MVP ID: M1369
Most applicable medical specialty(s):
Mental Health, Behavioral Health, Psychiatry
The Quality Care in Mental Health and Substance Use Disorders MVP focuses on the clinical theme of promoting prevention of and quality care in behavioral health, including mental health and substance use disorders (SUD).
Quality
Report 4 quality measures (one must be an outcome or a high priority measure):
- Quality ID: 009: Anti-Depressant Medication Management
- Quality ID: 134: Preventive Care and Screening: Screening for Depression and Follow-Up Plan
- Quality ID: 305: Initiation and Engagement of Substance Use Disorder Treatment
- Quality ID: 366: Follow-Up Care for Children Prescribed ADHD Medication (ADD)
- Quality ID: 370: Depression Remission at Twelve Months
- Quality ID: 382: Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment
- Quality ID: 383: Adherence to Antipsychotic Medications For Individuals with Schizophrenia
- Quality ID: 468: Continuity of Pharmacotherapy for Opioid Use Disorder (OUD)
- Quality ID: 502: Improvement or Maintenance of Functioning for Individuals with a Mental and/or Substance Use Disorder
- Quality ID: 504: Initiation, Review, And/Or Update To Suicide Safety Plan For Individuals With Suicidal Thoughts, Behavior, Or Suicide Risk
- Quality ID: 505: Reduction in Suicidal Ideation or Behavior Symptoms
- Quality ID: MBHR2: Anxiety Response at 6-months - Patient Reported Outcome, High Priority, QCDR
- Quality ID: MBHR7: Posttraumatic Stress Disorder (PTSD) Outcome Assessment for Adults and Children - Patient Reported Outcome, High Priority, QCDR
Improvement Activities
Report one improvement activity from the list below:
- IA_BE_12: Use evidence-based decision aids to support shared decision-making
- IA_BE_16: Promote Self-management in Usual Care
- IA_BE_23: Integration of patient coaching practices between visits
- IA_BE_26: Promote Use of Patient-Reported Outcome Tools
- IA_BMH_2: Tobacco use
- IA_BMH_5: MDD prevention and treatment interventions
- IA_BMH_7: Implementation of Integrated Patient Centered Behavioral Health Model
- IA_BMH_14: Behavioral/Mental Health and Substance Use Screening & Referral for Pregnant and Postpartum Women
- IA_BMH_15: Behavioral/Mental Health and Substance Use Screening & Referral for Older Adults
- IA_EPA_2: Use of telehealth services that expand practice access
- IA_MVP: Practice-Wide Quality Improvement in MIPS Value Pathways
- IA_PCMH: Electronic submission of Patient Centered Medical Home accreditation
- IA_PSPA_32: Use of CDC Guideline for Clinical Decision Support to Prescribe Opioids for Chronic Pain via Clinical Decision Support
Cost
Calculated by CMS using administrative claims data:
- Measure ID: COST_DEP_1: Depression
- Measure ID: COST_PRC_1: Psychoses and Related Conditions
- Measure ID: MSPB_1: Medicare Spending Per Beneficiary (MSPB) Clinician
Population Health Measures
CMS will calculate both population health measures using administrative claims data (if case minimum requirements are met) and assign the higher of these measures to the Quality score. If neither of the population health measures can be calculated, they will be excluded from scoring.
- #479: Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment Program (MIPS) Groups (Administrative Claims)(!!)
- #484: Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (Administrative Claims) (!!)
Promoting Interoperability
Report on the same PI measures required under traditional MIPS unless qualified for automatic reweighting or approved hardship exception:
- Actions to Limit or Restrict Compatibility or Interoperability of CEHRT Attestation
- e-Prescribing
- Query of the Prescription Drug Monitoring Program (PDMP)
- Provide Patients Electronic Access to Their Health Information
- Support Electronic Referral Loops By Sending Health Information AND
- Support Electronic Referral Loops By Receiving and Reconciling Health Information OR
- Health Information Exchange (HIE) Bi-Directional Exchange
- Enabling Exchange Under the Trusted Exchange Framework and Common Agreement (TEFCA)
- Immunization Registry Reporting
- Syndromic Surveillance Reporting
- Electronic Case Reporting
- Public Health Registry Reporting
- Clinical Data Registry Reporting
- Security Risk Analysis
- Safety Assurance Factors for EHR Resilience Guide (SAFER Guide)
- ONC Direct Review Attestation
MVP Registration
- MVP Participants must register between April 1 – December 1, 2026 to report an MVP in 2026.
- To register, MVP Participants must select:
- The MVP they intend to report.
- Any outcomes-based administrative claims measures on which the MVP Participant intends to be scored (if available).
- Whether they plan to administer the Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Survey, if it’s a quality measure option in the selected MVP.
- The participation option they plan to use: individual, group, subgroup, or APM Entity.
- Starting in 2026, to register for MVP reporting as a group, the practice will need to attest to their specialty composition (whether they are a single specialty group or multispecialty small practice) during the MVP registration process. CMS won't make this determination for the practice. All other groups will need to participate as subgroups or as individuals (if eligible) to report an MVP.
- If reporting as a subgroup, registration must also include:
- A list of Taxpayer Identification Numbers (TINs)/National Provider Identifiers (NPIs) in the subgroup;
- A plain language name for the subgroup (which will be used for public reporting);
- A description of the composition of the subgroup, which may be selected from a list or described in a narrative.
- MVP Participants won’t be able to:
- Submit/make changes to the MVP they select after the close of the registration period (December 1, 2026).
- Report on an MVP they didn’t register for during the 2026 performance year.
- Report on more than one MVP.