Measure Description
Percentage of individuals at least 18 years of age as of the beginning of the measurement 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 measurement period (12 consecutive months)
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.
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 measurement period with schizophrenia or schizoaffective disorder and at least two prescriptions filled for antipsychotic medications during the measurement period (12 consecutive months)
DENOMINATOR NOTE: 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
• 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.
TYPICAL ANTIPSYCHOTIC MEDICATIONS:
• fluphenazine decanoate (J2680)
• haloperidol decanoate (J1631)
ATYPICAL ANTIPSYCHOTIC MEDICATIONS:
• aripiprazole (J0401)
• aripiprazole lauroxil (Aristada)
• olanzapine pamoate (J2358)
• paliperidone palmitate (J2426)
• risperidone microspheres (J2794)
NOTE: 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:
• aripiprazole (J0401) – 28 days’ supply
• aripiprazole lauroxil (Aristada) – 28 days’ supply
• fluphenazine decanoate (J2680) – 28 days’ supply
• haloperidol decanoate (J1631) – 28 days’ supply
• olanzapine pamoate (J2358) – 28 days’ supply
• paliperidone palmitate (J2426) – 28 days’ supply
• risperidone microspheres (J2794) – 14 days’ supply
*Signifies that this CPT Category I 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.
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
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 measurement 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 measurement period
AND
**Patient encounter during the performance period determination Outpatient Setting Option 1 (CPT or HCPCS): 98960, 98961, 98962, 99078, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220,99241, 99242, 99243, 99244, 99245, 99281, 99282, 99283, 99284, 99285, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350,99385, 99386, 99387, 99395, 99396, 99397, 99401, 99402, 99403, 99404, 99411, 99412, 99429, 99510, G0155*, G0176*, G0177*, G0409, G0410*, G0411*, G0463*, H0002*, H0004*, H0031*, H0034*, H0035*, H0036*, H0037*, H0039*, H0040*, H2000*, H2001*, H2010*, H2011*, H2012*, H2013*, H2014*, H2015*, H2016*, H2017*, H2018*, H2019*, H2020*, M0064, S0201*, S9480*, S9484*, S9485*, T1015*
OR
Outpatient Setting Option 2 (CPT): 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90847, 90849, 90853, 90863*, 90867, 90868, 90869, 90870, 90875*, 90876*, 90880, 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99251*, 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, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90847, 90849, 90853, 90863*, 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, 99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337
Non-Acute Inpatient Setting Option 1 (HCPCS): H0017, H0018, H0019, T2048
OR
Non-Acute Inpatient Setting Option 2 (CPT): 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90847, 90849, 90853, 90863*, 90867, 90868, 90869, 90870, 90875*, 90876*, 99291
WITH
Place of Service (POS): 31, 32, 56
OR
Acute Inpatient Setting (CPT): 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90847, 90849, 90853, 90863*, 90867, 90868, 90869, 90870, 90875*, 90876*, 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99251*, 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, E75.4, F01.50, F01.51, F02.80, F02.81, F03.90, F03.91, F05, F10.27, 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 the first prescription is filled (index date) and lasts through the end of the measurement period, or death, whichever comes first. For prescriptions 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 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 PDC denominator is the number of days from the first prescription date through the end of the measurement period, or death date, 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)