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:
- You must select 4 quality measures from the list below
- (exception for clinicians in a small practice - see # 3 below)
- At least 1 measure must be an outcome measure
- If no outcome measures are available, you may report a high priority measure.
- 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.
- 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.
Measure | Measure Description | Collection Type | Specification(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)Activity | Activity Description | Activity 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:
- 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.
- You'll only be scored on the cost measures in this MVP for which you meet or exceed the established case minimum.
Measure | Description | Specification(s) | |
---|---|---|---|
Measure | Measure ID: COST_DEP_1 Depression | Patients receiving medical care to manage and treat depression. This chronic condition measure inclu... | |
Measure | Measure ID: COST_PRC_1 Psychoses and Related Conditions | Patients who receive inpatient treatment for psychoses or related conditions during the performance ... | |
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... |
To fulfill Promoting Interoperability requirements:
- 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.
- 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.
Measure | Objective name | Required/Optional | Specification(s) | |
---|---|---|---|---|
Measure | Measure ID: PI_EP_1 e-Prescribing | Electronic Prescribing | Required | |
Measure | Measure ID: PI_EP_2 Query of the Prescription Drug Monitoring Program (PDMP) | Electronic Prescribing | Required | |
Measure | Measure ID: PI_EP_2_EX_1 Query of the Prescription Drug Monitoring Program (PDMP) Exclusion | Electronic Prescribing | Optional | |
Measure | Measure ID: PI_EP_2_EX_2 Query of the Prescription Drug Monitoring Program (PDMP) Exclusion | Electronic Prescribing | Optional | |
Measure | Measure ID: PI_HIE_1 Support Electronic Referral Loops By Sending Health Information | Health Information Exchange | Required, unless submitting PI_HIE_5 or PI_HIE_6 | |
Measure | Measure ID: PI_HIE_4 Support Electronic Referral Loops By Receiving and Reconciling Health Information | Health Information Exchange | Required, unless submitting PI_HIE_5 or PI_HIE_6 | |
Measure | Measure ID: PI_HIE_5 Health Information Exchange (HIE) Bi-Directional Exchange | Health Information Exchange | Required, unless submitting PI_HIE_6 or the combination of PI_HIE_1 and PI_HIE_4 | |
Measure | Measure ID: PI_HIE_6 Enabling Exchange Under TEFCA | Health Information Exchange | Required, unless submitting PI_HIE_5 or the combination of PI_HIE_1 and PI_HIE_4 | |
Measure | Measure ID: PI_INFBLO_1 Actions to Limit or Restrict the Compatibility of CEHRT | Attestation | Required | |
Measure | Measure ID: PI_LVITC_2 Support Electronic Referral Loops By Receiving and Reconciling Health Information Exclusion | Health Information Exchange | Optional | |
Measure | Measure ID: PI_LVOTC_1 Support Electronic Referral Loops By Sending Health Information Exclusion | Health Information Exchange | Optional | |
Measure | Measure ID: PI_LVPP_1 e-Prescribing Exclusion | Electronic Prescribing | Optional | |
Measure | Measure ID: PI_ONCACB_1 ONC-ACB Surveillance Attestation | Attestation | Optional | |
Measure | Measure ID: PI_ONCDIR_1 ONC Direct Review Attestation | Attestation | Required | |
Measure | Measure ID: PI_PEA_1 Provide Patients Electronic Access to Their Health Information | Provider To Patient Exchange | Required | |
Measure | Measure ID: PI_PHCDRR_1 Immunization Registry Reporting | Public Health And Clinical Data Exchange | Required | |
Measure | Measure ID: PI_PHCDRR_1_EX_1 Immunization Registry Reporting Exclusion | Public Health And Clinical Data Exchange | Optional | |
Measure | Measure ID: PI_PHCDRR_1_EX_2 Immunization Registry Reporting Exclusion | Public Health And Clinical Data Exchange | Optional | |
Measure | Measure ID: PI_PHCDRR_1_EX_3 Immunization Registry Reporting Exclusion | Public Health And Clinical Data Exchange | Optional | |
Measure | Measure ID: PI_PHCDRR_1_PRE Immunization Registry Reporting Active Engagement Level 1 | Public Health And Clinical Data Exchange | Required | |
Measure | Measure ID: PI_PHCDRR_1_PROD Immunization Registry Reporting Active Engagement Level 2 | Public Health And Clinical Data Exchange | Required | |
Measure | Measure ID: PI_PHCDRR_2 Syndromic Surveillance Reporting | Public Health And Clinical Data Exchange | Optional | |
Measure | Measure ID: PI_PHCDRR_2_PRE Syndromic Surveillance Reporting Active Engagement Level 1 | Public Health And Clinical Data Exchange | Required | |
Measure | Measure ID: PI_PHCDRR_2_PROD Syndromic Surveillance Reporting Active Engagement Level 2 | Public Health And Clinical Data Exchange | Required | |
Measure | Measure ID: PI_PHCDRR_3 Electronic Case Reporting | Public Health And Clinical Data Exchange | Required | |
Measure | Measure ID: PI_PHCDRR_3_EX_1 Electronic Case Reporting Exclusion | Public Health And Clinical Data Exchange | Optional | |
Measure | Measure ID: PI_PHCDRR_3_EX_2 Electronic Case Reporting Exclusion | Public Health And Clinical Data Exchange | Optional | |
Measure | Measure ID: PI_PHCDRR_3_EX_3 Electronic Case Reporting Exclusion | Public Health And Clinical Data Exchange | Optional | |
Measure | Measure ID: PI_PHCDRR_3_PRE Electronic Case Reporting Active Engagement Level 1 | Public Health And Clinical Data Exchange | Required | |
Measure | Measure ID: PI_PHCDRR_3_PROD Electronic Case Reporting Active Engagement Level 2 | Public Health And Clinical Data Exchange | Required | |
Measure | Measure ID: PI_PHCDRR_4 Public Health Registry Reporting | Public Health And Clinical Data Exchange | Optional | |
Measure | Measure ID: PI_PHCDRR_4_PRE Public Health Registry Reporting Active Engagement Level 1 | Public Health And Clinical Data Exchange | Required | |
Measure | Measure ID: PI_PHCDRR_4_PROD Public Health Registry Reporting Active Engagement Level 2 | Public Health And Clinical Data Exchange | Required | |
Measure | Measure ID: PI_PHCDRR_5 Clinical Data Registry Reporting | Public Health And Clinical Data Exchange | Optional | |
Measure | Measure ID: PI_PHCDRR_5_PRE Clinical Data Registry Reporting Active Engagement Level 1 | Public Health And Clinical Data Exchange | Required | |
Measure | Measure ID: PI_PHCDRR_5_PROD Clinical Data Registry Reporting Active Engagement Level 2 | Public Health And Clinical Data Exchange | Required | |
Measure | Measure ID: PI_PPHI_1 Security Risk Analysis | Protect Patient Health Information | Required | |
Measure | Measure ID: PI_PPHI_2 SAFER Guides High Priority Practices Guide | Protect Patient Health Information | Required |
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.
Quality | Description | Collection Type | Specification(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 | |
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 |
Looking for a different MVP? Head back to Explore MIPS Value Pathways (MVPs)