MH Measures

When you register with CUHSM, you get access to our QRDA toolkit that will recommend which measures to report.

(1) QPP measures can be pre-selected by establishing the size of the relevant patient panel. That is, if only 10 patients are eligible for a measure, it can be fewer abstractions to collect data on 9 individual measures for 8 patients.

(2) Complex QPP measures require multiple clinical metrics that require a more intensive .EHR data query.

QPP measures for Mental Health Professionals - 2016

The list below denotes the 2016 QPP measures that may be used by Behavioral health professionals depending upon the population they treat, the services they provide and the way in which they report.

About the CUHSM Mental (MH) and Behavioral Health (BH) measures:

Includes all possible combinations of QPP measures for Behavioral Health professionals,
(including individual and custom QCDR measures and any measures within Measure Groups, GPRO and ACO)
Measure selection is affected by specialty and storage method of patient records
(i.e. EHR or other method)
Our patient panel Measure Analyzer will help you through this process

Q: Some QPP measures (such as Measure #9) involves reporting on patients who have been prescribed, or at least evaluated for the use of antidepressant medication. How can psychologists who lack the authority to prescribe report on a measure that involves medication?

A: This measure is not limited to only the health care professional who prescribed the antidepressant medication.
If you are reporting through a QCDR and providing psychotherapy to a patient who suffers from depression and is taking antidepressant medication prescribed by a physician, you can report the measure.

Instructions:

Choose scope of QPP report:
- A targeted patient population will control the scope of your QPP submission.
- Using a measure with a denominator that correlates with your patient panel will reduce the number of patient records to be tabulated for your QPP submission.

General categories of denominator population definitions in QPP measures:

1. Over age 18
2. Over age 65
3. Restricted by condition(s) defined in specific QPP measure

FIGURE 1: QPP Measures - Patient Panel over age 18

No EHR?	Meas #	NQS Domain	Measure description
	9	ECC	Major depressive disorder: antidepressant medication during acute phase
	106	ECC	Major depressive disorder: diagnostic evaluation
	107	ECC	Major depressive disorder: suicide risk assessment
E	128	CPH	Body mass index
E/N	130	PS	Documentation and verification of current medications in the medical record
	131	CPH	Pain assessment prior to initiation of patient treatment
E/N	134	CPH	Screening for clinical depression
	173	CPH	Unhealthy alcohol use
	181	PS	Elder maltreatment screen and follow-up plan
E	182	CCC	Functional Outcome Assessment
E	226	CPH	Preventive care and screening: tobacco use � screening and cessation intervention
	247	ECC	Substance use disorders � counseling regarding psychosocial and pharmacologic treatment options for alcohol dependence
	248	ECC	Substance Use Disorders: Screening for Depression Among Patients with Substance Abuse or Dependence
E/N	280	CCC	Staging of dementia
E/N	281	ECC	Cognitive Assessment
E/N	282	ECC	Functional status assessment
E/N	284	ECC	Neuropsychological symptom assessment
E/N	285	ECC	Screening for depressive symptoms
E/N	287	ECC	Counseling regarding safety concerns
E/N	288	ECC	Caregiver education and support
	325	ECC	Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions

FIGURE 2: QPP Measures - Patient Panel - Over age 65

No EHR?	Meas #	NQS Domain	Measure description
E/N	47	CCC	Advanced care plan
	181	PS	Elder maltreatment screen and follow-up plan
E/N	182	CCC	Functional Outcome Assessment
E	226	CPH	Preventive care and screening: tobacco use � screening and cessation intervention
	247	ECC	Substance use disorders � counseling regarding psychosocial and pharmacologic treatment options for alcohol dependence
	248	ECC	Substance Use Disorders: Screening for Depression Among Patients with Substance Abuse or Dependence
	325	ECC	Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions

FIGURE 3: QPP Measures - Referral Patient Panel

No EHR?	Meas #	NQS Domain	Measure description

			Mental health referral - post surgery counseling
			Functional Deficit: Change in Risk-Adjusted Functional Status
E/N	46	PS	Patient Safety - Medication Reconciliation (after discharge)
E/N	182	CCC	Functional Outcome Assessment (PROMIS)
E/N	280	CCC	Staging of dementia
E/N	281	ECC	Cognitive Assessment
E/N	282	ECC	Functional status assessment
E/N	284	ECC	Neuropsychological symptom assessment
E/N	285	ECC	Screening for depressive symptoms
E/N	287	ECC	Counseling regarding safety concerns
E/N	288	ECC	Caregiver education and support

Psychologists who do not find any measures in this entire list to be applicable to their services and/or patient population are advised to contact the CMS QualityNet Help Desk for assistance. The QualityNet Help Desk is available Monday through Friday, 7 a.m.-7 p.m. CST, by telephone at (866) 288-8912 (TTY (877) 715-6222). Inquiries may be sent by email.

How do I decide what measures to report?

QPP measures for Mental Health Professionals - 2016

Q: Some QPP measures (such as Measure #9) involves reporting on patients who have been prescribed, or at least evaluated for the use of antidepressant medication. How can psychologists who lack the authority to prescribe report on a measure that involves medication?