for MVP Health Care Behavioral Health Providers...2019 HEDIS Coding Reference Guide for MVP Behavioral Health Providers 4 Metabolic Testing CPT Codes for Glucose Testing: 80047, 80048,

MVPPR0013 (09/2019)

2019 HEDIS Coding Reference & Medications by Measure Guidefor MVP Health Care®

Behavioral Health Providers

Contents

HEDIS Coding Reference Guide Medications By Measure

This Reference Guide is updated annually. Visit ncqa.org/hedis/measures for updates throughout 2019. Information obtained from the NCQA-Volume 2 Technical Specifications for both 2019 HEDIS Measures and Value Sets.Current Procedural Terminology ©2014 American Medical Association. All rights reserved. Current Procedural Terminology (CPT) and Uniform Bill (UB) codes are stated to the minimum specificity required.

Follow-up Care for Children Prescribed ADHD Medication (ADD) . . . . . . . . . . . . . . . . . . .1

Use of Multiple Concurrent Antipsychotics in Children and Adolescents (APC) . . . . . . .3

Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM). . . . . . . .4

Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

Antidepressant Medication Management (AMM) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

Follow-up after Emergency Department Visit for Alcohol and other Drug Dependence (FUA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

Follow-up After Hospitalization for Mental Illness (FUH) . . . . . . . . . . . . . . . . . . . . . . . . . .12

Follow-up After Emergency Department Visits for Mental Illness (FUM) . . . . . . . . . . . .14

Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence (AOD) Treatment (IET) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

Adherence to Antipsychotic Medications for Individuals with Schizophrenia (SAA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20

Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia (SMC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23

Diabetes Monitoring for People with Diabetes and Schizophrenia (SMD) . . . . . . . . . . .27

Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (SSD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31

Medications for ADHD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34

Antidepressant Medications for AMM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34

Antipsychotic Medications for APC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34

Antipsychotic Medications for APM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34

Antipsychotic Combination Medications List for APM . . . . . . . . . . . . . . . . . . . . . . . . . . . .35

Antipsychotic Medications for APP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35

Antipsychotic Combination Medications List for APP . . . . . . . . . . . . . . . . . . . . . . . . . . . .35

Medication Treatment for Alcohol Abuse or Dependence Medications List for IET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35

Medication List for SAA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35

Long-Acting Injections 14-Days Supply Medications List for SAA . . . . . . . . . . . . . . . . . .35

Long-Acting Injections 28-Days Supply Medications List for SAA . . . . . . . . . . . . . . . . . .35

Diabetes Medications List for SMD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36

Diabetes Medications List for SSD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36

Appropriate Care and Associated Codes to Bill

CPT Codes ICD–10 Codes HCPCS Codes UB Revenue

2019 HEDIS Coding Reference Guide for MVP Behavioral Health Providers 1

Follow-up Care for Children Prescribed ADHD Medication (ADD)The percentage of children (6–12 years of age) who are newly prescribed attention-deficit/hyperactivity disorder (ADHD) medication who had at least three follow-up care visits within a 10-month period, one of which was within 30 days of when the first ADHD medication was dispensed.

Two rates are reported:The first is the Initiation Phase: These are the members who are 6–12 years of age as of the prescription dispense date for ADHD medication and who had one follow-up visit with a practitioner with prescribing authority during the 30-day Initiation Phase.

The second is the Continuation and Maintenance (C&M) Phase: These are the members who are 6–12 years of age as of the prescription dispense date for ADHD medication and who remained on the medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two follow-up visits with a practitioner within 270 days (nine months) after the Initiation Phase ended.

Do not count a visit on the index prescription start date (IPSD) as the initiation phase visit.

Do not count visits billed with a telehealth modifier or telehealth POS code in the initiation phase visit.

Exclude members who are in hospice, who have a diagnosis of narcolepsy, or members who have had an acute inpatient encounter with a principal diagnosis for mental health or chemical dependency. The above applies to both the initiation and the Continuation and Maintenance phases.

Exclude from measure any member with an Acute Inpatient Encounter with a principal diagnosis of mental health or chemical dependency for both the Initiation or the Continuation and Maintenance Phase:Acute Inpatient Value Set Codes to exclude: 99221, 99222, 99223, 992231, 992232, 99233, 99238, 99239, 99251–99255, 99291

Any of the following code combinations billed by a practitioner with prescribing authority to meet criteria for the Initiation Phase:An outpatient visit with Visit Setting Unspecified codes:90791, 90792, 90832, 90833, 90834, 90836–90840, 90845, 90847, 90849, 90853, 90875, 90876, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99251–99255 and with outpatient POS codes: 03,05, 07, 09, 11–20, 22, 33, 49, 50, 71, 72

Code an outpatient visit with BH Outpatient Value Set codes:98960, 98961, 98962, 99078, 99201–99205, 99211–99215, 99241–99245, 99341–99345, 99347–99350, 99381–99387, 99391–99397, 99401–99404, 99411, 99412, 99510

Code observation visit with the Observation Value Set codes:99217–99220

Health and Behavior Assessment/Intervention Value Set:96150–96154For an intensive outpatient encounter or partial hospitalization, use the Visit Setting Unspecified Value Set with Partial Hospitalization POS Value Set: See above for Visit Setting Unspecified Value Set codes. For Partial Hospitalization POS Value Set, use code: 52

Exclude any member either in the Initiation or the Continuation and Maintenance Phases with the following codes for Mental Health diagnosis value sets with Acute Inpatient Encounter:F03.90, F03.91, F20.0–F20.5, F20.81, F20.89, F20.9,F21–F24, F25.0, F25.1, F25.8, F25.9, F28, F29, F30.10–F30.13, F30.2, F30.3, F30.4, F30.8, F30.9

Exclude any member either in the Initiation or the Continuation and Maintenance Phases with the following codes for Chemical Dependency Value Set with an Acute Inpatient Encounter:F10.10, F10.11, F10.120, F10.121, F10.14, F10.150, F10.151, F10.159, F10.180, F10.181, F10.182, F10.188, F10.19, F10.20, F10.21, F10.220, F10.221, F10.229, F10.230, F10.231, F10.232

Exclude any member with the following codes for Narcolepsy:G47.411, G47.419, G47.421, G47.429

When coding Outpatient Visit using BH Outpatient Value Set, the following are the BH outpatient codes:G1055, G0176, G0177, G0409, G0463, H0002, H0004, H0031, H0034, H0036, H0037, H0039, H0040, H2000, H2010, H2011, H2013–H2020, M0064

For Intensive Outpatient Encounter or Partial Hospitalization use:G0410, G0411, H0035, H2001, H2012, S0201, S9480, S9484, S9485

Exclude the following codes for Acute Inpatient Encounter:0100, 0101, 0110–0114, 0119–0124, 0129–0134, 0139–0143

The following can be used with the BH Outpatient Value set:0510, 0513, 0515, 0516, 0517, 0519–0523, 0526–0529, 0900, 0902, 0903, 0904, 0911, 0914–0917, 0919, 0982, 0983

For an Intensive Outpatient Encounter or Partial Hospitalization use:0905, 0907, 0912, 0913




Follow-up Care for Children Prescribed ADHD Medication (ADD) continued.

A community mental health center visit uses the Visit Setting Unspecified Value Set with the Community Mental Health Center POS Value Set. See above codes for Visit Setting Unspecified Value Set. The Community Mental Health Center POS Value Set code is: 53

For the Continuation and Maintenance Phase, only one of the two visits (during days 31–300) may be a phone or telehealth visit.The Phone Visits Value Set:98966, 98967, 98968, 99441, 99442, 99443

To identify telehealth visits, use Telehealth Modifier Value Set:95

GT with the Telehealth POS Value Set Code:02

For the Continuation and Maintenance phase, the following outpatient encounters will meet the criteria for phase two:An outpatient visit;An observation visit;A health and behavior assessment/intervention visit;An intensive outpatient encounter or partial hospitalization visit; andA community mental health center visitThe specific codes are noted above in the initiation phase.




Use of Multiple Concurrent Antipsychotics in Children and Adolescents (APC)Children and adolescents 1–17 years of age who were treated with different antipsychotic medications and were on two or more concurrent antipsychotic medications for at least 90 consecutive days during the measurement year.

Members in hospice are excluded from the eligible population.

A lower rate indicates better performance.




Metabolic TestingCPT Codes for Glucose Testing:80047, 80048, 80050, 80053, 80069, 82947, 82950, 82951

LOINC Codes for Glucose Testing:10450-5, 1492-8, 1494-4, 1496-9, 1499-3, 1501-6, 1504-0, 1507-3, 1514-9, 1518-0, 1530-5, 1533-9, 1557-8, 1588-6, 17865-7, 20436-2, 20437-0, 20438-8, 20440-4, 26554-6, 41024-1, 49134-0, 6749-6, 9375-7

CPT Codes for HbA1c Testing:83036, 83037

CPT-CAT II codes:3045F, 3046F

LOINC Codes for HbA1c Testing:17856-6, 4548-4, 4549-2

CPT Codes for Cholesterol Testing:82465, 83718, 84478

LOINC Codes for Cholesterol Testing:2085-9, 2093-3, 2571-8, 3043-7, 9830-1

CPT Codes for LDL-C Testing:80061, 83700, 83701, 83704, 83721

CPT-CAT II Codes:3048F, 3049F, 3050F

LOINC Codes for LDL-C Testing:12773-8, 13457-7, 18261-8, 18262-6, 2089-1, 49132-4, 55440-2.

Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM)Children and adolescents 1–17 years of age who had two or more antipsychotic prescriptions and had metabolic testing.

To qualify, you need at least two antipsychotic medications or antipsychotic combination medications dispensing events of the same or different medications on different dates of service during the measurement year.

Members need to have both a blood glucose or HbA1c, and an LDL-C or Cholesterol blood testing on the same or different dates of service during the measurement year.





Exclude members who had BH Stand Alone Acute Inpatient Value Set with ICD-10 values sets for Schizophrenia, Bipolar Disorder and other psychotic and developmental disorders (BH Stand Alone Acute Inpatient Value Set):0100, 0101, 0110, 0111–0114, 0119–0124, 0129–0134, 0139–0144, 0149–0154, 0159, 0160, 0167, 0169, 0200–0204, 0206–0214, 0219, 0720–0724, 0729, 0987

For BH Outpatient setting exclude:0510, 0513, 0515, 0516, 0517, 0519–0523, 0526–0529, 0900, 0902, 0903, 0904, 0911, 0914–0917, 0919, 0982, 0983

For an intensive outpatient encounter or partial hospitalization use:0905, 0907, 0912, 0913

Exclude Electroconvulsive Therapy Value Set:0901

Psychosocial Care Value Set with or without Telehealth Modifier:G0176, G0177, G0409, G0410, G0411, H0004, H0035–H0040, H2000, H2001, H2011–H2014, H2017–H2020, S0201, S9480, S9484, S9485

HCPCS Exclusion Criteria with CodesBH Outpatient value set to exclude:G0155, G0176, G0177, G0409, G0463, H0002, H0004, H0031, H0034, H0036, H0037, H0039, H0040, H2000, H2010, H2011, H2013–H2020, M0064, T1015

For an intensive outpatient encounter or partial hospitalization, exclude member using the Partial Hospitalization/Intensive Outpatient Value Set:G0410, G0411, H0035, H2001, H2012, S0201, S9480, S9484, S9485

Exclude members with diagnosis of schizophrenia, bipolar disorder and other psychotic and developmental disorders that had a BH standalone acute inpatient encounterSchizophrenia Value Set:F20.0–F20.5, F20.81, F20.89, F20.9, F25.0, F25.1, F25.8, F25.9

Bipolar Disorder Value Set:F30.10–F30.13, F30.2, F30.03, F30.4, F30.8, F30.9. F31.0, F31.10–F31.13, F31.2, F31.30, F31.31, F30.32, F31.4, F31.5, F31.61–F31.64, F31.70–F31.78

Other Psychotic and Developmental Disorders Value Set:F22, F23, F24, F28, F29, F32.3–F33.3, F84.0, F84.2, F84.3, F84.5, F84.8, F84.9, F95.0, F95.1, F95.2, F95.8, F95.9

Exclude Electroconvulsive Therapy:GZB0ZZZ, GZB1ZZZ, GZB2ZZZ, GZB3ZZZ, GZB4ZZZ

CPT Codes for Psychosocial Care Value Set with or without telehealth modifier:90832, 90833, 90834, 90836–90840, 90845, 90846, 90847, 90849, 90853, 90875, 90876, 90880

Telehealth Modifier CodeExclude members who had Visit Setting Unspecified Value Set:90791, 90792, 90832, 90833, 90834, 90836–90840, 90845, 90847, 90849, 90853, 90875, 90876, 99221, 99222, 99223, 99231–99233, 99238, 99239, 99251–99255 with Acute Inpatient POS Value Set 21, 51 with ICD-10 Value Sets for Schizophrenia Value Set, bipolar Disorder Value Set, and Other Psychotic and Developmental Disorders Value Sets. (See ICD-10 Column) with or without Telehealth Modifier Value Set: 95, GT

Exclude an outpatient visit that codes to the Visit Setting Unspecified Value Set above with Outpatient POS Value Set:03, 05, 07, 09, 11–20, 22, 33, 49, 50, 71, 72

Exclude BH Outpatient Value Set:98960, 98961, 98962, 99078, 99201–99205, 99211–99215, 99241–99245,99341–99345, 99347–99350, 99381–99387, 99401–99404, 99411, 99412, 99483, 99510

For members seen in intensive outpatient encounter or partial hospitalization use Visit Setting Unspecified Value Set noted above with Partial Hospitalization POS value Set:52

Exclude members seen in a community mental health center and use the Visit Setting Unspecified Value Set noted above with the Community Mental Health Center POS Value Set:53

Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP)


Children and adolescents 1–17 years of age who had a new prescription for an antipsychotic medication and had documentation of psychosocial care as first-line treatment.

Exclude members for whom first-line antipsychotic medications may be clinically appropriate. For example, at least one acute inpatient encounter with a diagnosis of schizophrenia, schizoaffective disorder, bipolar disorder, other psychotic disorder, autism, or other developmental disorder during the measurement year.

Exclude members who had at least two visits in an outpatient, intensive outpatient or partial hospitalization setting, on different dates of service, with a diagnosis of schizophrenia, schizoaffective disorder, bipolar disorder, other psychotic disorder, autism, or other developmental disorder during the measurement year. Any member with the following code combination with or without telehealth modifier meet exclusion criteria: members with ICD-10 codes for Schizophrenia Value Set, Bipolar Disorder Value Set, and Other Psychotic and Developmental Disorders Value Set.




Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP) continued.

Exclude members who have Electroconvulsive Therapy:90870 is the electroconvulsive therapy value set

Exclude members in an Observation Visit:99217–99220 observation value set codes




Identify all acute and non-acute inpatient stays value sets with a diagnosis of major depression:0100, 0101, 0110, 0111–0114, 0116–0119, 0120–0124, 0126–0134, 0136–0144, 0146–0154, 0160, 0164, 0167, 0169–0174, 0179, 0190–0194, 0199–0204, 0206–0214, 0219, 1000, 1001, 1002

When coding BH outpatient value sets use the following codes:0510, 0513, 0515–0517, 0519–0523, 0526–0529, 0900, 0902, 0903, 0904, 0911, 0914–0917, 0919, 0982, 0983

Intensive outpatient or partial hospitalization codes:0905, 0907, 0912, 0913

For Electro-convulsive Therapy visits using CPT and ICD-10 use the following code:0901

ED visits codes are0450–0452, 0456, 0459, 0981

BH outpatient value set codes:G0155, G0176, G0177, G0409, G04063, H0002, H0004, H0031, H0036, H0037, H0039, H0040, H2000, H2010, H2011, H2013–H2020, M0064, T1015

For intensive outpatient or partial hospitalization used:G0410, G0411, H0035, H2001, H2012, S0201, S9480, S9484, S9485

Major Depression Value Set:F32.0–F32.4, F32.9, F33.0–F33.3, F33.41, F33.9

Electro-convulsive Therapy Value Set Codes:GZB0ZZZ, GZB1ZZZ–GZB4ZZZ

One of the Major Depression Value Set Codes needs to be used with any of the possible encounters to be consider eligible population.

Use outpatient visit (Visit Setting Unspecified Value Set CPT codes with Outpatient POS Value Set) with Major Depression Value Set with or without Telehealth Modifier Value SetVisit Setting Unspecified codes:90791, 90792, 90832, 90833, 90834, 90836–90840, 90845, 90847, 90849, 90853, 90875, 90876, 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99251–99255

Outpatient POS Codes:03, 05, 07, 09, 11–20, 22, 33, 49, 50, 71, 72

Telehealth Modifier Value Set Codes:95, GT

Another outpatient visit uses the BH outpatient value set codes with major depression value set codes with or without telehealth modifier Value Set codes (telehealth codes are 95, GT) BH outpatient value set codes:98960, 98961, 98962, 99078, 99201–99205, 99211–99215, 99241–99245, 99341–99345, 99347–99350, 99381–99387, 99391–99397, 99401–99404, 99411, 99412, 99483, 99510(For BH outpatient visits also see HCPCS and UBREV columns for pertinent codes)

For intensive outpatient or partial hospitalization visits with any diagnosis of major depression, use the above CPT codes for visit setting unspecified with the Partial Hospitalization POS Value Set Code:52 with major depression value set codes (ICD-10) with or without telehealth modifier code: 95, GT. Also, for intensive outpatient encounter or partial hospitalization with any diagnosis of major depression, see HCPCS and UBREV columns for intensive outpatient value set with major depression value set diagnosis codes.

Antidepressant Medication Management (AMM)Members 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression, and who remained on an antidepressant medication treatment for 84–180 days (three to six months).

Eligible population would need to have a diagnosis of major depression and had an encounter in one of the following settings during the measurement time period: acute or non-acute inpatient stay; outpatient visit; intensive outpatient encounter or partial hospitalization; community mental health center visit; electro-convulsive therapy; trans-cranial magnetic stimulation visit; observation visit; ED visit; phone and telehealth visits.




Antidepressant Medication Management (AMM) continued.

With the community mental health center visit encounter with any diagnosis of major depression, use the above Visit Setting Unspecified Value Set codes with the Community Mental Health POS Value Set code:53 with the ICD-10 Major Depression Value Set codes with or without the telehealth modifier codes.

For Electro-Convulsive Therapy visit with any diagnosis of major depression, use the electro-convulsive therapy Value Set code:90870 and electro-convulsive therapy ICD-10 codes and major depression value set codes and a UBREV code

For Trans-cranial magnetic stimulation visits with any diagnosis of major depression use the trans-cranial magnetic stimulation Value Set codes:90867, 90868, 90869 with a major depression value set ICD-10 code

For Telehealth visits with any diagnosis of major depression use the CPT codes for Visit Setting Unspecified Value Set above along with the telehealth POS Value Set codes:02 and the ICD-10 codes for major depression with or without a telehealth modifier value set code: 95, GT

For an observation visit with any diagnosis of major depression use the Observation Value Set Codes:99217–99220 with the ICD-10 Major Depression Value Set Codes

For a ED visit with any diagnosis of major depression you may use the ED Value Set Codes:99281–99285 with UBREV codes and ICD-10 major depression codes or you may use for ED visits the Visit Setting Unspecified Value Set codes above with ED POS Value Set code: 23 with major depression value set ICD-10




Antidepressant Medication Management (AMM) continued.

codes with or without a telehealth modifier code

For a Telephone Visit use the Telephone Visit Value Set Codes:98966, 98967, 98968, 99441, 99442, 99443 along with the ICD-10 Major Depression Value Set Codes




IET Stand Alone visits codes:0510, 0513, 0515, 0516, 0517, 0519–0523, 0526–0529, 0900, 0902–0907, 0911–0917, 0919, 0944, 0945, 0982, 0983

IET Stand Alone Visit codes:G0155, G0176, G0177, G0396, G0397, G0409, G0410, G0411, G0443, G0463, H0001, H0002, H0004, H0005, H0007, H0015, H0016, H0022, H0031, H0034–H0037, H0039, H0040, H0047, H2000, H2001, H2010–H2020, H2035, H2036, M0064, S0201, S9480, S9484, S9485, T1006, T1012, T1015

Alcohol and Other Drug Dependence codes:F10.10, F10.120, F10.121, F10.129, F10.14, F10.150, F10.151, F10.159, F10.180, F10.181, F10.182, F10.188, F10.19, F10.20, F10.220, F10.221, F10.229, F10.230, F10.231, F10.232, F10.239, F10.24, F10.250, F10.251, F10.259, F10.26, F10.27, F10.280, F10.281, F10.282, F10.288, F10.29, 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, F11220, F11.221, F11.222, F11.229, F11.23, F11.24, F11.250, F11.251, F11.259, F11.281, F11.282, F11.288, F11.29, F12.10, F12.120, F12.121, F12.122, F12.129, F12.150, F12.151, F12.159, F12.180, F12.188, F12.19, F12.20, F12.220, F12.221, F12.222, F12.229, F12.23, F12.250, F12.251, F12.259, F12.280, F12.288, F12.29, F13.10, F13.120, F13.121, F13.129, F13.14, F13.150, F13.151, F13.159, F13.180, F13.181, F13.182, F13.188, F13.19, F13.20, F13.220, F13.221, F13.229, F13.230, F13.231, F13.232, F13.239, F13.24, F13.250, F13.251, F13.259, F13.26, F13.27, F13.280, F13.281, F13.282, F13.288, F13.29, F14.10, F14.120, F14.121, F14.122, F14.129, F14.14, F14.150, F14.151, F14.159, F14.180, F14.181, F14.182, F14.188, F14.19, F14.20, F14.220, F14.221, F14.222, F14.229, F14.23, F14.24, F14.250, F14.251, F14.259, F14.280, F14.281, F14.282, F14.288, F14.29, F15.10, F15.120, F15.121, F15.122, F15.129, F15.14, F15.150, F15.151, F15.159, F15.180, F15.181, F15.182, F15.188, F15.19, F15.20, F15.220, F15.221, F15.222, F15.229, F15.23, F15.24, F15.250, F15.251, F15.259, F15.280, F15.281, F15.282, F15.288, F15.29, F16.10, F16.120, F16.121, F16.122, F16.129, F16.14, F16.150, F16.151, F16.159, F16.180, F16.183, F16.188, F16.19, F16.20, F16.220, F16.221,

IET standalone visits value set with a principal diagnosis of AOD abuse or dependence with or without telehealth modifier value sets:98960, 98961, 98962, 99078, 99201–99205, 99211–99215, 99241–99245, 99341–99345, 99347–99350, 99384–99387, 99394–99397, 99401–99404, 99408, 99409, 99411, 99412, 99483, 99510

IET Visits Group 1 Value Set with IET POS Group 1 Value Set and a principal diagnosis of AOD abuse or dependence with or without a telehealth modifier:90791, 90792, 90832, 90833, 90834, 90836–90840, 90845, 90847, 90849, 90853, 90875, 90876

IET POS Group 1 Value Set:2, 3, 5, 7, 9, 11–20, 22, 33, 49, 50, 52, 53, 57, 71, 72

Telehealth Modifier Value Set:95, GT

IET visits Group 2 Value Set with IET POS Group 2 Value Set and a principal diagnosis of AOD abuse or dependence with or without a telehealth modifier:IET Visits Group 2 codes:99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99251–99255

IET POS Group 2 Value Set:02, 52, 53

An Observation visit with a principal diagnosis of AOD abuse or dependence use the Observation Value Set codes with the AOD Abuse and Dependence ICD-10 Value Set:99217–99220

Phone Visits Value Set with principal diagnosis of AOD abuse or dependence with or without a telehealth modifier:98966, 98967, 98968, 99441, 99442, 99443

Follow-up after Emergency Department Visit for Alcohol and other Drug Dependence (FUA)The percentage of emergency department (ED) visits for members 13 years of age and older with a principal diagnosis of alcohol, or other drug (AOD) abuse or dependence, who had a follow up visit for AOD.

Two rates are reported:

1. Percentage of ED visits for which the member received follow-up within 30 days of the ED visit (31 total days).

2. The percentage of ED visits for which the member received follow-up within seven days of the ED visit (eight total days).

Members with detoxification-only chemical dependency benefits do not meet these criteria. To be eligible, the member would need an ED visit with a principal diagnosis of alcohol or other drug (AOD) abuse or dependence.

Exclude ED visits that result in an inpatient stay and ED visits followed by an admission to an acute or non-acute inpatient care setting on the date of the ED visit or within the 30 days after the ED visit, regardless of principal diagnosis for the admission.




Follow-up after Emergency Department Visit for Alcohol and other Drug Dependence (FUA) continued.

F16.229, F16.24, F16.250, F16.251, F16.259, F16.280, F16.283, F16.288, F16.29, F18.10, F18.120, F18.121, F18.129, F18.14, F18.150, F18.151, F18.159, F18.17, F18.180, F18.188, F18.19, F18.20, F18.220, F18.221, F18.229, F18.24, F18.250, F18.251, F18.259, F18.27, F18.280, F18.288, F18.29, F19.10, F19.120, F19.121, F19.122, F19.129, F19.14, F19.150, F19.151, F19.159, F19.16, F19.17, F19.180, F19.181, F19.182, F19.188, F19.19, F19.20, F19.220, F19.221, F19.222, F19.229, F19.230, F19.231, F19.232, F19.239, F19.24, F19.250, F19.251, F19.259, F19.26, F19.27, F19.280, F19.281, F19.282, F19.288, F19.29

Online Assessments Value Set with a principal diagnosis of AOD abuse or dependence:98969, 99444




BH Outpatient Visit codes:0510, 0513, 0515, 0516, 0517, 0519–0523, 0526–0529, 0900, 0902, 0903, 0904, 0911, 0914–0917, 0919, 0982, 0983

For Intensive outpatient encounter or Partial hospitalization use codes:0905, 0907, 0912, 0913

Electroconvulsive Therapy code:0901

Use the following HCPCS codes when coding the BH outpatient value set and replace the highlighted HCPC’s codes with the following:G0155, G0176, G0177, G0409, G04063, H0002, H0004, H0031, H0036, H0037, H0039, H0040, H2000, H2010, H2011, H2013-H2020, M0064, T1015

For intensive outpatient or partial hospitalization used:G0410, G0411, H0035, H2001, H2012, S0201, S9480, S9484, S9485

For both the 30 and 7 day follow-up with a mental health practitioner, the following meet criteria:Outpatient visit (visit setting unspecified value set) with outpatient POS Value Set with a mental health practitioner with or without a telehealth modifier: Visit Setting Unspecified codes:90791, 90792, 90832, 90833, 90834, 90836–90840, 90845, 90847, 90849, 90853, 90875, 90876, 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99251–99255

Outpatient POS Codes:03, 05, 07, 09, 11–20, 22, 33, 49, 50, 71, 72

Telehealth Modifier Value Set codes:95, GT

Another outpatient visit uses the BH outpatient value set codes with mental health practitioner, with or without telehealth modifier value set codes (telehealth codes are 95, GT). BH outpatient value set codes:98960, 98961, 98962, 99078, 99201–99205, 99211–99215, 99241–99245, 99341–99345, 99347–99350, 99381–99387, 99391–99397, 99401–99404, 99411, 99412, 99483, 99510 (for BH outpatient visits also see HCPCS and UBREV columns for pertinent codes)

Intensive outpatient encounter or partial hospitalization use the visit setting unspecified value set codes (see above) with Partial hospitalization POS Value Set codes (Code 52) with a mental health practitioner, with or without a telehealth modifier (see above). When you use an intensive outpatient encounter or partial hospitalization value set codes, see HCPCS and UBREV for appropriate partial hospitalization/intensive outpatient value set codes:

Follow-up After Hospitalization for Mental Illness (FUH)The percentage of discharges for members six years of age and older who were hospitalized for treatment of selected mental illness or intentional self-harm diagnoses, and who had a follow-up visit with a mental health practitioner.


1. Percentage of discharges for which the member received follow-up within 30 days after discharge.

2. Percentage of discharges for which the member received follow-up within seven days after discharge.

Do not count the day of discharge from the acute inpatient hospital when establishing date for the 7/30-day follow-up with a mental health practitioner.

To be eligible for the denominator of this measure, the member must have been discharge from an acute inpatient hospital (see UBREV codes for Inpatient stay) with a principal diagnosis of mental illness (see ICD-10 codes) or intentional self-harm (see ICD-10 codes).

Mental Health Diagnosis Value Set:F20.0, F20.1, F20.2, F20.3, F20.5, F20.81, F20.89, F20.9, F21, F22, F23, F24, F25.0, F25.1, F25.8, F25.9, F28, F29, F30.10, F30.11, F30.12 F30.13, F30.2, F30.3, F30.4, F30.8, F30.9, F31.0, F31.10, F31.11, F31.12, F31.13, F31.2, F31.30, F31.31, F31.32, F31.4, F31.5, F31.60, F31.61, F31.62, F31.63, F31.64, F31.70, F31.71, F31.72 F31.73, F31.74, F31.75, F31.76, F31.77, F31.78, F31.81, F31.89, F31.9, F32.0, F32.1, F32.2, F32.3, F32.4, F32.5, F32.8, F32.81, F32.89, F32.9, F33.0, F33.1, F33.2, F33.3, F33.40, F33.41, F33.42, F33.8, F33.9, F34.0 F34.1, F34.8, F34.81, F34.89, F34.9, F39, F40.00, F40.01, F40.02, F40.10, F40.11, F40.210, F40.218, F40.220, F40.228, F40.230-F40.233, F40.240-F40.243, F40.248, F40.290, F40.291, F40.298, F40.8, F40.9, F41.0, F41.1, F41.3, F41.8, F41.9, F42, F42.2, F42.3, F42.4, F42.8, F42.9, F43.0, F43.10, F43.11, F43.12, F43.20, F43.21, F43.22, F43.23, F43.24, F43.25, F43.29, F43.8, F43.9, F44.0-F44.2, F44.4–F44.7, F44.81, F44.89, F44.9, F45.0, F45.1, F45.20-F45.22, F45.29, F45.41, F45.42, F45.8, F45.9, F48.1, F48.2, F48.8, F48.9, F50.00–F50.02, F50.2, F50.8, F50.81, F50.82, F50.89, F50.9, F51.01-F51.05, F51.09, F51.11-F51.13, F51.19, F51.3, F51.4, F51.5, F51.8, F51.9, F52.0, F52.1, F52.21, F52.22, F52.31, F52.32, F52.4, F52.5, F52.6, F52.8, F52.9, F53, F53.0, F53.1, F59, F60.0, F60.1, F60.2, F60.3, F60.4, F60.5, F60.6, F60.7, F60.81, F60.89, F60.9 F63.0, F63.1, F63.2, F63.3, F63.81, F63.89, F63.9, F64.0, F64.1, F64.2, F64.8, F64.9, F65.0-F65.4, F65.50, F65.51, F65.52, F65.81, F65.82, F65.9, F66. F68.10, F68.11, F68.12, F68.13, F68.8, F68.A, F69, F80.0-F80.4, F80.81, F80.82, F80.89, F80.9, F81.0, F81.2, F81.81, F81.89, F81.9, F82. F84.0, F84.2, F84.3, F84.5, F84.8, F84.9, F88, F89. F90.0, F90.1, F90.2, F90.8, F90.9,




Follow-up After Hospitalization for Mental Illness (FUH) continued.

F91.0, F91.1, F91.2, F91.3, F91.8, F91.9, F93.0, F93.8, F93.9, F94.0, F94.1, F94.2, F94.8, F94.9. F95.0-F95.2, F95.8, F95.9, F98.0, F98.1, F98.21, F98.29, F98.3, F98.4, F98.5, F98.8, F98.9, F99

Intention Self-Harm Value Set:This grouping is over 4000 codes. The following are the categories that make up these codes:T14 Category, T36 Category–T65 Category, and T71 Category

Electroconvulsive therapy codes:GZB0ZZZ–GZB4ZZZ

Community mental health center visit uses the visit setting unspecified value set codes (see above) with the Community Mental Health Center POS Value Set code (53) with a mental health practitioner, with or without a telehealth modifier code (see above).For Electro-Convulsive Therapy visit use Electroconvulsive Therapy value set code:(90870) with Ambulatory Surgical Center POS Value Set (24); Community Mental Health Center POS value set (53); Outpatient POS value set (03, 05, 07, 09, 11–20, 22, 33, 49, 50, 71, 72); and Partial Hospitalization POS value set code (52) with a mental health practitioner.See electroconvulsive therapy ICD-10 codes and UBREV code.

A telehealth visit uses the Visit setting unspecified value set (see above) with a Telehealth POS Value Set code (02), with a mental health practitioner, with or without a telehealth modifier code (see above).For an Observation visit with a mental health practitioner use the Observation value set codes:99217–99220

For Transitional care management services, use the transitional care management services value set codes:99495, 99496 with a mental health practitioner, with or without a telehealth modifier code (see above)




ED Visit codes:0450, 0451, 0452, 0456, 0459, 0981

BH Outpatient Visit codes:0510, 0513, 0515, 0516, 0517, 0519–0523, 0526–0529, 0900, 0902, 0903, 0904, 0911, 0914–0917, 0919, 0982, 0983

Intensive Outpatient Encounter or Partial Hospitalization codes:0905, 0907, 0912, 0913

Electroconvulsive Therapy code:0901

BH Outpatient Visit codes:G0155, G0176, G0177, G0409, G0463, H0002, H0004, H0031, H0034, H0036, H0037, H0039, H0040, H2000, H2010, H2011, H2013-H2020, M0064, T1015

Intensive Outpatient Encounter or Partial Hospitalization codes:G0410, G0411, H0035, H2001, H2012, S0201, S9480, S9484, S9485

Mental Health Diagnosis Codes:F03.90, F03.91, F20.0, F20.1, F20.2, F20.3, F20.5, F20.81, F20.89, F20.9, F21, F22, F23, F24, F25.0, F25.1, F25.8, F25.9, F28, F29, F30.10, F30.11, F30.12 F30.13, F30.2, F30.3, F30.4, F30.8, F30.9, F31.0, F31.10, F31.11, F31.12, F31.13, F31.2, F31.30, F31.31, F31.32, F31.4, F31.5, F31.60, F31.61, F31.62, F31.63, F31.64, F31.70, F31.71, F31.72 F31.73, F31.74, F31.75, F31.76, F31.77, F31.78, F31.81, F31.89, F31.9, F32.0, F32.1, F32.2, F32.3, F32.4, F32.5, F32.8, F32.81, F32.89, F32.9, F33.0, F33.1, F33.2, F33.3, F33.40 F33.41, F33.42, F33.8, F33.9, F34.0 F34.1, F34.8, F34.81, F34.89, F34.9, F39, F40.00, F40.01 F40.02, F40.10, F40.11, F40.210, F40.218, F40.220, F40.228, F40.230, F40.231, F40.232, F40.233, F40.240, F40.241, F40.242, F40.243, F40.248, F40.290, F40.291, F40.298, F40.8, F40.9, F41.0, F41.1, F41.3, F41.8, F41.9, F42, F42.2–F42.4, F42.8, F42.9, F43.0, F43.10, F43.11, F43.12, F43.20, F43.21, F43.22, F43.23, F43.24, F43.25, F43.29, F43.8, F43.9, F44.0, F44.1, F44.2, F44.4, F44.5, F44.6, F44.7, F44.81, F44.89, F44.9, F45.0, F45.1, F45.20, F45.21, F45.22, F45.29, F45.41, F45.42, F45.8, F45.9, F48.1, F48.2, F48.8, F48.9, F50.00, F50.01, F50.02, F50.2, F50.8, F50.81, F50.89, F50.9, F51.01 F51.02, F51.03, F51.04, F51.05, F51.09, F51.11, F51.12, F51.13, F51.19, F51.3, F51.4, F51.5, F51.8, F51.9, F52.0, F52.1, F52.21, F52.22, F52.31, F52.32, F52.4, F52.5, F52.6, F52.8, F52.9, F53, F59, F60.0, F60.1, F60.2, F60.3, F60.4, F60.5, F60.6, F60.7, F60.81, F60.89, F60.9 F63.0, F63.1, F63.2, F63.3, F63.81, F63.89, F63.9, F64.0, F64.1, F64.2, F64.8, F64.9, F65.0, F65.1, F65.2, F65.3, F65.4, F65.50, F65.51, F65.52, F65.89, F65.9, F66, F68.10–68.13, F68.8, F69, F80.0, F80.1, F80.2, F80.4, F80.81, F80.82, F80.89, F80.9, F81.0, F81.2, F81.81, F81.89, F81.9, F82, F84.0-F84.3, F84.5, F84.8, F84.9,

The following criteria establishes the measure event for both the 30-day and seven day follow-up following an ED visit for mental illness or intentional self-harm with a mental health practitioner:ED Codes:99281–99285

For both indicators (30- and seven day follow-up), any of the following meet criteria for a follow-up visit.An outpatient visit (use visit setting unspecified value set codes: 90791, 90792, 90832, 90833, 90834, 90836–90840, 90845, 90847, 90849, 90853, 90875, 90876, 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99251–99255) with outpatient POS value set codes: (03, 05, 07, 09, 11–20, 22, 33, 49, 50, 71, 72) with a principal diagnosis of mental health diagnosis (see ICD-10 codes) with or without telehealth modifier value set codes: 95, GT

Outpatient Visit (use BH Outpatient Value Set:98960, 98961, 98962, 99078, 99201–99205, 99211–99215, 99241–99245, 99341–99345, 99347–99350, 99381–99387, 99391–99397, 99401–99404, 99411, 99412, 99483, 99510 with a principal diagnosis of a mental health disorder (see ICD-10 Codes) with or without telehealth modifier codes 95, GT

Intensive Outpatient Encounter or Partial Hospitalization (use the Visit Setting Unspecified Value Set Codes above) with the Partial Hospitalization POS Value Set code:(52) with a principal diagnosis of a mental health disorder (see ICD-10 codes), with or without telehealth modifier: 95,GT

Follow-up After Emergency Department Visits for Mental Illness (FUM)The percentage of emergency department (ED) visits for members six years of age and older with a principal diagnosis of mental illness or intentional self-harm, who had a follow-up visit for mental illness.


1. The percentage of ED visits for which the member received follow-up within 30 days of the ED visit (31 total days counting the day of the ED visit plus 30 days after).

2. The percentage of ED visits for which the member received follow-up within seven days of the ED visit (eight total days).

To establish the event the member must have had an ED visit (use ED value set) with a principal diagnosis of mental illness or intentional self-harm (use mental illness or intentional self-harm value set). The member must be six years of age or older on the day of the ED visit.

Exclude ED visits that result in an inpatient stay or admission to an acute or non-acute inpatient care setting on the date of the ED visit or within 30 days after the ED visit (31 total days) regardless of the principal diagnosis.




Follow-up After Emergency Department Visits for Mental Illness (FUM) continued.

F88, F89, F90.0, F90.1, F90.2, F90.8, F90.9, F94.0, F94.1, F94.2, F94.8, F94.9, F95.0, F95.1, F95.2, F95.8, F95.9, F98.0, F98.1, F98.21, F98.29, F98.3, F98.4, F98.5, F98.8, F98.9, F99

Intention Self-Harm Value Set: This grouping is over 4000 codes. The following are the categories that make up these ICD-10 Codes:T14 Category, T36 Category–T65 Category, and T71 Category

Electroconvulsive therapy ICD-10 PCS codes:GZB0ZZZ–GZB4ZZZ

Intensive outpatient encounter or partial hospitalization using the partial hospitalization/intensive outpatient value set codes:(See HCPCS and UBREV Codes), with a principal diagnosis of a mental health disorder (see the ICD-10 Codes).

Community mental health center visit: use the visit setting unspecified value set codes (see above) with the community mental health center POS value set:(53) with a principal diagnosis of a mental health disorder (see ICD-10 codes for mental health disorder), with or without telehealth modifier codes: 95, GT

Electroconvulsive Therapy (use electroconvulsive therapy value set code: (90870) (see ICD-10 codes for specific electroconvulsive ICD-10 PCS codes and see UBREV code column for applicable UBREV code) with the Ambulatory Surgical Center POS Value Set code:(24), Community Mental Health Center POS Value Set Code: (53), Outpatient POS Value Set Codes: (03, 05, 07, 09, 11–20, 22, 33, 49, 50, 71, 72), and the Partial Hospitalization POS Code: (52) with the principal diagnosis of mental health disorder(see the ICD-10 mental health diagnosis value set codes)

Telehealth Visit:Use the visit setting unspecified value set (see above) with telehealth POS value set code: (02) with the principal diagnosis of a mental health disorder (use ICD-10 mental health diagnosis value set codes) with or without telehealth modifier value set codes: (95, GT)

Observation Visit:Use the observation value set codes: (99217–99220) with the principal diagnosis of a mental health disorder (see ICD-10 mental health diagnosis codes)




Alcohol Abuse and Dependence:F10.10, F10.120, F10.121, F10.129, F10.14, F10.150, F10.151, F10.159, F10.180, F10.181, F10.182, F10.188, F10.19, F10.20, F10.220, F10.221, F10.229-F10.232, F10.239, F10.24, F10.250, F10.251, F10.259, F10.26, F10.27, F10.280-F10.282, F10.288, F10.29

Opioid Abuse and Dependence: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, F11.220, F11.221, F11.222, F11.229, F11.23, F11.24, F11.250, F11.251, F11.259, F11.281, F11.282, F11.288, F11.29

Other Drug Abuse and Dependence Codes:F12.10, F12.120, F12.121, F12.122, F12.129, F12.150, F12.151, F12.159, F12.180, F12.188, F12.19, F12.20, F12.220, F12.221, F12.222, F12.229, F12.23, F12.250, F12.251, F12.259, F12.280, F12.288, F12.29, F13.10, F13.120, F13.121, F13.129, F13.14, F13.150, F13.151, F13.159, F13.180, F13.181, F13.182, F13.188, F13.19, F13.20, F13.220, F13.221, F13.229, F13.230, F13.231, F13.232, F13.239, F13.24, F13.250, F13.251, F13.259, F13.26, F13.27, F13.280, F13.281, F13.282, F13.288, F13.29, F14.10, F14.120, F14.121, F14.122, F14.129, F14.14, F14.150, F14.151, F14.159, F14.180, F14.181, F14.182, F14.188, F14.19, F14.20, F14.220, F14.221, F14.222, F14.229, F14.23, F14.24, F14.250, F14.251, F14.259, F14.280, F14.281, F14.282, F14.288, F14.29, F15.10, F15.120, F15.121, F15.122, F15.129, F15.14, F15.150, F15.151, F15.159, F15.180, F15.181, F15.182, F15.188, F15.19, F15.20, F15.220, F15.221, F15.222, F15.229, F15.23, F15.24, F15.250, F15.251, F15.259, F15.280, F15.281, F15.282, F15.288, F15.29, F16.10, F16.120, F16.121,

Use the following IET Stand Alone Visits HCPCS codes with the appropriate ICD-10 codes:G0155, G0176, G0177, G0396, G0397, G0409, G0410, G0411, G0443, G0463, H0001, H0002, H0004, H0005, H0007, H0015, H0016, H0022, H0031, H0034–H0037, H0039, H0040, H0047, H2000, H2001, H2010, H2011, H2013–H2020, H2035, H2036, M0064, S0201, S9480, S9484, S9485, T1006, T1012, T1015

If the Index episode was for a diagnosis of Alcohol Abuse or Dependence or Opioid Abuse or Dependence with a medication treatment dispensing event or treatment during a visit use:H0020, H0033, J0571–J0575, J2315, S0109

For Acute or Non-Acute Inpatient Admissions use Inpatient Stay alone Value Sets with one of the following ICD-10 value sets: Alcohol Abuse and Dependence, Opioid Abuse and Dependence or Other Drug Abuse and Dependence.Inpatient Codes:0100, 0101, 0110–0114, 0116–0124, 0126–0134, 0136–0144, 0146–0154, 0156–0160, 0164, 0167, 0169–0174, 0179, 0190–0194, 0199, 0200–0204, 0206–0214, 0219, 1000, 1001, 1002

IET Stand Alone Visits:0510, 0513, 0515, 0516, 0517, 0519–0523, 0526–0529, 0900, 0902–0907, 0911–0917, 0919, 0944, 0945, 0982, 0983

ED Codes:0450, 0451, 0452, 0456, 0459, 0981

Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence (AOD) Treatment (IET)The percentage of adolescent and adult members 13 years and older with a new episode of alcohol or other drug (AOD) abuse or dependence who received the following:

Initiation of AOD Treatment:The percentage of members who initiate treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization, telehealth or medication treatment within 14 days of the diagnosis;

Or

Engagement of AOD Treatment:The percentage of members who initiated treatment and who had two or more additional AOD services or medication treatment within 34 days of the initiation visit.

Definition: IESD means Index Episode Start Date. For an outpatient, intensive outpatient, partial hospitalization, telehealth, detoxification or ED visit (not resulting in an inpatient stay), the IESD is the date of service. For an inpatient stay, the IESD is the date of discharge.

For an inpatient stay, the IESD is the date of discharge. For an ED and observation visits that results in an inpatient stay, the IESD is the date of the inpatient discharge (an AOD diagnosis is not required for the inpatient stay; use the diagnosis from the ED or observation visit to determine the diagnosis cohort).

Initiation of AOD treatment within 14 days of the IESD:ED Codes:(If the Index Episode was an inpatient discharge (or an ED visit that resulted in an inpatient stay), the inpatient stay is considered initiation of treatment and the member is compliant.)99281–99285

If the Index Episode was not an inpatient discharge, the member must initiate treatment on the IESD or in the 13 days after the IESD (14 total days). Any of the following code combinations, meet criteria for initiation: Acute or nonacute inpatient admission with diagnosis matching the IESD diagnosis cohort using one of the following:Alcohol Abuse and Dependence Value Set(See ICD-10 Codes for Alcohol Abuse and Dependence) Opioid Abuse and Dependence Value Set (see ICD-10 Codes under Opioid Abuse and Dependence) Other Drug Abuse and Dependence Value Set (see ICD-10 Codes for Other Drug Abuse and Dependence)To Identify Acute and Nonacute inpatient admissions: Identify all acute and nonacute inpatient stays (see UBREV codes for the Inpatient Stay Value Set) and identify the admission date for the stay.IET Stand Alone Visits Value Sets with Alcohol Abuse and Dependence, Opioid Abuse and Dependence or Other Drug Abuse and Dependence with or without Telehealth Modifier Value Set.98960, 98961, 98962, 99078, 99201–99205, 99211–99215, 99241–99245, 99341–99345, 99347–99350, 99384–99387, 99394–99397, 99401–99404, 99408, 99409, 99411, 99412, 99483, 99510




Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence (AOD) Treatment (IET) continued.

Telehealth Modifier Value Set codes:95 or GT

Observation Value Set (99217–99220) with a diagnosis matching the IESD diagnosis cohort using one of the following: Alcohol Abuse and Dependence Value Set, Opioid Abuse and Dependence Value Set, and Other Drug Abuse and Dependence Value Set. (See ICD-10 Codes)IET Visits Group 1 Value Set: (90791, 90792, 90832–90840, 90845, 90847, 90849, 90853, 90875, 90876) with IET POS Group 1 Value Set (02, 03, 05, 07, 09, 11-20, 22, 33, 49, 50, 52, 53, 57, 71, 72) and a diagnosis matching the IESD diagnosis cohort using one of the following: Alcohol Abuse and Dependence Value Set, Opioid Abuse and Dependence Value Set, Other Drug Abuse and Dependence Value Set with or with-out a telehealth modifier (95, GT).IET Visits Group 2 Value Set: (99221, 99222, 99223, 99231-99233, 99238, 99239, 99251–99255) with IET POS Group 2 Value Set (02, 52, 53) and a diagnosis matching the IESD diagnosis cohort using one of the following: Alcohol Abuse and Dependence Value Set, Opioid Abuse and Dependence Value Set, Other Drug Abuse and Dependence Value Set with or without a telehealth modifier (95, GT).A phone visit (98966, 98967, 98968, 99441, 99442, 99443) with a diagnosis matching the IESD diagnosis cohort using one the following: Alcohol Abuse and Dependence Value Set, Opioid Abuse and Dependence Value Set, Other Drug Abuse and Dependence Value Set.An online assessment value set (98969, 99444) with a diagnosis matching the IESD diagnosis cohort using one of the following: Alcohol Abuse and Dependence Value Set,

F16.122, F16.129, F16.14, F16.150, F16.151, F16.159, F16.180, F16.183, F16.188. F16.19, F16.20, F16.220, F16.221, F16.229, F16.24, F16.250, F16.251, F16.259, F16.280, F16.283, F16.288, F16.29, F18.10, F18.120, F18.121, F18.129, F18.14, F18.150, F18.151, F18.159, F18.17, F18.180, F18.188, F18.19, F18.20, F18.220, F18.221, F18.229, F18.24, F18.250, F18.251, F18.259, F18.27, F18.280, F18.288, F18.29, F19.10, F19.120, F19.121, F19.122, F19.129, F19.14, F19.150, F19.151, F19.159, F19.16, F19.17, F19.180, F19.181, F19.182, F19.188, F19.19, F19.20, F19.220, F19.221, F19.222, F19.229, F19.230, F19.231, F19.232, F19.239, F19.24, F19.250, F19.251, F19.259, F19.26, F19.27, F19.280, F19.281, F19.282, F19.288, F19.29





Opioid Abuse and Dependence Value Set, Other Drug abuse and Dependence Value Set.If the Index Episode was for a diagnosis of alcohol abuse or dependence a medication treatment dispensing event (see Medication Treatment for Alcohol Abuse or Dependence List) or medication treatment during a visit. (See HCPCS Codes)For Engagement of AOD Treatment identify all member compliant for the Initiation of AOD Treatment numerator. For those members who initiated treatment via an inpatient admission, the 34-day period for the two engagement visits begins the day after discharge.Identify members whose initiation of AOD treatment was a medication treatment event (see medication lists for Medication Treatment for Alcohol Abuse or Dependence or Medication List for Medication Treatment for Opioid Abuse or Dependence). These members are numerator compliant if they have two or more engagement events where only one can be an engagement medication treatment event.Next identify the remaining members whose initiation of AOD treatment was not a medication treatment event. These members are numerator compliant if they meet either of the following:* At least one engagement medication

treatment event or* At least two engagement visits.

(Note: Two engagement visits can be on the same date of service, but they must be with different providers in order to count as two events. An engagement visit on the same date of service as an engagement medication treatment event meets criteria as there is no requirement that they be with different providers.





To identify engagement, visit and assign appropriate codes use the same descriptions and medication treatment events used with the Initiation Visit.For the engagement visit medication treatment events use one or more medication treatment dispensing events beginning on the day after the initiation encounter through 34 days after the initiation event. For engagement visit with diagnosis of either alcohol abuse or dependence or opioid abuse or dependence use the same value sets and medication lists as used in the initiation event.




Use UB Rev codes for Behavioral Health (BH) Stand Alone Acute Inpatient Value Set with Schizophrenia Value Set under ICD-10 column.0100, 0101, 0110, 0111–0114, 0119–0124, 0129–0134, 0139–0144, 0149–0154, 0159, 0160, 0164, 0167, 0169, 0200–0204, 0206–0214, 0219, 0720–0724, 0729, 0987

Use the following UBREV codes with the BH Outpatient Value Set:0510, 0513, 0515, 0516, 0517, 0519–0523, 0526, 0529, 0900, 0902, 0903, 0904, 0911, 0914–0917, 0919, 0982, 0983

Use the following UBREV codes for Partial Hospitalization/Intensive Outpatient Value Set:0905, 0907, 0912, 0913

Electroconvulsive Therapy Code:0901

For ED visit use UBREV codes:0450, 0451, 0452, 0456, 0459, 0981

With the nonacute inpatient encounter using the BH stand alone nonacute inpatient CPT value set and HCPCS codes use the following UBREV codes:0118, 0128, 0138,0148, 0158, 0190–0194, 0199, 0524, 0525, 0550, 0551, 0552, 0559–0663, 0669, 1000, 1001, 1003, 1004, 1005

Use UB Rev ED Value Set with the ICD-10 Schizophrenia Value Set:0450, 0451, 0452, 0456, 0459, 0981

UB Rev BH Stand Alone Non-acute Inpatient Value Set with the ICD-10 Schizophrenia Value Set:0118, 0128, 0138, 0148, 0158, 0190–0194, 0199, 0524, 0525, 0550, 0551, 0552, 0559–0663, 1000, 1001, 1003, 1004, 1005

Use BH Outpatient HCPCS codes with the BH Outpatient CPT codes:G0155, G0176, G0177, G0409, G0463, H0002, H0004, H0031, H0034, H0036, H0037, HH0037, H0039, H0040, H2000, H2010, H2011, H2013–H2020, M0064, S0201, T1015

Partial Hospitalization/Intensive Outpatient encounters use codes:(G0410, G0411, H0035, H2001, H2012, S0201, S9480, S9484, S9485)

For nonacute inpatient encounter using BH standalone nonacute inpatient CPT values sets use:H0017, H0018, H0019, T2048

Schizophrenia Value Set codes to be used code combinations as noted in CPT Column:F20.0–F20.3, F20.5, F20.81, F20.89, F20.9, F25.0, F25.1, F25.8, F25.9Note the following Dementia codes for exclusion: F01.50, F01.51, F02.80, F02.81, F03.90, F03.91, F04, F10.27, F10.97, F13.27, F13.97, F18.17, F18.27, F18.97, F19.17, F19.27, F19.97, G30.0, G30.1, G30.8, G30.9, G31.83

Electroconvulsive Therapy codes:GZB0ZZZ-GZB4ZZZ (see UBREV codes).

Identify members with schizophrenia or schizoaffective disorder as those who met at least one of the following criteria during the measurement year:At least one acute inpatient en-counter with any diagnosis of schizophrenia or schizoaffective disorder. Use either of the following code combinations: BH Stand Alone Acute Inpatient Value Set (see UB Revenue Column for specific codes) with Schizophrenia Value Set (see ICD-10 Column) or Use this code combination Visit Setting Unspecified (codes 90791, 90792, 90832, 90833, 90834, 90836–90840, 90845, 90847, 90849, 90853, 90875, 90876, 99221, 99222, 99223, 99231, 99232, 99233, 99238, 992239, 99251–99255) with Acute Inpatient POS Value Set (21, 51) with the Schizophrenia Value Set (See ICD-10 Column).At least two visits in an outpatient, intensive outpatient, partial hospitalization, ED or nonacute inpatient setting, on different dates of service, with any diagnosis of schizophrenia or schizoaffective disorder. Two of the fol-lowing, with or without a telehealth Modifier Value Set (95, GT) meets criteria:An outpatient visit with any diagnosis of schizophrenia or schizoaffective disorder (see visit setting unspecified Value set CPT codes above)with outpatient POS Value Set (03, 05, 07, 09, 11–20, 22, 33, 49, 50, 71, 72) with Schizophrenia Value Set (see ICD-10 column).An outpatient visit with any diagnosis of schizophrenia or schizoaffective disorder (BH Outpatient Value Set): 98960, 98961, 98962,99078,99201–99205, 99211–99215, 99241–99245, 99341–99345, 99347–99350, 99381–99387, 99391–99397, 99401–9404, 99411, 99412, 99483,

Adherence to Antipsychotic Medications for Individuals with Schizophrenia (SAA)Members who are 19–64 years of age during the measurement year with Schizophrenia or schizoaffective disorder who were who were dispensed and remained on an antipsychotic medication for at least 80 % of the treatment period.

Exclude members who have a diagnosis of dementia (see ICD-10 column for the dementia codes to exclude).

Exclude members who did not have at least two antipsychotic medication dispensing events.




Adherence to Antipsychotic Medications for Individuals with Schizophrenia (SAA) continued.

99510, see HCPCS Column for BH outpatient codes) with Schizophrenia Value Set (see ICD-10 Column).An intensive outpatient encounter or partial hospitalization with any diagnosis of schizophrenia or schizoaffective disorder use Visit Setting Unspecified Value Set (see above CPT codes) with Partial Hospitalization POS Value Set codes (52) with Schizophrenia Value Set codes (see ICD-10 codes).An intensive outpatient encounter or partial hospitalization with any diagnosis of schizophrenia or schizoaffective disorder use Partial Hospitalization/Intensive Outpatient Value Set codes (see HCPCS and UBREV columns) with Schizophrenia Value Set (see ICD-10 Codes).A community mental health center visit with any diagnosis of schizophrenia or schizoaffective disorder use Visit Setting Unspecified Value Set (See CPT codes) with Community Mental Health Center POS Value Set (53) with Schizophrenia Value Set (See ICD-10 Codes).An electroconvulsive therapy 90870 (See also ICD-10 for Electroconvulsive therapy codes)An observation visit use the observation value set codes (99217–99220) with and diagnosis of schizophrenia or schizoaffective disorder. (See the ICD-10 Codes).An ED visit use the ED value Set codes (99281–99285 with the appropriate UBREV codes under the UB Revenue Column) with any diagnosis of schizophrenia or schizoaffective disorder (see ICD-10 codes).An ED visit with any diagnosis of schizophrenia or schizoaffective disorder use the visit setting unspecified value set codes (see above) with ED POS value set code




Adherence to Antipsychotic Medications for Individuals with Schizophrenia (SAA) continued.

(23) with the schizophrenia value set codes (see ICD-10 codes).A nonacute inpatient encounter using the BH Stand Alone Nonacute Inpatient Value Set codes (99304–99310, 99315–99318, 99324–99328, 99334–99337. See HCPCS and UBREV codes) with any diagnosis of schizophrenia or schizoaffective disorder using the schizophrenia value set ICD-10 codes.A nonacute inpatient encounter with any diagnosis of schizophrenia or schizoaffective disorder using the visit setting unspecified value set codes (see the CPT codes above) with the nonacute inpatient POS Value Set codes (31,32,56) with the schizophrenia value set codes. (See the ICD-10 codes)A telehealth visit with any diagnosis of schizophrenia or schizoaffective disorder using the visit setting unspecified value set codes (see above) with the telehealth POS value set code 02 with the schizophrenia value set codes (see the ICD-10 codes).




Codes to use with the BH Outpatient Value Set codes:G0155, G0176, G0177, G0409, G0463, H0002, H0004, H0031, H0036, H0037, H0039, H0040, H2000, H2010, H2011, H2013–H2020, M0064, T1015

Partial Hospitalization/Intensive Outpatient Value Set Codes:G0410, G0411, H0035, H2001, H2012, S0201, S9480, S9484, S9485

Use the following HCPCS codes with BH Stand Alone Nonacute Inpatient value set codes:H0017, H0018, H0019, T2048

When coding the CABG event use the following HCPCS codes:S2205–S2209

For the event PCI use the following codes:C9600, C9602, C9604, C9606, C9607

When coding the diagnosis of IVD with outpatient values set codes use the following codes:G0402, G0438, G0439, G0463, T1015

BH Stand Alone Nonacute Inpatient Value Set with Schizophrenia Value Set:H0017, H0018, H0019, T2048

CABG Value Set Codes:S2205–S2209

PCI Value Set Codes:C9600, C9602, C9604, C9606, C9607

Outpatient Value Set Codes use with the IVD ICD-10 Value Set Codes:G0402, G0438, G0439, G0463, T1015

BH Stand Alone Acute Inpatient Value Set UBREV codes use with the Schizophrenia Value Set codes under ICD-10 code:0112, 0113, 0114, 0119–0124, 0129–0134, 0139–0144, 0149–0152

Use the following codes with the appropriate BH Outpatient Value Set CPT codes and HCPCS codes:0510, 0513, 0515, 0516, 0517, 0519–0523, 0526–0529, 0900, 0902, 0903, 0904, 0911, 0914–0919, 0982, 0983

Partial Hospitalization/Intensive Outpatient Value Set codes:0905, 0907, 0912, 0913

Electroconvulsive therapy code:0901

ED visit use the value set codes:0450, 0451, 0452, 0456, 0549, 0981

Use the following UB Rev Codes with the BH Stand Alone Nonacute Inpatient value set codes:0118, 0128, 0138, 0148, 0158, 0190–0194, 0199, 0524, 0525, 0550-0552, 0559,0660-0663, 0669, 1000, 1001, 1003, 1004, 1005

In-patient Stay Value Set codes:0100, 0101, 0110–0114, 0116–0124, 0126–0134, 0136–0144, 0146–0154, 0156–0160, 0164, 0167, 0169–0174, 0179, 0190–0194, 0199–0204, 0206–0214, 0219, 1000, 1001, 1002

When coding the diagnosis IVD with the outpatient value set codes use the following codes:0510–0517, 0519–0523, 0526–0529, 0982, 0983

UB Rev codes to go with the acute Inpatient Value Set codes:0100, 0101, 0110–0114, 0119–0124, 0129–0134, 0139–0144, 0149–0154, 0159, 0160, 0164, 0167, 0169, 0200–0204, 0206–0214, 0219, 0720–0724, 0729, 0987

Schizophrenia Codes:F20.0–F20.3, F20.5, F20.81, F20.89, F20.9, F25.0, F25.1, F25.8, F25.9

Electroconvulsive therapy value set:GZB0ZZZ, GZB1ZZZ, GZB2ZZZ, GZB3ZZZ, GZB4ZZZMembers are identified as having cardiovascular disease in two ways: by event or by diagnosis.

For Event: Code AMI Val-ue Set with the Inpatient Stay Value Set:AMI Codes are: 121.01, 121.02, 121.09, 121.11, 121.19, 121.21, 121.29, 121.3, 121.4, 121.9, 121.A, 121.A9

For Event: Any of the fol-lowing during the year prior to the measurement year meet criteria:Code AMI Value Set with the Inpatient Stay Value Set. (Inpatient Stay Value Set codes see UB Rev column)For a CABG event code: Use the following ICD10PCS codes:0210083, 0210088, 0210089, 0210093, 0210098, 0210099, 0211083, 0211088, 0210089, 0211093, 0211098, 0211099, 0212083, 0212088, 0212089, 0212093, 0212098, 0212099, 0213083, 0213088, 0213089, 0213093, 0213098, 0213099, 021008C, 021008F, 021008W, 021009C, 021009F, 021009W, 02100A3, 02100A8, 02100A9, 02100AC, 02100AF, 02100AW, 02100J3, 02100J8, 02100J9, 02100JC, 02100JF, 02100JW, 02100K3, 02100K8, 02100K9, 02100KC, 02100KF, 02100KW, 02100Z3, 02100Z8, 02100Z9, 02100ZC, 02100ZF, 021108C, 021108F, 021108W, 021109C, 021109F, 021109W, 02110A3, 02110A8, 02110A9, 02110AC, 02110AF, 02110AW, 02110J3, 02110J8, 02110J9, 02110JC, 02210JF, 02110JW, 02110K32, 02110K8, 02110K9, 02110KC, 02110KF, 02110KW, 02110Z3, 02110Z8, 02110Z9, 02110ZC, 02110ZF, 021208C, 021208F, 021208W, 021209C, 021209F, 021209W, 02120A3,

Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia (SMC)Members 18–64 years of age with Schizophrenia or Schizoaffective Disorder and Cardiovascular Disease, who had an LDL-C test during the measurement year.

For the purpose of this measure, cardiovascular disease is defined either as a diagnosis of IVD (Ischemic Vascular Disease) or Inpatient treatment for AMI, CABG, or PCI.

Identify members with schizophrenia or schizoaffective disorder who meet at least one of the following criteria during the measurement year:At least one acute inpatient encounter with any diagnosis of schizophrenia or schizoaffective disorder. Either of the following code combinations meets criteria: BH Stand Alone Acute Inpatient Value Set (see under UB Revenue column) or Visit Setting Unspecified Value Set codes 90833–90840, 90845, 90847, 90849, 90853, 90875, 90876, 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99251, 99252, 99253 with the Acute Inpatient POS Value Set 21, 51 and with the Schizophrenia Value Set codes (see the ICD-10 codes).At least two visits in an outpatient, intensive outpatient, partial hospitalization, ED or nonacute inpatient setting, on different date of service, with any diagnosis of schizophrenia or schizoaffective disorder. Two of any of any of the following, with or without a telehealth modifier (95, GT) meets criteria:An outpatient visit with any diagnosis of schizophrenia or schizoaffective disorder using the Visit Setting Unspecified Vale Set (see above) with the Outpatient POS Value Set codes 03, 05, 07, 11–20, 22, 33, 49, 50, 71, 72 with the ICD-10 Schizophrenia codes.An outpatient visit with any diagnosis of schizophrenia or schizoaffective disorder with the BH Outpatient Value Set codes 98960, 98961, 98962, 99078, 99201–99205, 99211–99215, 99241–99245, 99341–99345, 99347–99350, 99381–99387, 99391–99387, 99401–99404, 99411, 99412, 99483, 99510 (see accompanying HCPCS and UB Revenue codes).




Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia (SMC) continued.

Must have at least two visits in an outpatient , intensive outpatient, partial hospitalization, ED or nonacute inpatient setting on different dates use the following codes:BH standalone outpatient /PH/IOP Value Set use with Schizophrenia Value Set Codes:0510, 0513, 0516, 0517, 0519–0523, 0526–0259, 0900–0905, 0907, 0911–0917, 0919, 0982, 0983

Code BH Stand Alone Nonacute Inpatient Value Set with Schizophrenia ICD-10 Value Set:0118, 0128, 0138, 0148, 0158, 0190–0194, 0199, 0524, 0525, 0550, 0551, 0552, 0559–0663, 0669, 1000–1005

Inpatient Stay Value Set Codes. Use with AMI Value Set and IVD Value Set:0100, 0101, 0110–0124, 0126–0134, 0136–0144, 0146–0154, 0156–0160, 0164, 0167, 0169-0174, 0179, 0190–0194, 0199–0204, 0206–0214, 0219, 1000, 1001, 1002

Outpatient Value Set Codes use with the IVD Value Set:0510–0517, 0519–0523, 0526–0529, 0982, 0983

Acute Inpatient Value Set Codes to be used with IVD Value Set codes under the ICD-10 column:0100, 0101, 0110–0114, 0119–0124, 0129–0134, 0139–0144, 0149–0154, 0159–0160, 0164, 0167, 0169, 0200–0204, 0206–0214, 0219, 0720–0724, 0729, 0987

02120A8, 02120A9, 02120AC, 02120AF, 02120AW, 02120J3, 02120J8, 02120J9, 02120JC, 02120JF, 02120JW, 02120K3, 02120K8, 02120K9, 02120KC, 02120KF, 02120KW, 02120Z3, 02120Z8, 02120Z9, 02120ZC, 02120ZF, 021308C, 021308F021208W, 021309C, 021309F, 021309W, 02130A3, 02130A8, 02130A9, 02130AC, 02130AF, 021030AW, 02130J3, 02130J8, 02130J9, 02130JC, 02130AF, 02130JW, 02130K3, 02130K8, 02130K9, 02130KC, 02130KF, 02130KW, 02130Z3, 02130Z8, 02130Z9, 02130ZC, 02130ZF (see CPT codes for CABG and HCPCS codes)

For the event PCI code, the following:0270346, 02704356, 0270366, 02703736, 0270446, 0270456, 0270466, 0270476, 0271346, 0271356, 0271366, 0271376, 0271446, 0271456, 0271466, 0271476, 0272346, 0272356, 0272366, 027376, 0272446, 0272456, 0272466, 0272476, 0273346, 0273356, 0273366, 0273376, 0273446, 0273456, 0273466, 0273476, 02703E6, 02704E6, 02713E6, 02714E6, 02723E6, 02724E6, 02733E6, 027034Z, 027035Z, 027036Z, 027037Z, 02703D6, 02703DZ, 02703EZ, 02703F6, 02703FZ, 02703G6, 02703GZ, 02703T6, 02703TZ, 02703Z6, 02703ZZ, 027044Z, 027045Z, 027046Z, 027047Z, 02704D6, 02704DZ, 02704EZ, 02704F6, 02704FZ, 02704G6, 02704GZ, 02704T6, 02704TZ , 02704Z6, 02704ZZ, 027134Z, 027135Z, 027136Z, 027137Z, 02713D6, 02713DZ,02713EZ, 02713F6, 02713FZ, 02713G6, 02713GZ, 02713T6, 02713TZ, 02713Z6, 02713ZZ, 027144Z, 027145Z, 027146Z, 027147Z, 02714D6, 02714DZ, 02714EZ, 02714F6, 02714FZ, 02714G6, 02714GZ, 02714T6, 02714TZ, 02714Z6, 02714ZZ, 027234Z, 027235Z, 027236Z, 027237Z, 02723D6, 02723DZ, 02723EZ, 02723F6, 02723FZ, 02723G6, 02723GZ, 02723T6, 02723TZ, 02723Z6, 02723ZZ, 027244Z, 027245Z, 027246Z, 027247Z, 02724D6, 02724DZ, 02724EZ, 02724F6, 02724FZ, 02724G6, 02724GZ,

An intensive outpatient encounter or partial hospitalization with any diagnosis of schizophrenia or schizoaffective disorder using the Visit Setting Unspecified Value Set codes (see the above CPT codes) with Partial Hospitalization POS Value Set code 52 and the ICD-10 Schizophrenia Value Set codes.An Intensive Outpatient Encounter or partial hospitalization with any diagnosis of schizophrenia or schizoaffective disorder use the Partial Hospitalization/Intensive Outpatient Value Set Codes (see HCPCS Codes and UB Rev Codes) and the Schizophrenia Value Set Codes (see ICD-10 codes).A Community Mental Health Center visit with any diagnosis of schizophrenia or schizoaffective disorder use Visit Setting Unspecified Value set codes (see above CPT codes) with Community Mental Health Center POS Value Set Code (53) with the Schizophrenia Value Set codes. (see ICD-10 codes).For Electroconvulsive therapy use the Electroconvulsive Therapy Value Set codes: For CPT codes it is 90870; See ICD-10 and UB Revenue codes.For an Observation visit use the Observation Value Set codes: 99217–99220 with any diagnosis of schizophrenia or schizoaffective disorder (see the schizophrenia value set codes under ICD-10).For an ED visit use the ED value set codes (the CPT codes are 99281–99285; see UB Revenue Codes) with any diagnosis of schizophrenia or schizoaffective disorder (See ICD-10 codes).For an ED visit with any diagnosis of schizophrenia or schizoaffective disorder use the Visit Setting Unspecified Value Set codes (see above) with the ED POS Value Set code





02724T6, 02724TZ, 02724Z6, 02724ZZ, 027334Z, 027335Z, 027336Z, 027337Z, 02733D6, 02733DZ, 02733EZ, 02733F6, 02733FZ, 02733G6, 02733GZ, 02733T6, 02733TZ, 02733Z6, 02733ZZ, 027344Z, 027345Z, 027346Z, 027347Z, 02734D6, 02734DZ, 02734EZ, 02734F6, 02734FZ, 02734G6, 02734GZ, 02734T6, 02734TZ, 02734Z6

For Diagnosis use the IVD diagnosis codes:I20.0, I20.8, I20.9, I24.0, I24.8, I24.9, I25.10, I25.110, I25.111, I25.118,I25.119, I25.5, I25.6,I25.700, I25.701, I25.708-I25.711, I25.718-I25.721, I25.728-I25.731, I25.738, I25.739, I25.750, I25.751, I25.758-I25.761, I25.768, I25.769, I25.790, I25.791, I25.798, I25.799, I25.810-I25.812, I25.82-I25.84, I25.89, I25.9, I63.20,I63.211-I63.213, I63.219, I63.22, I63.231-I63.233, I63.239, I63.29, I63.50, I63.511, I63.512, I63.513, I63.519, I63.521-I63.523, I63.529, I63.531-I63.533, I63.539, I63.541-I63.543, I63.549, I63.59, I65.01, I65.02, I65.03, I65.09, I65.1, I65.21, I65.22, I65.23, I65.29, I65.8, I65.9, 166.01, I66.02, I66.03, I66.09, I66.11, I66.12, I66.13, I66.19, I66.21–I66.23, I66.29, I66.3, I66.8, I66.9, I67.2, I70.1,I70.201–I70.203, I70.208-I70.213, I70.218, I70.219, I70.221–I70.223, I70.228, I70.229, I70.231–I70.235, I70.238, I70.239, I70.241–I70.245, I70.241, I70.249, I70.25, I70.261-I70.263, I70.268, I70.269, I70.291, -I70.293, I70.298, I70.299, I70.301–I70.303, I70.308, I70.309, I70.311–I70.313, I70.318, I70.319, I70.321,–I70.323, I70.328, I70.329, I70.331, I70.335, I70.338, I70.339, I70.341–I70.345, I70.348, I70.349, I70.35, I70.361-I70.363, I70.368, I70.369, I70.391, I70.392, I70.393, I70.398, I70.399, I70.401–I70.403, I70.408, I70.409, I70.411–I70.413, I70.418, I70.419, I70.421–I70.423, I70.428, I70.429,

(23) with the schizophrenia value set (see the ICD-10 codes).For a nonacute inpatient encounter use the BH Stand Alone Nonacute Inpatient Value Set codes: 99304–99310, 99315, 99316, 99318, 99324–99328, 99334–99337. See HCPCS and UB Rev codes to use with the BH Stand Alone Nonacute Inpatient Value Set codes.For a nonacute inpatient encounter with any diagnosis of schizophrenia or schizoaffective disorder you can use Visit Setting Unspecified Value Set codes (See Above) with the nonacute POS value set codes: (31, 32, 56) with the ICD-10 Schizophrenia Value Set codes.For a telehealth visit with any diagnosis of schizophrenia or schizoaffective disorder use the Visit Setting Unspecified Value Set codes (see above) with the Telehealth POS Value Set code (02) with Schizophrenia Value Set ICD-10 codes.For a CABG event use: 33510–33514, 33516–33519, 33521, 33522, 33523, 33533–33536For the event PCI use: 92920, 92924, 92928, 92933, 92937, 92941, 92143, 92980, 92982, 92995To identify members with IVD they need to have met at least either of the following criteria during both the measurement year and the year prior to the measurement year:At least one outpatient visit using the outpatient value set (99201–99205, 99211–99215, 99241–99245, 99341–99345, 99347–99350, 99381–99387, 99391–99397, 99401–99404, 99411, 99412, 99429, 99455, 99456, 99483) with a diagnosis of IVD (see the ICD-10 codes as well as HCPCS and UB Rev codes.A phone visit when identifying a member with diagnosis of IVD. Use the following phone codes: 98966, 98967,





I70.431–I70.435, I70.438, I70.439, I70.441–I70.345, I70.448, I70.449, I70.45, I70.461–I70.463, I70.468, I70.469, I70.491–I70.493, I70.498, I70.499,I70.501–I70.503, I70.508, I70.509, I70.511–I70.513, I70.518, I70.519, I70.521–I70.523, I70.528, I70.529, I70.531–I70.535, I70.538, I70.539, I70.541–I70.545, I70.548, I70.549, I70.55, I70.561–I70.563, I70.568, I70.569, I70.591–I70.593, I70.598, I70.599, I70.601–I70.603, I70.608, I70.609, I70.611–I70.613, I70.618, I70.619, I70.621–I70.623, I70.628, I70.629, I70.631–I70.635, I70.638, I70.639, I70.641–I70.645, I70.648, I70.649, I70.65, I70.661–I70.663, I70.668, I70.669, I70.691–I70.693, I70.698, I70.699, I70.701–I70.703, I70.708, I70.709, I70.711–I70.713, I70.718, I70.719, I70.721–I70.723, I70.728, I70.729, I70.731–I70.735, I70.738, I70.739, I70.741–I70.745, I70.748, I70.749, I70.75, I70.761–I70.763, I70.768, I70.769, I70.791–I70.793, I70.798, I70.799, I70.92, I75.01–I75.013, I75.019, I75.021–I75.023, I75.029, I75.81, I75.89, T82.855A, T82.855D, T82.855S, T82.856A, T82.856D, T82.856S

98968, 99441, 99442, 99443 with any of the ICD-10 IVD codes.An online assessment when identifying a member with a diagnosis of IVD. Use the following CPT codes: 98969, 99444 with the ICD-10 IVD codes.At least one acute inpatient encounter using the following: 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99251–99255, 99251; along with the appropriate UB Rev codes without telehealth.Only one of the two visits may be a telehealth visit, a phone visit or an online assessment. Identify telehealth visits by the presence of a telehealth modifier code 95 or GT or the presence of a telehealth POS code: 02

LDL-C Screening:80061, 83700, 83701, 83704, 83721

LDL-C Tests for LOINC:12773–8, 13457–7, 18261–8, 18262–6, 2089–1, 49132–4, 55440–2

LDL-C Tests for CPT-CAT-II codes:3048F, 3049F, 3050F




BH Stand Alone Acute Inpatient Value Set with the Schizophrenia ICD-10 Value Set Codes (note: use these UB Rev codes with the Acute Inpatient Value Set codes and Diabetes codes in Step 2):0100, 0101, 0110–0114, 0119–0124, 0129–0134, 0139–0144, 0149–0154, 0159–0160, 0164, 0167, 0169, 0200–0204, 0206–0214, 0219, 0720–0724,0729, 0987

For the outpatient visit use the BH Outpatient Value Set codes:0510, 0513, 0515, 0516, 0517, 0519–0523, 0526–0529, 0900, 0902, 0903, 0904, 0911, 0914–0917, 0919, 0982, 0983

For intensive outpatient encounter or partial hospitalizations use the Partial Hospitalization/Intensive Outpatient Value Set codes:0905, 0907, 0912, 0913

For Electroconvulsive Therapy use code:0901

For an ED Visit use codes:0450, 0451, 0452, 0456, 0459, 0981

For a nonacute inpatient encounter use the BH Stand Alone Nonacute Inpatient codes:0118, 0128, 0138, 0148, 0158, 0190–0194, 0199, 0524, 0525, 0550, 0551, 0552, 0559, 0660–0663, 0669, 1000, 1001, 1003, 1004, 1005

For outpatient encounter use codes:0510–0517, 0519–0523, 0527, 0528, 0529, 0982, 0983

For ED visits use codes:0450, 0451, 0452, 0456, 0459, 0981

When coding outpatient visit with BH Outpatient Value set codes use:G0155, G0176, G0177, G0409, G0463, H0002, H0004, H0031, H0034, H0036, H0037, H0039, H0040, H2000, H2010, H2011, H2013–H2020, M0064, T1015

For intensive outpatient encounters or partial hospitalizations use Partial Hospitalization/Intensives Outpatient Value Set Codes:G0410, G0411, H0035, H2001, H2012, HS0201, S9480, S9484, S9485

For a nonacute inpatient encounter use the BH Stand Alone Nonacute Inpatient codes:H0017, H0018, H0019, T2048

For the acute inpatient encounter use codes:G0402, G0438, G0439, G0463, T1015

Schizophrenia or Schizoaffective disorder codes:F20.0–F20.3, F20.5, F20.81, F20.89, F20.9, F25.0, F25.1, F25.8, F25.9

Electroconvulsive Therapy Codes:GZB0ZZZ, GZB1ZZZ, GZB2ZZZ, GZB3ZZZ, GZB4ZZZ

Diabetes:E10.10, E10.11, E10.21, E10.22, E10.29, E10.311, E10.319, E10.321, E10.3211, E10.3212, E10.3213, E10.3219, E10.329, E10.3291–E10.3293, E10.3299, E10.331, E10.3311–E10.3313, E10.3319, E10.339, E10.3391–E10.3393, E10.3399, E10.341, E10.3411–E10.3413, E10.3419, E10.349, E10.3491–E10.3493, E10.3499, E10.351, E10.3511–E10.3513, E10.3519, E10.3521–E10.3523, E10.3529, E10.3531–E10.3533, E10.3539, E10.3541–E10.3543, E10.3549, E10.3551–E10.3553, E10.3559, E10.359, E10.3591–E10.3593, E10.3599, E10.36, E10.37X1–E10.37X3, E10.37X9, E10.39, E10.40, E10.41, E10.42, E10.43, E10.44, E10.49, E10.51, E10.52, E10.59, E10.610, E10.618, E10.620, E10.621, E10.622, E10.628, E10.630, E10.638, E10.641, E10.649, E10.65, E10.69, E10.8, E10.9, E11.00, E11.01, E11.11, E11.21, E11.22, E11.29, E11.311, E11.319, E11.321, E11.3211–E11.3213, E11.3219, E11.329, E11.3291–E11.3293, E11.3299, E11.331, E11.3311–E11.3313, E11.3319, E11.339, E11.3391–E11.3393, E11.3399, E11.341, E11.3411–E11.3413, E11.3419, E11.349, E11.3491, E11.3492, E11.3493, E11.3499, E11.351, E11.3511–E11.3513, E11.3519– E11.3523, E11.3529, E11.3531–E11.3533, E11.3539, E11.3541–E11.3543, E11.3549, E11.3551–E11.3553, E11.3559, E11.359, E11.3591, E11.3592, E11.3593, E11.3599, E11.36, E11.37X1–E11.37X3, E11.37X9, E11.39, E11.40, E11.41, E11.42, E11.43,

There are two steps to identify the eligible population.Step 1:Identify members with schizophrenia or schizoaffective disorder as those who met at least one to the following criteria during the measurement year:At least one acute inpatient en-counter with any diagnosis of schizophrenia or schizoaffective disorder. Either of the following code combinations meets criteria: BH Stand Alone Acute Inpatient Value Set (See UB Rev Codes) with Schizophrenia Value Set (see ICD-10 codes) or Visit Setting Unspecified Value Set codes (90791, 90792, 90832, 90833, 90834, 90840, 90845, 90847, 90849, 90853, 90875, 90876, 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99251–99255) with Acute Inpatient POS Value Set (21, 51) with Schizophrenia Value Set (see ICD-10 codes), or met at least two visits in an outpatient, intensive outpatient, partial hospitalization, ED or Nonacute inpatient setting, on different dates of service, with any diagnosis of schizophrenia or schizoaffective disorder. Two of any of the following, with or without a telehealth modifier (95, GT) meets criteria:An outpatient visit with any diagnosis of schizophrenia or schizoaffective disorder (see visit setting unspecified value set code above) with outpatient POS value set codes (03, 05, 07, 09, 11–20, 22, 33, 49, 50, 71, 72) with schizophrenia value set codes (see ICD-10 codes).An outpatient visit with any diagnosis of schizophrenia or schizoaffective disorder using the BH outpatient value set CPT codes: 98960, 98961, 98962, 99078, 99201–99205, 99211–99215, 99241–99245,

Diabetes Monitoring for People with Diabetes and Schizophrenia (SMD)Members 18–64 years of age with Schizophrenia or Schizoaffective Disorder and Diabetes, who had both an LDL-C test and an HbA1c test during the measurement year.

Members may be identified as having diabetes during the measurement year or the year prior to the measurement year.

Only one of the two visits may be a telehealth visit, a telephone visit or an online assessment. Identify telehealth visits by the presence of a telehealth modifier value set code (95, or GT) or the presence of a telehealth POS value set code (02) associated with an outpatient visit. Use the following code combination to identify phone visits and online assessments:

Phone visits value set codes (98966, 98967, 98968, 99441, 99442, 99443) with the ICD-10 Diabetes codes.

Online Assessment visits value set codes (98969, 99444) with the ICD-10 Diabetes Codes.




Diabetes Monitoring for People with Diabetes and Schizophrenia (SMD) continued.

E11.44, E11.49, E11.51, E11.52, E11.59, E11.610, E11.618, E11.620, E11.621, E11.622, E11.628, E11.630, E11.638, E11.641, E11.649, E11.65, E11.69, E11.8, E11.9, E13.00, E13.01, E13.10, E13.11, E13.21, E13.22, E13.29, E13.311, E13.319, E13.321, E13.3211 E13.3213, E13.3219, E13.329, E13.3291–E13.3293, E13.3299, E13.331, E13.3311–E13.3313, E13.3319, E13.339, E13.3391–E13.3393, E13.3399, E13.341, E13.3411–E13.3413, E13.3419, E13.349, E13.3491–E13.3493, E13.3499, E13.351, E13.3511–E13.3513, E13.3519, E13.3521–E13.3523, E13.3529, E13.3531–E13.3533, E13.3539, E13.3541–E13.3543, E13.3549, E13.3551–E13.3553, E13.3559, E13.359, E13.3591, E13.3592, E13.3593, E13.3599, E13.36, E13.37X1–E13.37X3, E13.37X9, E13.39, E13.40, E13.41, E13.42, E13.43, E13.44, E13.49, E13.51, E13.52, E13.59, E13.610, E13.618, E13.620, E13.621, E13.622, E13.628, E13.630, E13.638, E13.641, E13.649, E13.65, E13.69, E13.8, E13.9, O24.011, O24.012, O24.013, O24.019, O24.02, O24.03, O24.111, O24.112, O24.113, O24.119, O24.12, O24.13, O24.311, O24.312, O24.313, O24.319, O24.32, O24.33, O24.811, O24.812, O24.813, O24.819, O24.82, O24.83

99341–99345, 99347–99350, 99381–99387, 99391–99397, 99401–99404, 99411, 99412, 99483, 99510 (see HCPCS and UB Rev codes) with Schizophrenia Value Set ICD-10 codes.An intensive outpatient encounter or partial hospitalization with any diagnosis of schizophrenia or schizoaffective disorder (use the visit setting unspecified value set codes as noted above) with the Partial Hospitalization POS Value Set codes (52) with the Schizophrenia Value Set ICD-10 codes. An intensive outpatient encounter or partial hospitalization with any diagnosis of schizophrenia or schizoaffective disorder using Partial Hospitalization/Intensive Outpatient Value Set codes (see HCPCS and UB Rev Codes) with Schizophrenia Value Set ICD-10 codes.For a community mental health center visit with any diagnosis of schizophrenia or schizoaffective disorder use the visit setting unspecified CPT codes (see above) with the Community Mental Health Center POS Value Set code (53) with the Schizophrenia ICD-10 Value Set Codes.For Electroconvulsive therapy use the Electroconvulsive therapy value set code (90870) with the appropriate ICD-10 and UB Rev codes.For an observation visit use the Observation Value Set Codes (99217-99220) with any diagnosis of schizophrenia or schizoaffective disorder (see the ICD-10 codes for schizophrenia).For an ED visit use the ED Value Set codes (99281–99285) with any diagnosis of schizophrenia or schizoaffective disorder codes (see the ICD-10 codes for schizophrenia).For an ED visit with any diagnosis of schizophrenia or schizoaffective





disorder use the Visit Setting Unspecified Value Set codes (see codes above) with the ED POS Value Set code (23) with the ICD-10 Schizophrenia Codes.For a nonacute inpatient encounter use the BH Stand Alone Nonacute Inpatient Value Set codes of 99304–99310, 99315, 99316, 99318, 99324–99328, 99334–99337) with the appropriate HCPCS and UB Rev codes with any diagnosis of schizophrenia or schizoaffective disorder using the Schizophrenia ICD-10 codes.A nonacute inpatient encounter with any diagnosis of schizophrenia or schizoaffective disorder using the Visit Setting Unspecified Value Set codes (see above) with Nonacute Inpatient POS Value Set codes (31, 32, 56) with the ICD-10 Schizophrenia value set codes.A telehealth visit with any diagnosis of schizophrenia or schizoaffective disorder using the Visit Setting Unspecified Value Set codes (see above) with the Telehealth POS Value Set code (02) with the ICD-10 Schizophrenia Value Set codes.

Step 2:After identifying members from Step 1 who also have diabetes (see ICD-10 codes for diabetes codes) There are two ways to identify members with diabetes either by claim/encounter data and by pharmacy data.To be an eligible population the organization must use both methods of identification.For claim/encounter data members who met any of the following criteria during the measurement year or the year prior to the measurement year (count services that occur over both years):At least one acute inpatient encounter using the Acute Inpatient Value





Set Codes (99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99251–99255, 99291) with the diagnosis of Diabetes (See ICD-10 codes) without Telehealth.At least two outpatient visits using the Outpatient Value Set Codes (99201–99205, 99211–99215, 99241–99245, 99341-99345, 99347–99350, 99381–99387, 99391–99397, 99401–99404, 99411, 99412, 99429, 99455, 99456, 99483, (See HCPCS and UB Rev for further codes) observation visits use the Observation Value Set Codes (99217–99220), ED visits use the ED Value Set Codes (99281–99285 with the appropriate UB Rev Codes), or nonacute encounters use the Nonacute Inpatient Value Set Codes (See above under BH Stand Alone Nonacute Inpatient Value Set codes with the appropriate UB Rev Codes) with the ICD-10 Diabetes Codes. (Note only include nonacute inpatient encounters with the nonacute inpatient value set without telehealth.

HbA1C Test:83036, 83037

LOINC codes for HbA1c Tests:17856-6, 4548-4, 4549-2

CPT-CAT-ll codes for HbA1c Tests:3044F, 3045F, 3046F

LDL-C Tests:80061, 83700, 83701, 83704, 83721

LDL-C LOINC codes:12773-8, 13457-7, 18261-8, 18262-6, 49132-4, 55440-2

LDL-C CPT-CAT-ll Codes:3048F, 3049F, 3050F




BH Stand Alone Acute Inpatient Value Set with the Schizophrenia or Bipolar, or Other Bipolar ICD-10 Value Set Codes:0100, 0101, 0110–0114, 0119–0124, 0129–0134, 0139–0144, 0149–0154, 0159–0160, 0164, 0167, 0169, 0200–0204, 0206–0214, 0219, 0720–0724,0729, 0987

For an outpatient visit use codes:0510, 0513, 0515-0517, 0519–0523, 0526–0529, 0900, 0902, 0903, 0904, 0911, 0914–0917, 0919, 0982, 0983

For an intensive outpatient encounter or partial hospitalization use codes:0905, 0907, 0912, 0913

For Electroconvulsive Therapy use code:0901

For an ED visit use codes:0450, 0451, 0452, 0456, 0459, 0981

For a nonacute inpatient encounter use codes:0118, 0128,0138,0148, 0158, 0190–0194, 0199, 0524, 0525, 0550, 0551, 0552, 0559, 0660–0663, 0669, 1000–1005

Outpatient Visit codes:GO155, G0176, G0177, G0409, G0463, H0002, H0004, H0031, H0034, H0036, H0037, H0039, H0040, H2000, H2010, H2011, H2013–H2020, M0064, T1015

For intensive outpatient encounter or partial hospitalization use codes:G0410, G0411, H0035, H2001, H2012, S0201, S9480, S9484, S9485.

For nonacute inpatient encounters use codes:H0017, H0018, H0019, T2048

Schizophrenia codes only:F20.0–F20.3, F20.5, F20.81, F20.89, F20.9, F25.0, F25.1, F25.8, F25.9

Bipolar Disorder:F30.10–F30.13, F30.2–F30.4, F30.8, F30.9, F31.0, F31.10–F31.13, F31.2, F31.30–F31.32, F31.4, F31.5, F31.60–F31.64, F31.70–F31.78

Other Bipolar Disorder Value Set Codes:F31.81, F31.89, F31.9

Electroconvulsive Therapy Codes:GZB0ZZZ, GZB1ZZZ, GZB2ZZZ, GZB3ZZZ, GZB4ZZZ

Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (SSD)The percentage of members 18–64 years of age with schizophrenia, schizoaffective disorder, or bipolar disorder, who were dispensed an antipsychotic medication and had a diabetes screening test during the measurement year.

Exclude members with diagnosis of diabetes.

To identify the eligible population for this measure, members must be diagnosed with schizophrenia or bipolar disorder and meet at least one of the following criteria during the measurement year:At least one acute inpatient encounter with any diagnosis of schizophrenia, schizoaffective disorder or bipolar disorder. Any of the following code combinations meet criteria:BH Stand Alone Acute Inpatient Value Set codes (see UB Rev Codes) with Schizophrenia Value set codes (see ICD-10 codes) bipolar Disorder Value Set codes (see ICD-10 codes); Other Bipolar Disorder Value Set codes (see ICD-10 codes).Visit Setting Unspecified Value Set codes (90791, 90792, 90832, 90833, 90834, 90836–90840, 90847, 90849, 90853, 90875, 90876, 99221, 99222, 99223, 99233, 99238, 99239, 99251–99255) with Acute Inpatient POS Values Set Codes 21, 51) with Schizophrenia Value Set codes (see ICD-10 codes); Bipolar Disorder Value Set codes (see ICD-10 codes) and Other Bipolar Disorder Value Set Codes (see ICD-10 codes).At least two of the following, on different dates of service, with or without a telehealth modifier (95, GT) where both encounters have any diagnosis of schizophrenia or schizoaffective disorder or both encounters have any diagnosis of bipolar disorder or other bipolar disorder value set (see ICD-10 for all diagnostic codes).An outpatient visit using the Visit Setting Unspecified Value Set Codes (see the codes above) with the Outpatient POS Value Set Code (03, 05, 07, 09, 11–20, 22, 33, 49, 50, 71, 72)An outpatient visit using the BH Outpatient Value Set codes (98960, 98961, 98962, 99078, 99201–99205,




Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (SSD) continued.

99211–99215, 99241-99245, 99341–99345, 99347–99350, 99381–99387, 99391-99397, 99401–99404, 99411,99412, 99483, 99510 (see HCPCS and UB Rev for additional codes).For an intensive outpatient encounter or partial hospitalization use the Visit Setting Unspecified Value Set Codes (See codes above) with the Partial Hospitalization POS Value Set Code (52).For an intensive outpatient encounter or partial hospitalization use the Partial Hospitalization/Intensive Outpatient Value Set codes (see HCPCS and UB Rev Codes).For a community mental health center visit use the Visit Setting Unspecified Value Set Codes (see above) with the Community Mental Health Center POS Value Set Code (53).For an Electroconvulsive therapy visit use the Electroconvulsive Therapy Value Set Code (90870 and the appropriate ICD10-PCS codes and UB Rev code).

For an observation visit use the Observation Value Set Codes:99217–99220

For an ED visit use the ED Value Set Codes:99281–99285 with the appropriate UB Rev CodesFor an ED visit use the Visit Set-ting Unspecified Value Set Codes (see above) with the ED POS Value Set Code (23)

For a nonacute inpatient encounter use the BH Stand Alone Nonacute Inpatient Value Set Codes:99304–99310, 99315, 99316, 99318, 99324–99328, 99334–99337 (see HCPCS and UB Rev columns for the appropriate codes)




Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (SSD) continued.

For a nonacute inpatient encounter use the Visit Setting Unspecified Value Set Codes (see above) with the Nonacute Inpatient POS Value Set codes (31, 32, 56).For a telehealth visit use the Visit Setting Unspecified Value Set Codes (see above) with the Telehealth POS Value Set Code (02).

Glucose Tests:80047, 80048, 80050, 80053, 80069, 82947, 82950, 82951

LOINC Glucose Tests: 10450-5, 1492-8, 1494-4, 1496-9, 1499-3, 1501-6, 1504-0, 1507-3, 1514-9, 1518-0, 1530-5, 1533-9, 1554-5, 1557-8, 1558-6, 17865-7, 20436-2, 20437-0, 20438-8, 20440-4, 26554-6, 41024-1, 49134-0, 6749-6, 9375-7

HbA1c Tests:83036, 83037

HbA1c LOINC Codes:17856-6, 4548-4, 4549-2

HbA1c CPT-CAT-ll Codes:3044F, 3045F, 3046F

2019 Medications By Measure 34

Medications for ADHDIdentify all children in the specified age range who were dispensed an ADHD medication from the ADHD Medication List below during the 12-month intake period.

Description Prescription

CNS Stimulants Amphetamine-dextroamphetamineDexmethylphenidate DextroamphetamineLisdexamfetamine MethylphenidateMethamphetamine

Alpha-2 Receptor Agonists Clonidine Guanfacine

Miscellaneous ADHD Medications Atomoxetine

Antidepressant Medications for AMMFor the effective acute phase of treatment: At least 84 days (12 weeks) of treatment with antidepressant medication (Antidepressant Medications List), beginning on the IPSD through 114 days after the Index Prescription Start Date (IPSD) (115 total days). This allows gaps in medication treatment up to a total of 31 days during the 115-day period. Gaps can include either washout period gaps to change medication or treatment gaps to refill the same medication.

For the continuation phase of treatment: At least 180 days (six months) of treatment with antidepressant medication (Antidepressant Medications List), beginning on the IPSD through 231 days after the IPSD (232 total days). This allows gaps in medication treatment up to a total of 52 days during the 232-day period. Gaps can include either washout period gaps to change medication or treatment gaps to refill the same medication.


Miscellaneous Antidepressants Bupropion Vilazodone Vortioxetine

Monoamine Oxidase Inhibitors Isocarboxazid Phenelzine SelegilineTranylcypromine

Phenylpiperazine Antidepressants

Nefazodone Trazodone

Psychotherapeutic Combinations

Amitriptyline-chlordiazepoxideAmitriptyline-perphenazineFluoxetineolanzapine

SNRI Antidepressants Desvenlafaxine Duloxetine LevomilnacipranVenlafaxine Citalopram EscitalopramFluoxetine Fluvoxamine ParoxetineSertraline

Tetracyclic Antidepressants Maprotiline Mirtazapine

Tricyclic Antidepressants Amitriptyline Amoxapine ClomipramineDesipramine Doxepin (> 6 mg) ImipramineNortriptyline Protriptyline Trimipramine

Antipsychotic Medications for APCMembers with 90 days of continuous antipsychotic medication treatment during the measurement year. Identify members in the specified age range who were dispensed an antipsychotic medication (Antipsychotic Medications List) during the measurement year.


Miscellaneous Antipshychotic Agents

Aripiprazole Asenapine BrexpiprazoleCariprazine Clozapine HaloperidolIloperidone Loxapine LurisadoneMolindone Olanzapine PaliperidonePimozide QuetiapineQuetiapine fumarateRisperidone Ziprasidone

Phenothiazine Antipsychotics Chlorpromazine Fluphenazine PerphenazinePerphenazineamitriptylineProchlorperazine Thioridazine Trifluoperazine

Thioxanthenes Thiothixene

Long-Acting Injections Aripiprazole Fluphenazine decanoateHaloperidol decanoate OlanzapinePaliperidone palmitate Risperidone

Antipsychotic Medications for APMAt least two antipsychotic medication dispensing events from the Antipsychotic Medications List of the same or different medications, on different dates of service during the measurement year.

At least two antipsychotic medication dispensing events from the Antipsychotic Combination Medications List of the same or different medications, on different dates of service during the measurement year.




Phenothiazine Antipsychotics Chlorpromazine Fluphenazine PerphenazineProchlorperazine Thioridazine Trifluoperazine




Medication Treatment for Alcohol Abuse or Dependence Medications List for IET


Aldehyde Dehydrogenase Inhibitor

Disulfiram (oral)

Antagonist Disulfiram (oral)

Other Buprenorphine (sublingual tablet and implant)Buprenorphine/naloxone (sublingual tablet, buccal film, sublingual film)

Medication List for SAADispensed an antipsychotic medication (Oral Antipsychotic Medications List; Long-Acting Injections 14-Days Supply Medications List or Long-Acting Injections 28-Days Supply Medications List) on an ambulatory basis.


Miscellaneous Antipsychotic Agents (oral)

Aripiprazole Asenapine BrexpiprazoleCariprazine Clozapine HaloperidolIloperidone Loxapine LurisadoneMolindone Olanzapine PaliperidoneQuetiapine Quetiapine fumarateRisperidone Ziprasidone

Phenothiazine Antipsychotics (oral)

Chlorpromazine Fluphenazine PerphenazineProchlorperazine Thioridazine Trifluoperazine

Psychotherapeutic Combinations (oral)

Amitriptyline-perphenazine

Thioxanthenes (oral) Thioxanthenes (oral)

Long-Acting Injections 14-Days Supply Medications List for SAA


Long-Acting Injections 14-Days Supply

Risperidone

Long-Acting Injections 28-Days Supply Medications List for SAA


Long-Acting Injections 28-Days Supply

Aripiprazole Fluphenazine decanoateHaloperidol decanoate OlanzapinePaliperidone palmitate

Antipsychotic Combination Medications List for APM



Fluoxetine-olanzapine Perphenazine-amitriptyline

Antipsychotic Medications for APPIdentify all members in the specified age range who were dispensed an antipsychotic medication (Antipsychotic Medications List; Antipsychotic Combination Medications List see two tables below) during the Intake Period.




Phenothiazine Antipsychotics Chlorpromazine Fluphenazine PerphenazineProchlorperazine Thioridazine Trifluoperazine



Antipsychotic Combination Medications List for APP



Fluoxetine-olanzapine Perphenazine-amitriptyline


Diabetes Medications List for SSDMembers who were dispensed insulin or oral hypoglycemics/antihyperglycemics on an ambulatory basis during the measurement year or the year prior to the measurement year (see the Diabetes Medications List for approved medications).

Glucophage/metformin as a solo agent is not included because it is used to treat conditions other than diabetes; members with diabetes on these medications are identified through diagnosis codes only.


Alpha-glucosidase Inhibitors Acarbose Miglitol

Amylin Analogs Pramlinitide

Antidiabetic Combinations Alogliptin-metformin Alogliptin-pioglitazoneCanagliflozin-metformin Dapagliflozin-metforminEmpaglifozin-linagliptin Empagliflozin-metforminGlimepiride-pioglitazone GlimepiriderosiglitazoneGlipizide-metformin Glyburide-metforminLinagliptin-metformin Metformin-pioglitazoneMetformin-repaglinide Metformin-rosiglitazoneMetformin-saxagliptin Metformin-sitagliptinSitagliptin-simvastatin

Insulin Insulin aspart Insulin aspart-insulin aspart protamineInsulin degludec Insulin detemirInsulin glargine Insulin glulisineInsulin isophane humanInsulin isophane-insulin regularInsulin lispro Insulin lispro-insulin lispro protamineInsulin regular humanInsulin human inhaled

Meglitinides Nateglinide Repaglinide

Glucagon-like Peptide-1 (GLP1) Agonists

Albiglutide DulaglutideExenatide Liraglutide

Sodium Glucose Cotransporter 2 (SGLT2) Inhibitor

Canagliflozin DapagliflozineEmpagliflozin

Sulfonylureas Chlorpropamide Glimepiride GlipizideGlyburide Tolazamide Tolbutamide

Thiazolidinediones Pioglitazone Rosiglitazone

Dipeptidyl Peptidase-4 (DDP-4) inhibitors

Alogliptin LinagliptinSaxagliptin Sitaglipin

Diabetes Medications List for SMDMembers who were dispensed insulin or oral hypoglycemics/antihyperglycemics on an ambulatory basis during the measurement year or the year prior to the measurement year (see the Diabetes Medications List for approved medications).

Glucophage/metformin as a solo agent is not included because it is used to treat conditions other than diabetes; members with diabetes on these medications are identified through diagnosis codes only.


Alpha-glucosidase Inhibitors Acarbose Miglitol

Amylin Analogs Pramlinitide

Antidiabetic Combinations Alogliptin-metformin Alogliptin-pioglitazoneCanagliflozin-metformin Dapagliflozin-metforminEmpaglifozin-linagliptin Empagliflozin-metforminGlimepiride-pioglitazone Glipizide-metforminGlyburide-metformin Linagliptin-metforminMetformin-pioglitazone Metformin-repaglinideMetformin-rosiglitazone Metformin-saxagliptinMetformin-sitagliptin

Insulin Insulin aspart Insulin aspart-insulin aspart protamineInsulin degludec Insulin detemirInsulin glargine Insulin glulisineInsulin isophane humanInsulin isophane-insulin regularInsulin lispro Insulin lispro-insulin lispro protamineInsulin regular humanInsulin human inhaled

Meglitinides Nateglinide Repaglinide

Glucagon-like Peptide-1 (GLP1) Agonists

Albiglutide DulaglutideExenatide Liraglutide

Sodium Glucose Cotransporter 2 (SGLT2) Inhibitor

Canagliflozin DapagliflozineEmpagliflozin

Sulfonylureas Chlorpropamide Glimepiride GlipizideGlyburide Tolazamide Tolbutamide

Thiazolidinediones Pioglitazone Rosiglitazone

Dipeptidyl Peptidase-4 (DDP-4) inhibitors

Alogliptin LinagliptinSaxagliptin Sitaglipin

Documents

for MVP Health Care Behavioral Health Providers...2019 HEDIS Coding Reference Guide for MVP Behavioral Health Providers 4 Metabolic Testing CPT Codes for Glucose Testing: 80047, 80048,