil (Aristada) (J1944) – 28 days’ supply
• olanzapine pamoate (J2358) – 28 days’ supply
• paliperidone palmitate (J2426) – 28 days’ supply
• risperidone microspheres (J2794) – 14 days’ supply

Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years at the beginning of the measurement period

AND

Diagnosis for schizophrenia or schizoaffective disorder (ICD-10-CM): F20.0, F20.1, F20.2, F20.3, F20.5, F20.81, F20.89, F20.9, F25.0, F25.1, F25.8, F25.9

AND

Filled at least two prescriptions during the performance period for any combination of the qualifying oral antipsychotic medications listed under “Denominator Note” or the long-acting injectable antipsychotic medications listed under “Denominator Note” (i.e. those medications with the following HCPCS codes: J2680, J1631, J0401, J1944, J2358, J2426, J2794)

AND

At least two encounters** with a diagnosis of schizophrenia or schizoaffective disorder (see code set below) with different dates of service in an outpatient setting, emergency department setting, or non-acute inpatient setting during the performance period

OR

At least one encounter** with a diagnosis of schizophrenia or schizoaffective disorder (see code set below) in an acute inpatient setting during the performance  period

AND

**Patient encounter during the performance period determination Outpatient Setting Option 1 (CPT or HCPCS): 98960, 98961, 98962, 99078, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99242*, 99243*, 99244*, 99245*, 99281, 99282, 99283, 99284, 99285*, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99385*, 99386*, 99387*, 99395*, 99396*, 99397*, 99401*, 99402*, 99403*, 99404*, 99411*, 99412*, 99424, 99426, 99429*, 99490, 99491, 99510, G0155*, G0176*, G0177*, G0409, G0410*, G0411*, G0463*, G0469*, G0470*, H0002*, H0004*, H0031*, H0034*, H0035*, H0036*, H0037*, H0039*, H0040*, H2000*, H2001*, H2010*, H2011*, H2012*, H2013*, H2014*, H2015*, H2016*, H2017*, H2018*, H2019*, H2020*, S0201*, S9480*, S9484*, S9485*, T1015*

OR

Outpatient Setting Option 2 (CPT):  90791, 90792, 90832, 90834, 90837, 90839, 90845, 90847, 90849, 90853, 90867, 90868, 90869, 90870, 90875*, 90876*, 90880, 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239,  99252*, 99253*, 99254*, 99255*, 99291

WITH

Place of Service (POS):  03, 05, 07, 09, 11, 12, 13, 14, 15, 20, 22, 24, 33, 49, 50, 52, 53, 71, 72

OR

Emergency Department Setting Option 1 (CPT):  99281, 99282, 99283, 99284, 99285*

OR

Emergency Department Setting Option 2 (CPT):  90791, 90792, 90832, 90834, 90837, 90839, 90845, 90847, 90849, 90853, 90867, 90868, 90869, 90870, 90875*, 90876*, 99291

WITH

Place of Service (POS): 23

OR

Non-Acute Inpatient Setting Option 1 (CPT): 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 

Non-Acute Inpatient Setting Option 1 (HCPCS): H0017, H0018, H0019, T2048

OR

Non-Acute Inpatient Setting Option 2 (CPT):  90791, 90792, 90832, 90834, 90837, 90839, 90845, 90847, 90849, 90853, 90867, 90868, 90869, 90870, 90875*, 90876*, 99291

WITH

Place of Service (POS): 31, 32, 56

OR

Acute Inpatient Setting (CPT):  90791, 90792, 90832, 90834, 90837, 90839, 90845, 90847, 90849, 90853, 90867, 90868, 90869, 90870, 90875*, 90876*, 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99252*, 99253*, 99254*, 99255*, 99291

WITH

Place of Service (POS): 21, 51

AND NOT

DENOMINATOR EXCLUSION:

Diagnosis for dementia (ICD-10-CM): E75.00, E75.01, E75.02, E75.09, E75.10, E75.11, E75.19, E75.244, E75.4, F01.50, F01.51, F01.511, F01.518, F01.52, F01.53, F01.54, F01.A0, F01.A11, F01.A18, F01.A2, F01.A3, F01.A4, F01.B0, F01.B11, F01.B18, F01.B2, F01.B3, F01.B4, F01.C0, F01.C11, F01.C18, F01.C2, F01.C3, F01.C4, F02.80, F02.81, F02.811, F02.818, F02.82, F02.83, F02.84, F02.A0, F02.A11, F02.A18, F02.A2, F02.A3, F02.A4, F02.B0, F02.B11, F02.B18, F02.B2, F02.B3, F02.B4, F02.C0, F02.C11, F02.C18, F02.C2, F02.C3, F02.C4, F03.90, F03.91, F03.911, F03.918, F03.92, F03.93, F03.94, F03.A0, F03.A11, F03.A18, F03.A2, F03.A3, F03.A4, F03.B0, F03.B11, F03.B18, F03.B2, F03.B3, F03.B4, F03.C0, F03.C11, F03.C18, F03.C2, F03.C3, F03.C4, F05, F10.27, F11.122, F13.27, F13.97, F18.17, F18.27, F18.97, F19.17, F19.27, F19.97, G30.0, G30.1, G30.8, G30.9, G31.09, G31.83

Numerator

Individuals in the denominator who have a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic medications

NUMERATOR NOTE: The PDC is calculated as follows:

PDC NUMERATOR:

The PDC numerator is the sum of the days covered by the days’ supply of all antipsychotic prescriptions. The period covered by the PDC starts on the day within the performance period when the first prescription is filled (i.e., the index date) and lasts through the end of the performance period, or death, whichever comes first. For prescriptions with a days’ supply that extends beyond the end of the performance period, count only the days for which the drug was available to the individual during the performance period. If there are prescriptions for the same drug (generic name) on the same date of service, keep the prescription with the largest days’ supply. If prescriptions for the same drug (generic name) overlap, then adjust the prescription start date to be the day after the previous fill has ended.

PDC DENOMINATOR:

The period covered by the PDC starts on the day within the performance period when the first prescription is filled (i.e., the index date) and lasts through the end of the performance period, or death, whichever comes first.

Numerator Options:

Performance Met:

Individual had a PDC of 0.8 or greater (G9512)

OR

Performance Not Met:

Individual did not have a PDC of 0.8 or greater (G9513)