Measure 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
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) eligible clinicians who perform the quality actions described in the measure 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 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
Adults aged 18 years and older who had a diagnosis of OUD
Definitions:
Pharmacotherapy for OUD –
• Buprenorphine
• Naltrexone (oral)
• Buprenorphine/naloxone
• Methadone
• Naltrexone (extended-release injectable)
Denominator Identification Period – The period in which eligible adults can have a denominator eligible event. The denominator identification period is defined as 18 months. The denominator identification period is from 07/01/2018 to 12/31/2019.
Denominator Criteria (Eligible Cases):
Adults aged ≥ 18 years on date of encounter
AND
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, 11.29, 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 denominator identification period (CPT or HCPCS): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99281, 99282, 99283, 99284, 99285, 99291 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0402, G0438, G0439
AND
Adults currently taking pharmacotherapy for OUD: M1032
AND NOT
DENOMINATOR EXCLUSION:
Pharmacotherapy for OUD initiated after June 30th of performance period: M1033
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 the performance period (01/01/2019 – 12/31/2019). If the adult has a denominator eligible encounter in the last 180 days of the performance period, they may review medical history or ‘look-back’ 180 days to determine numerator compliance. If the adult is identified as a new patient or newly diagnosed patient and the MIPS eligible clinician is unable to determine numerator compliance since they would need 180 days for consideration of continuity of pharmacology from the time of the denominator encounter, they may exclude that patient from the denominator.
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)