2026 #468 MIPS Measure Continuity of Pharmacotherapy for Opioid Use Disorder (OUD)

‌2026 COLLECTION TYPE:

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

‌MEASURE TYPE: Process – High Priority

‌Description:

Percentage of adults aged 18 years and older with pharmacotherapy for opioid use disorder (OUD) who have at least 180 days of continuous treatment.

‌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 pharmacotherapy for OUD. 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.

Eligibility to submit results for a patient requires a qualifying encounter in the performance year, i.e., between January 1, 2026, and December 31, 2026. 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, 2025, and June 30, 2026:

1. Have a diagnosis of OUD
2. Receive pharmacotherapy for OUD

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:

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

Definitions:
Qualifying Encounter – Encounter during the performance year

Pharmacotherapy for OUD –

• • Buprenorphine
  • Buprenorphine (extended-release injectable, intramuscular)
  • Buprenorphine (extended-release injectable, subcutaneous)
  • Naltrexone (oral)
  • Buprenorphine/naloxone
  • Methadone
  • 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/ 2025 to 6/30/ 2026. 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 an 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

AND

Diagnosis of OUD on date of qualifying encounter: F11.10, F11.120, F11.121, F11.122, F11.129, F11.13, 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

AND

Encounter during the measurement period (CPT or HCPCS): 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015, 98016, 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

AND

Adults currently taking pharmacotherapy for OUD: M1032

‌Numerator:

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/ 2025– 12/31/ 2026).

Numerator Options:

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)

OR

Denominator Exception: Adults who are deliberately phased out of Medication Assisted Treatment (MAT) prior to 180 days of continuous treatment (M1035)

OR

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)

RATIONALE

Continuous pharmacotherapy for OUD is identified on the basis of the days covered by the days’ supply of all prescription claims for any OUD medication (see list below) or number of days for which the drug was dispensed in a physician office or treatment center with the exceptions noted in this paragraph. The period of continuous pharmacotherapy starts on the day the first claim for an OUD medication is filled/supplied (index date) and lasts through the days’ supply of the last claim for an OUD medication. To meet the 180-day requirement and be eligible for the measure, the date on the first claim for an OUD medication must fall at least 180 days before the end of the measurement period. For claims with a days’ supply that extends beyond the end of the measurement period, count only the days for which the drug was available to the individual during the measurement period. If two or more prescription claims occur on the same day or overlap, the surplus based on the days’ supplies accumulates over all prescriptions. However, if another claim is submitted after a claim for an injectable OUD medication or an oral OUD medication that is dispensed in an office or treatment center, the surplus from the day’s supply for the injectable or office-dispensed medication is not retained.

An individual is considered to have continuous pharmacotherapy with OUD medication if there is no treatment gap of more than seven days. A gap is defined as a period during which the individual does not have oral OUD medication available based on the days’ supply or is more than 7 days overdue for having an injection or implantation of an extended-release OUD medication
OUD Medication List
• Buprenorphine
• Buprenorphine (extended-release injectable, intramuscular)
• Buprenorphine (extended-release injectable, subcutaneous)
• Naltrexone (oral)
• Buprenorphine/naloxone
• Methadone
• Naltrexone (extended-release injectable).

Justification of Measure Definition: We define treatment continuity as (1) receiving at least 180 days of treatment and (2) no gaps in medication use of more than 7 days.

Our definition of minimum duration is based on the fact that the FDA registration trials for OUD drugs studied the effect of treatment over three to six months (US FDAa, undated; US FDAb, undated), and we have no evidence for effectiveness of shorter durations. In addition, several recommendations support a minimum six-month treatment period as the risk of relapse is the highest in the first 6-12 months after start of opioid abstinence (US FDAa, undated; US FDAb, undated; US DHHS, 2015). Longer treatment duration is associated with better outcomes compared to shorter treatments and the best outcomes have been observed among patients in long-term methadone maintenance programs (“Effective medical treatment of opiate addiction”, 1998; Gruber et al., 2008; Moos et al., 1999; NIDA, 1999; Ouimette et al., 1998; Peles et al., 2013). Studies with long-term follow-up suggest that ongoing pharmacotherapy is associated with improved odds of opioid abstinence (Hser et al., 2015; Weiss et al., 2015). We did not specify a maximum duration of treatment, as no upper limit for duration of treatment has been empirically established (US DHHS, 2015).

The rationale for using a treatment gap of more than seven days in our definition is that the measure includes three active ingredients with different pharmacological profiles. There is substantial evidence for an elevated mortality risk immediately after treatment cessation (Cornish et al., 2010; Cousins et al., 2016; Davoli et al, 2007; Degenhardt et al., 2009; Gibson & Degenhardt, 2007; Pierce et al., 2016). Research suggests that methadone tolerance is lost after three days and this three-day threshold has been used in other observational methadone studies and in developing a
United Kingdom treatment guideline which recommends revaluating patients for intoxication and withdrawal after a three-day methadone treatment gap (Cousins et al., 2016; Cousins et al., 2011; “Drug Misuse and Dependence— Guidelines on Clinical Management”, 1999). Across all the medications, the mortality risk is highest in the first four weeks out of treatment, with many studies showing an increase in mortality in days 1-14 after treatment cessation.