2026 #383 MIPS Measure Adherence to Antipsychotic Medications For Individuals with Schizophrenia

‌2026 COLLECTION TYPE:

MERIT-BASED INCENTIVE PAYMENT SYSTEM (MIPS) CLINICAL QUALITY MEASURE (CQM)

‌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:‌

Reporting Frequency:

This measure is to be submitted a minimum of once per performance period for denominator eligible cases as defined in the denominator criteria.

‌Intent and Clinician Applicability:

This measure is intended to reflect the quality of services provided for patients with a diagnosis of schizophrenia or schizoaffective disorder. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions as defined by the numerator based on the services provided and the measure-specific denominator coding.

‌Measure Strata and Performance Rates:

This measure contains one strata defined by a single submission criteria. This measure produces a single performance rate.

‌Implementation Considerations:

For the purposes of MIPS implementation, this patient-process measure is submitted a minimum of once per patient for the performance period. The most advantageous quality data code will be used if the measure is submitted more than once.

‌Telehealth:

TELEHEALTH ELIGIBLE: This measure is appropriate for and applicable to the telehealth setting. Patient encounters conducted via telehealth using encounter code(s) found in the denominator encounter criteria are allowed for this measure. Therefore, if the patient meets all denominator criteria for a telehealth encounter, it would be appropriate to include them in the denominator eligible patient population. Telehealth eligibility is at the measure level for inclusion within the denominator eligible patient population and based on the measure specification definitions which are independent of changes to coding and/or billing practices.

‌Measure Submission:

The quality data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third party intermediaries that utilize this collection type for submissions; however, these codes may be submitted for those third party intermediaries that utilize Medicare Part B claims data. The coding provided to identify the measure criteria: Denominator or Numerator, may be an example of coding that could be used to identify patients that meet the intent of this clinical topic. When implementing this measure, please refer to the ‘Reference Coding’ section to determine if other codes or code languages that meet the intent of the criteria may also be used within the medical record to identify and/or assess patients. 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.

ORAL ANTIPSYCHOTIC MEDICATIONS: NOTE: The following are the oral antipsychotic medications for the denominator. The route of administration includes all oral formulations of the medications listed below.	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:	ANTIPSYCHOTIC COMBINATIONS:	ANTIPSYCHOTIC MEDICATIONS:
aripiprazole	perphenazine-amitriptyline	aripiprazole
asenapine		aripiprazole lauroxil (Aristada)
brexipprazole		fluphenazine decanoate
cariprazine		haloperidol decanoate
aripiprazole		olanzapine pamoate
chlorpromazine		paliperidone palmitate
clozapine		risperidone microspheres
fluphenazine
haloperidol
iloperidone
loxapine
lumateperone
lurasidone
molindone
olanzapine
paliperidone
perphenazine
prochlorperazine
quetiapine
quetiapine fumarate (Seroquel)
risperidone
thioridazine
thiothixene
trifluoperazine
ziprasidone

‌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: M1452

‌Reference Coding:

Denominator Exclusion for Dementia [M1452] is defined by the following coding only:

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)

RATIONALE:

A large body of evidence has shown that antipsychotic medications (APMs) are effective in treating acute psychotic exacerbations of schizophrenia and in reducing the likelihood of relapse. Guidelines from the National Institute for Clinical Excellence (NICE) and the American Psychiatric Association (APA) emphasize the importance of treatment adherence and uninterrupted antipsychotic regimens to prevent symptoms and relapse [1,2]. However, some studies estimate that the rate of adherence to APMs among patients diagnosed with schizophrenia is about 50 percent, much lower than the 80 percent threshold often used to define adherence [3]. Factors associated with poor medication adherence include greater symptom severity, a more frequent dosing regimen, poor insight, and a more negative attitude towards drugs [4,5]. Some studies have also identified Latino and African American ethnicity, lack of housing, and co-occurring behavioral health and substance use conditions as predictors of increased nonadherence to antipsychotic medications [6]. This measure describes the degree of compliance or non-compliance with recommendations related to medication adherence among patients with schizophrenia and, in doing so, has the potential to improve management of schizophrenia. This measure addresses a Healthy People 2030 goal to increase the proportion of adults with serious mental illness who receive treatment [7].

Although the prevalence of schizophrenia in the adult American population is less than 1%, this population has a higher risk of premature mortality than the general population [8]. The estimated average potential life lost is 28.5 years for individuals with schizophrenia compared to the general population [9]. The overall U.S. cost of schizophrenia has been estimated at $155.7 billion annually with direct health care costs of $37.7 billion [10]. Antipsychotic medications have proven to be effective in treating this disease. Additionally, adherence to APMs has been associated with lower rates of preventable diabetes hospitalizations and lower rates of emergency department utilization among patients with schizophrenia [11,12,13].