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QPP measures for Mental Health Professionals - 2016

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

About the QCDR Mental Health (MH) measures:

  • Includes all possible combinations of QPP measures,
    (including
    individual and custom QCDR measures and any measures within Measure Groups, GPRO and ACO)
  • Measure selection is affected by specialty and storage method of patient records
    (i.e. EHR or other method)

Instructions:

1. Use column labeled 'No EHR?' to determine which measures to consider. 
This column shows the measures applicable depending on whether or not an EHR is used at the practice.

  • (E) indicates measures used if provider uses an EHR
       (or equivalent software such as Practice Management or Billing software that processes CPT/IDT/G codes)
  • (N) indicates measures used if no EHR utilization.

The presence of either (E) or (N) indicates measures that meet 2016 requirements and are measures commonly used by providers in previous QPP reporting periods. 

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

General categories of denominator population definitions in QPP measures: 

1. All patients over age 18
2. All patients over age 65
3. Patients selected by specific conditions defined by QPP measure denominator spec

FIGURE 1: QPP Measures - Patient population (Denominator) - Patients over age 18 (*)

No
EHR?
Meas
#
NQS
Domain
    Measure description
E 128 CPH Body mass index
E 130 PS Documentation and verification of current medications in the medical record
  131 CPH Pain assessment prior to initiation of patient treatment
E 134 CPH Screening for clinical depression (*  >12 years age)
  173 CPH Unhealthy alcohol use
E 226 CPH Preventive care and screening: tobacco use — screening and cessation intervention

FIGURE 2: QPP Measures - Patient population (Denominator) - Patients over age 65

 

No
EHR?
Meas
#
NQS
Domain
    Measure description
E/N 47 CCC Advanced care plan
E/N 111 CPH Pneumonia Vaccination Status for Older Adults
  181 PS Elder maltreatment screen and follow-up plan
 E/NN 318 PS Falls: Screening for future fall risk

 

FIGURE 3: QPP Measures - Patient population (Denominator) defined by measure

 

No
EHR?
Meas
#
NQS
Domain
    Measure description
  9 ECC Major depressive disorder: antidepressant medication during acute phase
E/N 46 PS Patient Safety - Medication Reconciliation (after discharge)
  106 ECC Major depressive disorder: diagnostic evaluation
  107 ECC Major depressive disorder: suicide risk assessment
E/N 182 CCC Functional Outcome Assessment (PROMIS)
  247 ECC Substance use disorders — counseling regarding psychosocial and pharmacologic treatment options for alcohol dependence
  248 ECC Substance Use Disorders: Screening for Depression Among Patients with Substance Abuse or Dependence
E/N 266 ECC Epilepsy: Seizure Type(s) and Current Seizure Frequency(ies)
  280 CCC Staging of dementia
E/N 281 ECC Cognitive Assessment
  282 ECC Functional status assessment
  284 ECC Neuropsychological symptom assessment
  285 ECC Screening for depressive symptoms
  287 ECC Counseling regarding safety concerns
  288 ECC Caregiver education and support
E/N 374 CCC Closing the referral loop: receipt of specialist report
      Post surgery counseling referral (must include #374)
E/N 217 CCC Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Knee Impairments
E/N 218 CCC Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Hip Impairments
E/N 220 CCC Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Lumbar Spine Impairments
E/N 221 CCC Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Shoulder Impairments
       

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

 
 

For more information, click on the links below:

 

 

  More information at these links:

CUHSM QCDR Measures approved by CMS - Non QPP Program - Patient Adherence Measures
• 2014 • 2015 • 2016 • 2017 • 2018 • 2019 • 2017_07_Non_Compliance_letter • 2017_QCDRbenchmarks •

Contact Us

For more information, contact us via email at clientservices@cuhsm.org

Phone:  (888) 979-2499 x2

Universal Health System Metric Tools referenced on this site:
CMS Submission Toolkit, CST-CMS Submission Template, PQRS
Audit Tool, PQRS Validator, GPRO Aggregator,
    QCDR-HISP, QRDASolutions, and
NwHIN Sleuth are trademarks of CMS Gateways, LLC
All other products mentioned are registered trademarks or trademarks of their respective companies.

QCDR-HISP = Qualified Clinical Data Registry - Health Information Service Provider

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Last modified: Tuesday November 10, 2020.