U.S. flag

An official website of the United States government

Search (beta)
Help
Explore MIPS Value Pathways (MVPs) page

Quality Care in Mental Health and Substance Use Disorders

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).

Measures/Activites and Requirements (MVP ID: M1369):

To fulfill quality requirements:

  1. You must select 4 quality measures from the list below
  2. (exception for clinicians in a small practice - see # 3 below)
  3. At least 1 measure must be an outcome measure
    • If no outcome measures are available, you may report a high priority measure.
  4. If you are part of a small practice (i.e., 15 or fewer clinicians) reporting quality measures through Medicare Part B claims, you don't need to report additional measures beyond the Medicare Part B claims measures available in this MVP. Reporting all of the Medicare Part B claims measures in this MVP will fulfill your quality reporting requirements.
  5. You must collect data for each measure for the 12-month performance period of the associated performance year (e.g., January 1, 2024 - December 31, 2024).

TIP: For small practices (participating at the individual, group or subgroup level) reporting Medicare Part B claims measures: To meet data completeness requirements, you'll need to start reporting the Medicare Part B claims measures in your selected MVP in January 2024, prior to the MVP registration period.

TIP: Make sure that you select measures that are appropriate to your patient population. Measures that don't meet case minimum or data completeness criteria will earn zero points.

Quality Measures (MVP ID: M1369)
MeasureMeasure DescriptionCollection TypeSpecification(s)
Measure

Quality ID: 009

Anti-Depressant Medication Management

Measure Type: Process

High Priority: No

Percentage of patients 18 years of age and older who were treated with antidepressant medication, ha...

Electronic clinical quality measures (eCQMs)

Review Q009 eCQM Specification
Measure

Quality ID: 134

Preventive Care and Screening: Screening for Depression and Follow-Up Plan

Measure Type: Process

High Priority: No

Percentage of patients aged 12 years and older screened for depression on the date of the encounter ...

Electronic clinical quality measures (eCQMs)

MIPS clinical quality measures (MIPS CQMs)

Medicare Part B claims measures

Review Q134 eCQM SpecificationDownload Q134 MIPS CQM Specification (PDF)Download Q134 Medicare Part B Claims Specification (PDF)
Measure

Quality ID: 305

Initiation and Engagement of Substance Use Disorder Treatment

Measure Type: Process

High Priority: Yes

Percentage of patients 13 years of age and older with a new substance use disorder (SUD) episode who...

Electronic clinical quality measures (eCQMs)

Review Q305 eCQM Specification
Measure

Quality ID: 366

Follow-Up Care for Children Prescribed ADHD Medication (ADD)

Measure Type: Process

High Priority: No

Percentage of children 6-12 years of age and newly prescribed a medication for attention-deficit/hyp...

Electronic clinical quality measures (eCQMs)

Review Q366 eCQM Specification
Measure

Quality ID: 370

Depression Remission at Twelve Months

Measure Type: Outcome

High Priority: Yes

The percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or ol...

Electronic clinical quality measures (eCQMs)

MIPS clinical quality measures (MIPS CQMs)

Review Q370 eCQM SpecificationDownload Q370 MIPS CQM Specification (PDF)
Measure

Quality ID: 382

Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment

Measure Type: Process

High Priority: Yes

Percentage of patient visits for those patients aged 6 through 16 years at the start of the measurem...

Electronic clinical quality measures (eCQMs)

Review Q382 eCQM Specification
Measure

Quality ID: 383

Adherence to Antipsychotic Medications For Individuals with Schizophrenia

Measure Type: Intermediate Outcome

High Priority: Yes

Percentage of individuals at least 18 years of age as of the beginning of the performance period wit...

MIPS clinical quality measures (MIPS CQMs)

Download Q383 MIPS CQM Specification (PDF)
Measure

Quality ID: 468

Continuity of Pharmacotherapy for Opioid Use Disorder (OUD)

Measure Type: Process

High Priority: Yes

Percentage of adults aged 18 years and older with pharmacotherapy for opioid use disorder (OUD) who ...

MIPS clinical quality measures (MIPS CQMs)

Download Q468 MIPS CQM Specification (PDF)
Measure

Quality ID: 487

Screening for Social Drivers of Health

Measure Type: Process

High Priority: Yes

Percent of patients 18 years and older screened for food insecurity, housing instability, transporta...

MIPS clinical quality measures (MIPS CQMs)

Download Q487 MIPS CQM Specification (PDF)
Measure

Quality ID: 502

Improvement or Maintenance of Functioning for Individuals with a Mental and/or Substance Use Disorder

Measure Type: Patient Reported Outcome

High Priority: Yes

The percentage of individuals aged 18 and older with a mental and/or substance use disorder who demo...

MIPS clinical quality measures (MIPS CQMs)

Download Q502 MIPS CQM Specification (PDF)
Measure

Quality ID: 504

Initiation, Review, And/Or Update To Suicide Safety Plan For Individuals With Suicidal Thoughts, Behavior, Or Suicide Risk

Measure Type: Process

High Priority: Yes

Percentage of adult aged 18 years and older with suicidal ideation or behavior symptoms (based on re...

MIPS clinical quality measures (MIPS CQMs)

Download Q504 MIPS CQM Specification (PDF)
Measure

Quality ID: 505

Reduction in Suicidal Ideation or Behavior Symptoms

Measure Type: Patient Reported Outcome

High Priority: Yes

The percentage of patients aged 18 and older with a mental and/or substance use disorder AND suicida...

MIPS clinical quality measures (MIPS CQMs)

Download Q505 MIPS CQM Specification (PDF)
Measure

Quality ID: MBHR2

Anxiety Response at 6-months

Measure Type: Patient Reported Outcome

High Priority: Yes

The percentage of adult patients (18 years of age or older) with an anxiety disorder (e.g., generali...

Qualified Clinical Data Registry (QCDR)

Download All 2024 QCDR Specifications
Measure

Quality ID: MBHR7

Posttraumatic Stress Disorder (PTSD) Outcome Assessment for Adults and Children

Measure Type: Patient Reported Outcome

High Priority: Yes

The percentage of patients with a history of a traumatic event (i.e., an experience that was unusual...

Qualified Clinical Data Registry (QCDR)

Download All 2024 QCDR Specifications

You must report 1 of the following 3 options:

1. Two medium weighted improvement activities from the list below, or

2. One high weighted improvement activity from the list below, or

3. The IA_PCMH activity (participation in a certified or recognized patient-centered medical home or a comparable specialty practice).

Download 2024 Improvement Activities Inventory (ZIP)
Improvement Activities (MVP ID: M1369)
ActivityActivity DescriptionActivity Weighting
Activity

Activity ID: IA_AHE_1

Enhance Engagement of Medicaid and Other Underserved Populations

To improve responsiveness of care for Medicaid and other underserved patients: use time-to-treat dat...high
Activity

Activity ID: IA_AHE_12

Practice Improvements that Engage Community Resources to Address Drivers of Health

Select and screen for drivers of health that are relevant for the eligible clinician’s population us...high
Activity

Activity ID: IA_AHE_3

Promote Use of Patient-Reported Outcome Tools

Demonstrate performance of activities for employing patient-reported outcome (PRO) tools and corresp...high
Activity

Activity ID: IA_AHE_5

MIPS Eligible Clinician Leadership in Clinical Trials or CBPR

Lead clinical trials, research alliances, or community-based participatory research (CBPR) that iden...medium
Activity

Activity ID: IA_AHE_9

Implement Food Insecurity and Nutrition Risk Identification and Treatment Protocols

Create or improve, and then implement, protocols for identifying and providing appropriate support t...medium
Activity

Activity ID: IA_BE_12

Use evidence-based decision aids to support shared decision-making.

Use evidence-based decision aids to support shared decision-making....medium
Activity

Activity ID: IA_BE_16

Promote Self-management in Usual Care

To help patients self-manage their care, incorporate culturally and linguistically tailored evidence...medium
Activity

Activity ID: IA_BE_23

Integration of patient coaching practices between visits

Provide coaching between visits with follow-up on care plan and goals....medium
Activity

Activity ID: IA_BMH_14

Behavioral/Mental Health and Substance Use Screening & Referral for Pregnant and Postpartum Women

Screen for perinatal mood and anxiety disorders (PMADs) and substance use disorder (SUD) in pregnant...high
Activity

Activity ID: IA_BMH_15

Behavioral/Mental Health and Substance Use Screening & Referral for Older Adults

Complete age-appropriate screening for mental health and substance use in older adults, as well as s...high
Activity

Activity ID: IA_BMH_2

Tobacco use

Tobacco use: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and ...medium
Activity

Activity ID: IA_BMH_5

MDD prevention and treatment interventions

Major depressive disorder: Regular engagement of MIPS eligible clinicians or groups in integrated pr...medium
Activity

Activity ID: IA_BMH_7

Implementation of Integrated Patient Centered Behavioral Health Model

Offer integrated behavioral health services to support patients with behavioral health needs who als...high
Activity

Activity ID: IA_EPA_2

Use of telehealth services that expand practice access

Create and implement a standardized process for providing telehealth services to expand access to ca...medium
Activity

Activity ID: IA_MVP

Practice-Wide Quality Improvement in MIPS Value Pathways

Create a quality improvement initiative within your practice and create a culture in which all staff...high
Activity

Activity ID: IA_PCMH

Electronic submission of Patient Centered Medical Home accreditation

I attest that I am a Patient Centered Medical Home (PCMH) or Comparable Specialty Practice that has ...
Activity

Activity ID: IA_PM_6

Use of Toolsets or Other Resources to Close Health and Health Care Inequities Across Communities (Use of toolset or other resources to close healthcare disparities across communities)

Address inequities in health outcomes by using population health data analysis tools to identify hea...medium
Activity

Activity ID: IA_PSPA_32

Use of CDC Guideline for Clinical Decision Support to Prescribe Opioids for Chronic Pain via Clinical Decision Support

In order to receive credit for this activity, MIPS eligible clinicians must utilize the Centers for ...high

Important information to consider:

  1. You don’t have to submit any data for this performance category. We'll use Medicare claims data to calculate your cost measure performance.
    • You don't select cost measures during MVP registration. CMS will calculate your performance on all the cost measures included in the MVP based on available Medicare claims data.
  2. You'll only be scored on the cost measures in this MVP for which you meet or exceed the established case minimum.
Cost Measures (MVP ID: M1369)
MeasureDescriptionSpecification(s)
Measure

Measure ID: COST_DEP_1

Depression

Patients receiving medical care to manage and treat depression. This chronic condition measure inclu...

Download COST_DEP_1 Specification (PDF)

Measure

Measure ID: COST_PRC_1

Psychoses and Related Conditions

Patients who receive inpatient treatment for psychoses or related conditions during the performance ...

Download COST_PRC_1 Specification (PDF)

Measure

Measure ID: MSPB_1

Medicare Spending Per Beneficiary (MSPB) Clinician

The MSPB Clinician measure assesses the risk-adjusted cost to Medicare for services performed as a r...

Download MSPB_1 Specification (PDF)

To fulfill Promoting Interoperability requirements:

  1. Submit the required Promoting Interoperability measures (the same as under traditional MIPS) listed below. Bonus points are available for reporting measures that aren't required.
    • If you're reporting as a subgroup, you'll submit your affiliated group's data for the Promoting Interoperability performance category.
  2. Review if you qualify for automatic reweighting of the Promoting Interoperability performance category based on your clinician type, special status, or an approved Promoting Interoperability Performance Category Hardship Exception Application.

Clinician Types for Automatic Reweighting:

    • Clinical social worker

Special Status for Automatic Reweighting:

    • Ambulatory Surgical Center (ASC)-based
    • Hospital-based
    • Non-patient facing
    • Small practice

Promoting Interoperability Performance Category Hardship Exception Qualifications:

    • Decertified EHR technology
    • Insufficient internet connectivity
    • Experience extreme and uncontrollable circumstances (e.g., disaster, practice closure, severe financial distress, vendor issues)
    • Lack control over availability of CEHRT (Certified Electronic Health Record Technology)

Note: Promoting Interoperability requirements are the same in MVPs as they are in traditional MIPS. Learn more about Promoting Interoperability requirements.

Promoting Interoperability Measures (All MVPs)
MeasureObjective nameRequired/OptionalSpecification(s)
Measure

Measure ID: PI_EP_1

e-Prescribing

Electronic PrescribingRequired

Review 2024 PI_EP_1 Measure Specification

Measure

Measure ID: PI_EP_2

Query of the Prescription Drug Monitoring Program (PDMP)

Electronic PrescribingRequired

Review 2024 PI_EP_2 Measure Specification

Measure

Measure ID: PI_EP_2_EX_1

Query of the Prescription Drug Monitoring Program (PDMP) Exclusion

Electronic PrescribingOptional

Review 2024 PI_EP_2_EX_1 Measure Specification

Measure

Measure ID: PI_EP_2_EX_2

Query of the Prescription Drug Monitoring Program (PDMP) Exclusion

Electronic PrescribingOptional

Review 2024 PI_EP_2_EX_2 Measure Specification

Measure

Measure ID: PI_HIE_1

Support Electronic Referral Loops By Sending Health Information

Health Information ExchangeRequired, unless submitting PI_HIE_5 or PI_HIE_6

Review 2024 PI_HIE_1 Measure Specification

Measure

Measure ID: PI_HIE_4

Support Electronic Referral Loops By Receiving and Reconciling Health Information

Health Information ExchangeRequired, unless submitting PI_HIE_5 or PI_HIE_6

Review 2024 PI_HIE_4 Measure Specification

Measure

Measure ID: PI_HIE_5

Health Information Exchange (HIE) Bi-Directional Exchange

Health Information ExchangeRequired, unless submitting PI_HIE_6 or the combination of PI_HIE_1 and PI_HIE_4

Review 2024 PI_HIE_5 Measure Specification

Measure

Measure ID: PI_HIE_6

Enabling Exchange Under TEFCA

Health Information ExchangeRequired, unless submitting PI_HIE_5 or the combination of PI_HIE_1 and PI_HIE_4

Review 2024 PI_HIE_6 Measure Specification

Measure

Measure ID: PI_INFBLO_1

Actions to Limit or Restrict the Compatibility of CEHRT

AttestationRequired

Review 2024 PI_INFBLO_1 Fact Sheet

Measure

Measure ID: PI_LVITC_2

Support Electronic Referral Loops By Receiving and Reconciling Health Information Exclusion

Health Information ExchangeOptional

Review 2024 PI_LVITC_2 Measure Specification

Measure

Measure ID: PI_LVOTC_1

Support Electronic Referral Loops By Sending Health Information Exclusion

Health Information ExchangeOptional

Review 2024 PI_LVOTC_1 Measure Specification

Measure

Measure ID: PI_LVPP_1

e-Prescribing Exclusion

Electronic PrescribingOptional

Review 2024 PI_LVPP_1 Measure Specification

Measure

Measure ID: PI_ONCACB_1

ONC-ACB Surveillance Attestation

AttestationOptional

Review 2024 PI_ONCACB_1 Measure Specification

Measure

Measure ID: PI_ONCDIR_1

ONC Direct Review Attestation

AttestationRequired

Review 2024 PI_ONCDIR_1 Details

Measure

Measure ID: PI_PEA_1

Provide Patients Electronic Access to Their Health Information

Provider To Patient ExchangeRequired

Review 2024 PI_PEA_1 Measure Specification

Measure

Measure ID: PI_PHCDRR_1

Immunization Registry Reporting

Public Health And Clinical Data ExchangeRequired

Review 2024 PI_PHCDRR_1 Measure Specification

Measure

Measure ID: PI_PHCDRR_1_EX_1

Immunization Registry Reporting Exclusion

Public Health And Clinical Data ExchangeOptional

Review 2024 PI_PHCDRR_1_EX_1 Measure Specification

Measure

Measure ID: PI_PHCDRR_1_EX_2

Immunization Registry Reporting Exclusion

Public Health And Clinical Data ExchangeOptional

Review 2024 PI_PHCDRR_1_EX_2 Measure Specification

Measure

Measure ID: PI_PHCDRR_1_EX_3

Immunization Registry Reporting Exclusion

Public Health And Clinical Data ExchangeOptional

Review 2024 PI_PHCDRR_1_EX_3 Measure Specification

Measure

Measure ID: PI_PHCDRR_1_PRE

Immunization Registry Reporting Active Engagement Level 1

Public Health And Clinical Data ExchangeRequired

Review 2024 PI_PHCDRR_1_PRE Measure Specification

Measure

Measure ID: PI_PHCDRR_1_PROD

Immunization Registry Reporting Active Engagement Level 2

Public Health And Clinical Data ExchangeRequired

Review 2024 PI_PHCDRR_1_PROD Measure Specification

Measure

Measure ID: PI_PHCDRR_2

Syndromic Surveillance Reporting

Public Health And Clinical Data ExchangeOptional

Review 2024 PI_PHCDRR_2 Measure Specification

Measure

Measure ID: PI_PHCDRR_2_PRE

Syndromic Surveillance Reporting Active Engagement Level 1

Public Health And Clinical Data ExchangeRequired

Review 2024 PI_PHCDRR_2_PRE Measure Specification

Measure

Measure ID: PI_PHCDRR_2_PROD

Syndromic Surveillance Reporting Active Engagement Level 2

Public Health And Clinical Data ExchangeRequired

Review 2024 PI_PHCDRR_2_PROD Measure Specification

Measure

Measure ID: PI_PHCDRR_3

Electronic Case Reporting

Public Health And Clinical Data ExchangeRequired

Review 2024 PI_PHCDRR_3 Measure Specification

Measure

Measure ID: PI_PHCDRR_3_EX_1

Electronic Case Reporting Exclusion

Public Health And Clinical Data ExchangeOptional

Review 2024 PI_PHCDRR_3_EX_1 Measure Specification

Measure

Measure ID: PI_PHCDRR_3_EX_2

Electronic Case Reporting Exclusion

Public Health And Clinical Data ExchangeOptional

Review 2024 PI_PHCDRR_3_EX_2 Measure Specification

Measure

Measure ID: PI_PHCDRR_3_EX_3

Electronic Case Reporting Exclusion

Public Health And Clinical Data ExchangeOptional

Review 2024 PI_PHCDRR_3_EX_3 Measure Specification

Measure

Measure ID: PI_PHCDRR_3_PRE

Electronic Case Reporting Active Engagement Level 1

Public Health And Clinical Data ExchangeRequired

Review 2024 PI_PHCDRR_3_PRE Measure Specification

Measure

Measure ID: PI_PHCDRR_3_PROD

Electronic Case Reporting Active Engagement Level 2

Public Health And Clinical Data ExchangeRequired

Review 2024 PI_PHCDRR_3_PROD Measure Specification

Measure

Measure ID: PI_PHCDRR_4

Public Health Registry Reporting

Public Health And Clinical Data ExchangeOptional

Review 2024 PI_PHCDRR_4 Measure Specification

Measure

Measure ID: PI_PHCDRR_4_PRE

Public Health Registry Reporting Active Engagement Level 1

Public Health And Clinical Data ExchangeRequired

Review 2024 PI_PHCDRR_4_PRE Measure Specification

Measure

Measure ID: PI_PHCDRR_4_PROD

Public Health Registry Reporting Active Engagement Level 2

Public Health And Clinical Data ExchangeRequired

Review 2024 PI_PHCDRR_4_PROD Measure Specification

Measure

Measure ID: PI_PHCDRR_5

Clinical Data Registry Reporting

Public Health And Clinical Data ExchangeOptional

Review 2024 PI_PHCDRR_5 Measure Specification

Measure

Measure ID: PI_PHCDRR_5_PRE

Clinical Data Registry Reporting Active Engagement Level 1

Public Health And Clinical Data ExchangeRequired

Review 2024 PI_PHCDRR_5_PRE Measure Specification

Measure

Measure ID: PI_PHCDRR_5_PROD

Clinical Data Registry Reporting Active Engagement Level 2

Public Health And Clinical Data ExchangeRequired

Review 2024 PI_PHCDRR_5_PROD Measure Specification

Measure

Measure ID: PI_PPHI_1

Security Risk Analysis

Protect Patient Health InformationRequired

Review 2024 PI_PPHI_1 Measure Specification

Measure

Measure ID: PI_PPHI_2

SAFER Guides High Priority Practices Guide

Protect Patient Health InformationRequired

Review 2024 PI_PPHI_2 Measure Specification

You must select 1 population health measure at the time of MVP registration.

  • You don't have to submit any data for this measure, we'll calculate the population health measures for you using administrative claims data.
  • This measure will be excluded from scoring if the measure doesn't have a benchmark or meet the case minimum.
  • Population health isn't a new performance category. The population health measure you select during MVP registration will be scored as part of the quality performance category provided you meet the case minimum.
  • Subgroups will be evaluated at the affiliated group level.
Population Health Measures (All MVPs)
QualityDescriptionCollection TypeSpecification(s)
Quality

Quality ID: 479

Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups

Measure Type: Outcome

High Priority: Yes

This measure is a re-specified version of the measure, "Risk-adjusted readmission rate (RARR) of unp...

Administrative claims measures

Download 2024 Q479 Measure Specifications (ZIP)

Quality

Quality ID: 484

Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions

Measure Type: Outcome

High Priority: Yes

Annual risk-standardized rate of acute, unplanned hospital admissions among Medicare Fee-for-Service...

Administrative claims measures

Download 2024 Q484 Measure Specifications (ZIP)