Percentage of adults aged 18 years and older with pharmacotherapy for opioid use disorder (OUD) who have at least 180 days of continuous treatment.
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 measurement period that meet additional denominator criteria described below. 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: Patient encounters for this measure conducted via telehealth (e.g., encounters coded with GQ, GT, 95, or POS 02 modifiers) are allowable.
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.
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.
Eligibility to submit results for a patient requires a qualifying encounter in the performance year, i.e., between January 1, 2023, and December 31, 2023. 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, 2022, and June 30, 2023:
- Have a diagnosis of OUD
- Receive pharmacotherapy for OUD
Qualifying Encounter – Encounter during the performance year
Pharmacotherapy for OUD –
- Naltrexone (oral)
- 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 07/1/2022 to 6/30/2023. 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 a 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
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, 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
Encounter during the measurement period (CPT or HCPCS): 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
Adults currently taking pharmacotherapy for OUD: M1032
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 (07/01/2022– 12/31/2023).
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)
Denominator Exception: Adults who are deliberately phased out of Medication Assisted Treatment (MAT) prior to 180 days of continuous treatment (M1035)
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)
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 medications were identified using National Drug Codes (NDCs) for the following:
- Buprenorphine (oral)
- Naltrexone (oral)
- Buprenorphine and Naloxone (oral)
And HCPCS codes for the following:
- Oral Buprenorphine or Buprenorphine/naloxone (when dispensed in office)
- Injectable and implanted Buprenorphine
- Methadone administration
- Naltrexone (extended-release injectable)
The National Drug Codes (NDCs) for the oral medications and the HCPCS codes for the injectable/implantable medications and office-dispensed oral medications (methadone and buprenorphine/naloxone) are contained in the sheets called “NDCs” and “HCPCS Codes”, respectively, in the Excel file called “NQF 3175 OUD Code Lists” which is attached to this form under Item S.2b. Note that the NDC code list DOES NOT include NDC codes for methadone, as it can legally only be dispensed as OUD pharmacotherapy in licensed treatment centers. Buprenorphine can be dispensed through a pharmacy or in an office and is therefore identified based on either NDC or HCPCS codes.
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.
Clinical Recommendation Statements
This is a process measure as it is quantifying medication compliance for a specific period of time and not abstinence from addictive use of opioids. By looking at adherence or continuity of pharmacotherapy for opioid use disorder, we are touching on an intermediate outcome as well. As such, no clinical recommendations are included.