Measure Description
All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during Opioid Therapy documented in the medical record
Instructions
This measure is to be submitted a minimum of once per performance period for all patients being prescribed opioids for duration longer than six weeks during the performance period. There is no diagnosis associated with this measure. 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.
NOTE: Include only patients that have 6 weeks opioid use through September 30 of the performance period. This will allow the follow-up evaluation of at least 90 days after opioid therapy within the performance period.
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
All patients 18 and older prescribed opiates for longer than six weeks duration
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Patient encounter during the performance period (CPT): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 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
WITHOUT
Telehealth Modifier: GQ, GT, 95, POS 02
AND
Patients prescribed opiates for longer than six weeks: G9561
AND NOT
DENOMINATOR EXCLUSION:
Patients who were in hospice at any time during the performance period: M1022, M1025, M1026
Numerator
Patients who had a follow-up evaluation conducted at least every three months during opioid therapy
Definition:
Follow-Up Evaluation – periodic MIPS eligible clinician encounters to reassess patients on Continuous Opioid Therapy (COT) as warranted by changing circumstances surrounding the patient. Monitoring should include:
• Documentation of pain intensity and level of functioning
• Assessments of progress toward achieving therapeutic goals
• Presence of adverse events
• Adherence to prescribed therapies
Numerator Options:
Performance Met: Patients who had a follow-up evaluation conducted at least every three months during opioid therapy (G9562)
OR
Performance Not Met: Patients who did not have a follow-up evaluation conducted at least every three months during opioid therapy (G9563)
Rationale
Clinicians should periodically reassess all patients on COT. Regular monitoring of patients once COT is initiated is critical because therapeutic risks and benefits do not remain static and can be affected by changes in the underlying pain condition, presence of coexisting disease, or changes in psychological or social circumstances. Monitoring is essential to identify patients who are benefiting from COT, those who might benefit more with restructuring of treatment or receiving additional services such as treatment for addiction, and those whose benefits from treatment are outweighed by harms.
Clinical Recommendation Statements
Clinicians should reassess patients on COT periodically and as warranted by changing circumstances. Monitoring should include documentation of pain intensity and level of functioning, assessments of progress toward achieving therapeutic goals, presence of adverse events, and adherence to prescribed therapies (strong recommendation, low-quality evidence).
In patients on COT who are at high risk or who have engaged in aberrant drug-related behaviors, clinicians should periodically obtain urine drug screens or other information to confirm adherence to the COT plan of care (strong recommendation, low-quality evidence).
In patients on COT not at high risk and not known to have engaged in aberrant drug-related behaviors, clinicians should consider periodically obtaining urine drug screens or other information to confirm adherence to the COT plan of care (weak recommendation, low-quality evidence).