CMS Measure ID: #468
Collection Type: CQM
Reporting Frequency: Once per patient per year
High Priority: Yes
NQS Domain: Effective Clinical Care
Measure Age: > 2 years
This measure is to be submitted a minimum of once per performance period for all adults aged 18 years and older with pharmacotherapy for OUD seen during the denominator identification period. This measure may be submitted by Merit-based Incentive Payment System (MIPS) Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure 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:
Measure data may be submitted by individual MIPS eligible clinicians, groups, or third party intermediaries. The listed denominator criteria are used to identify the intended population. The numerator options included in this specification are used to submit the quality actions as allowed by the measure.
Percentage of adults aged 18 years and older with pharmacotherapy for opioid use disorder (OUD) who have at least 180 days of continuous treatment
Adults aged 18 years and older who had a qualifying encounter during the performance year, and a diagnosis of OUD and pharmacotherapy for OUD during the denominator identification period.
Eligibility to submit results for a patient requires a qualifying encounter in the performance year, i.e., between January 1, 2023, and December 31, 2023. Solely administering or prescribing OUD medication does not convey eligibility to submit.
If a patient has a qualifying encounter within the performance year, the patient is included in the denominator, if the following criteria are met in the denominator identification period between July 1, 2022, and June 30, 2023:
- Have a diagnosis of OUD
- Receive pharmacotherapy for OUD
Qualifying Encounter – Encounter during the performance year
Pharmacotherapy for OUD –
- Naltrexone (oral)
- Naltrexone (extended-release injectable)
Denominator Identification Period – The period in which eligible adults receive pharmacotherapy for OUD. The denominator identification period is defined as the 12-month period from 07/1/2022 to 6/30/2023. The denominator identification period includes the first six months of the reporting year and the last six months of the previous year to ensure that all included patients can be observed for at least 180 days of treatment in the reporting year. Patients started on treatment in the second half of the reporting year will be included in the denominator of the subsequent year. The patient must have at least one OUD medication and one visit with a OUD diagnosis during the denominator identification period to be eligible for the measure
Denominator Criteria (Eligible Cases):
Adults aged ≥ 18 years on date of qualifying encounter
Diagnosis of OUD: F11.10, F11.120, F11.121, F11.122, F11.129, F11.14, F11.150, F11.151, F11.159, F11.181, F11.182, F11.188, F11.19, F11.20, F11.21, F11.220, F11.221, F11.222, F11.229, F11.23, F11.24, F11.250, F11.251, F11.259, F11.281, F11.282, F11.288, F11.29, F11.90, F11.920, F11.921, F11.922, F11.929, F11.93, F11.94, F11.950, F11.951, F11.959, F11.981, F11.982, F11.988, F11.99
Encounter during the measurement period (CPT or HCPCS): 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99281, 99282, 99283, 99284, 99285, 99291 99304, 99305,99306, 99307, 99308, 99309, 99310, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, G0402, G0438, G0439
Adults currently taking pharmacotherapy for OUD: M1032
Adults in the denominator who have at least 180 days of continuous pharmacotherapy with a medication prescribed for OUD without a gap of more than seven days
NUMERATOR NOTE: Numerator compliance is expected to be determined within an 18-month period that includes the measurement period and the 6 months prior to the measurement period (07/01/2022– 12/31/2023).
Performance Met: Adults who have at least 180 days of continuous pharmacotherapy with a medication prescribed for OUD without a gap of more than seven days (M1034)
Denominator Exception: Adults who are deliberately phased out of Medication Assisted Treatment (MAT) prior to 180 days of continuous treatment (M1035)
Performance Not Met: Adults who have not had at least 180 days of continuous pharmacotherapy with a medication prescribed for OUD without a gap of more than seven days (M1036)