2025 MIPS Measure Adherence to Antipsychotic Medications For Individuals with Schizophrenia

2025 COLLECTION TYPE:

MIPS CLINICAL QUALITY MEASURES (CQMS)

‌MEASURE TYPE:‌Intermediate Outcome – High Priority

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.

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 who are 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 (including but not limited to encounters coded with GQ, GT, POS 02, POS 10) are allowable. Please note that effective January 1, 2025, while a measure may be denoted as telehealth eligible, specific denominator codes within the encounter may no longer be eligible due to changes outlined in the CY 2024 PFS Final Rule List of Medicare Telehealth Services.

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 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 by MIPS eligible clinicians, groups, or third-party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third-party intermediaries that utilize Medicare Part B claims data. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.

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 for the denominator. The route of administration includes all oral formulations of the medications listed below.

Antipsychotic Medications:

• aripiprazole
• asenapine
• brexipprazole
• cariprazine
• chlorpromazine
• clozapine
• fluphenazine
• haloperidol
• iloperidone
• loxapine
• lumateperone
• lurasidone
• molindone
• olanzapine
• paliperidone
• perphenazine
• prochlorperazine
• quetiapine
• quetiapine fumarate (Seroquel)
• risperidone
• thioridazine
• thiothixene
• trifluoperazine
• ziprasidone

Antipsychotic Combinations:

• perphenazine-amitriptyline

Long-Acting Injectable Antipsychotic Medications:

Note: The following are the long-acting (depot) injectable antipsychotic medications for the denominator. The route of administration includes all injectable and intramuscular formulations of the medications listed below.

ANTIPSYCHOTIC MEDICATIONS:

• aripiprazole
• aripiprazole lauroxil (Aristada)
• fluphenazine decanoate
• haloperidol decanoate
• olanzapine pamoate
• paliperidone palmitate
• risperidone microspheres

Denominator Criteria (eligible Cases):

Patients aged ≥ 18 years at the beginning of the performance period

And

Diagnosis for schizophrenia or schizoaffective disorder during at least one encounter in an acute inpatient setting (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

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

Or

Diagnosis for schizophrenia or schizoffective disorder during at least two encounters in an outpatient, emergency department, or non-acute inpatient setting (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

Outpatient, Emergency Department, or Non-Acute Inpatient Setting (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 90839, 90845, 90847, 90849, 90853, 90867, 90868, 90869, 90870, 90875*, 90876*, 90880, 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015, 98016, 98960, 98961, 98962, 99078, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99238, 99239, 99242*, 99243*, 99244*, 99245*, 99252*, 99253*, 99254*, 99255*, 99281, 99282, 99283, 99284, 99285*, 99291, 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*, H0017, H0018, H0019, 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*, T2048

With

Outpatient Place of Service (POS): 02, 03, 04, 05, 07, 09, 10, 11, 12, 13, 14, 15, 16, 17, 19, 20, 22, 24, 33, 49,50, 52, 53, 54, 57, 58, 62, 65, 71, 72

Or

Emergency Department Place of Service (POS): 23

Or

Non-Acute Inpatient Place of Service (POS): 31, 32, 55, 56, 61

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”: M1380

And Not

Denominator Exclusion:

Patient ever had a diagnosis of 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: Most Recent Glycemic Status Assessment (hb A1c or Gmi) Level > 9.0% (M1211)

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)