Quality Measures for Behavioral Health Clinics: Technical Specifications and Resource Manual

Acknowledgement

Quality Measures for Behavioral Health Clinics: Technical Specifications and Resource Manual

was prepared by the Substance Abuse and Mental Health Services Administration (SAMHSA). 

The document was made Section 508 compliant under contract number 

HHS75S20322D00049/75S20323F42003 with SAMHSA, U.S. Department of Health and Human 

Services (HHS). Zoram Kaul, Ph.D. served as contracting officer representative.

Disclaimer

The views, opinions, and content of this publication are those of the author and do not 

necessarily reflect the views, opinions, or policies of SAMHSA. Nothing in this document 

constitutes a direct or indirect endorsement by SAMHSA or HHS of any non-federal entity’s 

products, services, or policies.

Recommended Citation

Substance Abuse and Mental Health Services Administration: Quality Measures for Behavioral 

Health Clinics: Technical Specifications and Resource Manual. Substance Abuse and Mental 

Health Services Administration, 2024.

Originating Office

Division of Community Behavioral Health, Center for Mental Health Services, and Office of 

Evaluation, Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental 

Health Services Administration, 5600 Fishers Lane, Rockville, MD 20857, SAMHSA. Released 

2024. 

Nondiscrimination Notice

The Substance Abuse and Mental Health Services Administration (SAMHSA) complies with 

applicable Federal civil rights laws and does not discriminate on the basis of race, color, 

national origin, age, disability, religion, or sex (including pregnancy, sexual orientation, and 

gender identity). SAMHSA does not exclude people or treat them differently because of race, 

color, national origin, age, disability, religion, or sex (including pregnancy, sexual orientation, 

and gender identity). 

Released 2024.
2

License Agreements and Acknowledgements 

Use of the Quality Measures for Behavioral Health Clinics (BHC) Technical 

Specifications and Resource Manual indicates acceptance of the following 

license agreements:

A. Centers for Medicare and Medicaid Services (CMS) Medicaid Adult Core Set or the 

Medicaid Child Core Set: The following measures, for which CMS is the measure steward, are 

derived from the CMS Medicaid Adult Core Set or the CMS Medicaid Child Core Set:

Screening for Depression and Follow-Up Plan: Age 18 and Older (CDF-AD)

Screening for Depression and Follow-Up Plan: Ages 12 to 17 (CDF-CH)

Use of Pharmacotherapy for Opioid Use Disorder (OUD-AD)

Use of the technical specifications based on the Technical Specifications and Resource Manual 

for the Medicaid Adult Core Set or the Child Core Set indicates acceptance of the following 

license agreements:

The American Medical Association (AMA) and the American Hospital Association (AHA) permit 

the use of Current Procedural Terminology (CPT) and National Uniform Billing Committee 

(NUBC) UB-04 codes solely for the purpose of reporting state data on Medicaid and CHIP Core 

Set measures to the Centers for Medicare & Medicaid Services (CMS).

For Proprietary Codes in the Adult and Child Core Sets:

CPT® codes, descriptions and other data only are copyright 2022 American Medical 

Association(AMA). All rights reserved. CPT is a trademark of the American Medical Association. 

No fee schedules, basic units, relative values or related listings are included in CPT. The AMA 

assumes no liability for the data contained or not contained herein. Applicable FARS/HHSARS 

restrictions apply to government use.

Copyright © 2022, the American Hospital Association (AHA), Chicago, Illinois. Reproduced 

with permission. No portion of the AHA copyrighted materials contained within this publication 

may be copied without the express written consent of the AHA. AHA copyrighted materials 

including the UB-04 codes and descriptions may not be removed, copied, or utilized within any 

software, product, service, solution or derivative work without the written consent of the AHA. If 

an entity wishes to utilize any AHA materials, please contact the AHA at (312) 893-6816.

Making copies or utilizing the content of the UB-04 Manual, including the codes and/or 

descriptions, for internal purposes, resale and/or to be used in any product or publication; creating 

any modified or derivative work of the UB-04 Manual and/or codes and descriptions; and/or 

making any commercial use of UB-04 Manual or any portion thereof, including the codes and/or 

descriptions, is only authorized with an express license from the American Hospital Association.

To license the electronic data file of UB-04 Data Specifications, contact Tim Carlson at (312) 

893-6816 or Laryssa Marshall at (312) 893-6814. You may also contact us at 

ub04@healthforum.com.

Some measure specifications contain coding from LOINC® (https://loinc.org). The LOINC table, 

LOINC codes, LOINC panels and form file, LOINC linguistic variants file, LOINC/RSNA 

Radiology Playbook, and LOINC/IEEE Medical Device Code Mapping Table are copyright © 

1995–2022, Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes 

(LOINC) Committee and are available at no cost under the license at https://loinc.org/terms-ofuse.

“SNOMED” and “SNOMED CT” are registered trademarks of the International Health 

Terminology Standards Development Organisation (IHTSDO).

“HL7” is the registered trademark of Health Level Seven International. 
3

For the CMS Screening for Depression and Follow-up Plan measures in the Adult and Child

Core Sets:

These performance measures are not clinical guidelines and do not establish a standard of medical 

care, and have not been tested for all potential applications.

THE MEASURE AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT 

WARRANTY OF ANY KIND.

Limited proprietary coding is contained in the measure specifications for convenience. Users of 

the proprietary code sets should obtain all necessary licenses from the owners of these code sets. 

PCPI disclaims all liability for use or accuracy of any Current Procedural Terminology (CPT®) or 

other coding contained in the specifications.

CPT® contained in the Measure specifications is copyright 2004–2021 American Medical 

Association. LOINC® is copyright 2004–2021 Regenstrief Institute, Inc. This material contains 

SNOMED Clinical Terms® (SNOMED CT®) copyright 2004–2021 International Health 

Terminology Standards Development Organisation. ICD-10 is copyright 2021 World Health 

Organization. All Rights Reserved.

For the CMS Use of Pharmacotherapy for Opioid Use Disorder measure in the Adult Core 

Set:

The Use of Pharmacotherapy for Opioid Use Disorder (OUD) measure is maintained by The 

Lewin Group for Centers for Medicare & Medicaid Services (CMS) Programs through the Home 

and Community-Based Services (HCBS) Measures Development, Endorsement, Maintenance, 

and Alignment contract HHSM-500-2014-00033I, Task Order 75FCMC19F0004.

For Proprietary Codes:

Limited proprietary coding is contained in the measure specifications for user convenience. Users 

of proprietary code sets should obtain all necessary licenses from the owners of the code sets. 

Lewin disclaims all liability for use or accuracy of any CPT or other codes contained in the 

specifications. Professional organizations frequently update their codes. Code lists for calculation 

of this measure were accurate as of May 2021.

The International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) 

is published by the World Health Organization (WHO). ICD-10-CM is an official Health 

Insurance Portability and Accountability Act standard.

Level II HCPCS codes in these specifications are approved and maintained jointly by the AlphaNumeric Panel (consisting of CMS, the Health Insurance Association of America, and the Blue 

Cross and Blue Shield Association.)

The National Drug Code (NDC) Directory is published by the U.S. Food and Drug 

Administration and is made available under the Open Database License at 

https://opendatacommons.org/licenses/odbl/1.0/. Any rights in individual contents of the database 

are licensed under the Database Contents License at 

https://opendatacommons.org/licenses/dbcl/1.0/.

For Codes in the Public Domain used in the Child and Adult Core Sets measures:

The International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) is 

published by the World Health Organization (WHO). ICD-9-CM is an official Health Insurance 

Portability and Accountability Act standard.

The International Classification of Diseases, 9th Revision, Procedure Coding System (ICD-9-

PCS) is published by the World Health Organization (WHO). ICD-9-PCS is an official Health 

Insurance Portability and Accountability Act standard.

The International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) 

is published by the World Health Organization (WHO). ICD-10-CM is an official Health 
4

Insurance Portability and Accountability Act standard.

The International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-

PCS) is published by the World Health Organization (WHO). ICD-10-PCS is an official Health 

Insurance Portability and Accountability Act standard.

The National Drug Code (NDC) Directory is published by the U.S. Food and Drug 

Administration and is made available under the Open Database License at 

https://opendatacommons.org/licenses/odbl/1.0/. Any rights on individual contents of the database 

are licensed under the Database Contents License at 

https://opendatacommons.org/licenses/dbcl/1.0/.

B. Centers for Medicare and Medicaid Services (CMS) Non-Medicaid Core Set Measure: The 

CMS-stewarded measure, Screening for Social Drivers of Health (SDOH), is included in this 

manual and is subject to the following:

COPYRIGHT

This measure was developed by The Physicians Foundation. This measure is currently stewarded 

by the Centers for Medicare & Medicaid. This measure is in the public domain.

These performance measures are not clinical guidelines and do not establish a standard of medical 

care, and have not been tested for all potential applications.

THE MEASURES AND SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT 

WARRANTY OF ANY KIND.

Limited proprietary coding is contained in the measure specifications for convenience. Users of 

the proprietary code sets should obtain all necessary licenses from the owners of these code sets.

CPT® contained in the Measure specifications is copyright 2004-2022 American Medical 

Association. LOINC® is copyright 2004-2022 Regenstrief Institute, Inc. This material contains 

SNOMED Clinical Terms® (SNOMED CT®) copyright 2004-2022 International Health 

Terminology Standards Development Organisation. ICD-10 is copyright 2022 World Health 

Organization. All Rights Reserved

C. Mathematica Inc. Electronic Quality Measures: The following Mathematica Inc.-stewarded

electronic measures are incorporated by reference into this manual: 

Adult Major Depressive Disorder (MDD): Suicide Risk Assessment (SRA-A) 

Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment (SRA-C).

Use of these Mathematica measures indicates acceptance of the following license agreements:

Copyright 2022 Mathematica Inc. All Rights Reserved. The PCPI and AMA’s significant past 

efforts and contributions to the development and updating of the Measures are acknowledged.

The Measures are not a clinical guideline, do not establish a standard of medical care, and have not 

been tested for all potential applications. 

The Measures, while copyrighted, can be reproduced and distributed, without modification, for 

noncommercial purposes, e.g., use by health care providers in connection with their practices. 

Commercial use is defined as the sale, license, or distribution of the Measures for commercial gain, 

or incorporation of the Measures into a product or service that is sold, licensed or distributed for 

commercial gain. 

Commercial uses of the Measures require a license agreement between the user and Mathematica. 

Neither Mathematica, the PCPI, nor the American Medical Association (AMA), nor the former 

AMA-convened Physician Consortium for Performance Improvement® (AMA-PCPI), nor their 

members shall be responsible for any use of the Measures.

Mathematica encourages use of the Measures by other health care professionals, where appropriate.

THE MEASURES AND SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT 

WARRANTY OF ANY KIND.

Limited proprietary coding may be contained in the Measures specifications for convenience. A 
5

license agreement must be entered prior to a third party’s use of Current Procedural Terminology 

(CPT®) or other proprietary code set contained in the Measures. Any other use of CPT or other 

coding by a third party is strictly prohibited. Mathematica, the AMA, and former members of the 

PCPI disclaim all liability for use or accuracy of any CPT® or other coding contained in the 

specifications. 

CPT® contained in the Measures specifications is copyright 2004-2021 American Medical 

Association. LOINC® is copyright 2004-2021 Regenstrief Institute, Inc. This material contains 

SNOMED Clinical Terms® (SNOMED CT®) copyright 2004-2021 International Health 

Terminology Standards Development Organisation. ICD-10 is copyright 2021 World Health 

Organization. All Rights Reserved.

D. Minnesota Community Measurement Measure: Use of the Minnesota Community 

Measurement measure Depression Remission at Six Months (DEP-REM-6), is subject to the 

following:

© MN Community Measurement, 2023. All rights reserved.

CPT® contained in the Measure specifications is copyright 2004-2022 American Medical 

Association. ICD-10 is copyright 2022 World Health Organization. All Rights Reserved.

E. National Committee for Quality Assurance (NCQA: The following adjusted measures 

in this manual are stewarded by NCQA: 

Preventive Care and Screening: Unhealthy Alcohol Use: Screening and Brief Counseling 

(ASC)

Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention (TSC)

Weight Assessment and Counseling for Nutrition and Physical Activity for 

Children/Adolescents (WCC-CH)

Controlling High Blood Pressure (CBP-AD)

Follow-Up After Hospitalization for Mental Illness, ages 18+ (adult) (FUH-AD)

Follow-Up After Hospitalization for Mental Illness, ages 6 to 17 (child/adolescent) (FUHCH)

Initiation and Engagement of Substance Use Disorder Treatment (IET-AD)

Follow-Up After Emergency Department Visit for Mental Illness (FUM-CH and FUMAD)

Follow-Up After Emergency Department Visit for Substance Use (FUA-CH and FUAAD)

Plan All-Cause Readmissions Rate (PCR-AD)

Follow-Up Care for Children Prescribed Attention-Deficit Hyperactivity Disorder 

(ADHD) Medication (ADD-CH)

Antidepressant Medication Management (AMM-AD)

Hemoglobin A1c Control for Patients with Diabetes (HBD-AD)

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

(APP-CH)

Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM-CH)

NCQA Copyright Notice and Disclaimer

The HEDIS®1 measures and specifications were developed by and are owned by NCQA. The 

HEDIS measures and specifications are not clinical guidelines and do not establish a standard of 

1The Healthcare Effectiveness Data and Information Set (HEDIS®) is a registered trademark of NCQA.
6

medical care. NCQA makes no representations, warranties, or endorsement about the quality of 

any organization or physician that uses or reports performance measures and NCQA has no liability 

to anyone who relies on such measures and specifications. NCQA holds a copyright in these 

materials and can rescind or alter these materials at any time. These materials may not be modified 

by anyone other than NCQA. Use of the Rules for Allowable Adjustments of HEDIS to make 

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and are subject to a license at the discretion of NCQA. Except as otherwise permitted by NCQA, 

any use of the materials to identify records or calculate measure results requires a custom license 

and may necessitate certification pursuant to NCQA’s Measure Certification Program. Reprinted 

with permission by NCQA. © 2024 NCQA, all rights reserved.

Limited proprietary coding is contained in the measure specifications for convenience. NCQA 

disclaims all liability for use or accuracy of any third-party code values contained in the 

specifications. 

CPT Copyright 2024 American Medical Association. All rights reserved. CPT® is a registered 

trademark of the American Medical Association. Applicable FARS/DFARS Restrictions Apply to 

Government Use. Fee schedules, relative value units, conversion factors and/or related components 

are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. 

The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA 

assumes no liability for data contained or not contained herein.

The CDC Race and Ethnicity code system was developed by the U.S. Centers for Disease Control 

and Prevention (CDC). NCQA’s use of the code system does not imply endorsement by the CDC 

of NCQA, or its products or services. The code system is otherwise available on the CDC website 

for no charge.

Certain NullFlavor codes are owned and copyrighted by Health Level Seven International (HL7); 

2024

The American Hospital Association holds a copyright to the Uniform Billing Codes (“UB”) 

contained in the measure specifications. The UB Codes in the HEDIS specifications are included 

with the permission of the AHA. All uses of the UB Codes may require a license from the AHA. 

Specifically, anyone desiring to use the UB Codes in a commercial product to generate HEDIS 

results, or for any other commercial use, must obtain a commercial use license directly from the 

AHA. To inquire about licensing, contact ub04@aha.org.

Health Care Provider Taxonomy Code Set codes copyright [current year] AMA. The codes are 

published in cooperation with the National Uniform Claim Committee (NUCC) by the AMAS. 

Applicable FARS/DFARS restrictions apply.

NCQA Measure Certification Disclaimer 

Unadjusted Uncertified Measures: A calculated measure result (a “rate”) from a HEDIS measure 

that has not been certified via NCQA’s Measure Certification Program and is based on unadjusted 

HEDIS specifications may not be called a “Health Plan HEDIS rate” until it is audited and 

designated reportable by an NCQA-Certified HEDIS Compliance Auditor. Until such time, such 

measure rates shall be designated or referred to as “Uncertified, Unaudited Health Plan HEDIS 
7

Rates.” 

Adjusted Uncertified Measures: A calculated measure result (a “rate”) from a HEDIS measure 

that has not been certified via NCQA’s Measure Certification Program, and is based on adjusted

HEDIS specifications, may not be called an “Adjusted HEDIS rate” until it is audited and 

designated reportable by an NCQA-Certified HEDIS Compliance Auditor. Until such time, such 

measure rates shall be designated or referred to as “Adjusted, Uncertified, Unaudited HEDIS 

Rates.” 
8

Table of Contents

License Agreements and Acknowledgements.......................................................................................2

I. INTRODUCTION...............................................................................................................................11

Background .........................................................................................................................................11

Overview of updates to the BHC measures.......................................................................................11

Purposes of quality measure reporting...............................................................................................12

Specification sources..........................................................................................................................12

The Behavioral Health Clinic Quality Measures..................................................................................13

II. DATA COLLECTION AND REPORTING OF THE BEHAVIORAL HEALTH CLINIC

QUALITY MEASURES............................................................................................................................16

Data Collection and Preparation for Reporting....................................................................................16

Measurement years and measurement periods...................................................................................16

Reporting at the BHC level................................................................................................................17

The population to be measured ..........................................................................................................17

Population size requirements for reporting........................................................................................19

Data sources or collection methods....................................................................................................19

Includable claims...............................................................................................................................21

Code and medication lists..................................................................................................................21

Risk adjustment..................................................................................................................................22

Reporting and Submission of Measures...............................................................................................22

Who collects and reports the data.......................................................................................................22

Data-reporting templates....................................................................................................................22

Data auditing......................................................................................................................................23

Changes to aspects of Quality Bonus Programs ................................................................................23

Submission deadlines.........................................................................................................................23

III. TECHNICAL SPECIFICATION COMPONENTS.........................................................................25

Description.........................................................................................................................................25

Definitions..........................................................................................................................................25

Eligible Population.............................................................................................................................25

Measure Specification........................................................................................................................27

Additional Notes................................................................................................................................28

Frequently Asked Questions..............................................................................................................28

IV. CLINIC-COLLECTED MEASURE TECHNICAL SPECIFICATIONS........................................29

Clinic-Collected Measures Required for Submission as Part of CCBHC Demonstration ..................30

Time to Services (I-SERV)................................................................................................................31

Depression Remission at Six Months (DEP-REM-6)........................................................................40

Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling (ASC).....51
9

Screening for Social Drivers of Health (SDOH)................................................................................61

Important Supplemental Materials for Clinic-Collected Required BHC Measures derived from CMS 

Medicaid Adult and/or Child Core Set Measures (CDF-AD and CDF-CH) .....................................66

Measure CDF-AD: Screening for Depression and Follow-Up Plan: Age 18 and Older ...................70

Measure CDF-CH: Screening for Depression and Follow-Up Plan: Ages 12 to 17..........................77

Clinic-Reported Measures Optional for Submission as Part of CCBHC Demonstration....................84

Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention (TSC)................85

Adult Major Depressive Disorder (MDD): Suicide Risk Assessment (SRA-A) ...............................94

Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment (SRA-C)......98

Important Supplemental Materials for Clinic-Collected Optional BHC Measures derived from CMS 

Medicaid Adult and/or Child Core Set Measures (WCC-CH).........................................................102

Measure WCC-CH: Weight Assessment and Counseling for Nutrition and Physical Activity for 

Children/Adolescents,......................................................................................................................106

Important Supplemental Materials for Clinic-Collected Optional BHC Measures derived from CMS 

Medicaid Adult and/or Child Core Set Measures (CBP-AD)..........................................................111

Measure CBP-AD: Controlling High Blood Pressure,.....................................................................113

V. STATE-COLLECTED MEASURE TECHNICAL SPECIFICATIONS ........................................119

State-Collected Measures Required for Submission as Part of CCBHC Demonstration..................120

Patient Experience of Care Survey (PEC) .......................................................................................121

Youth and Family Experience of Care Survey (Y/FEC)..................................................................124

Important Supplemental Materials for State-Collected Required BHC Measures derived from CMS 

Medicaid Adult and/or Child Core Set Measures (AMM-AD)........................................................127

Measure AMM-AD: Antidepressant Medication Management,......................................................129

Important Supplemental Materials for State-Collected Required BHC Measures derived from CMS 

Medicaid Adult and/or Child Core Set Measures (OUD-AD).........................................................133

Measure OUD-AD: Use of Pharmacotherapy for Opioid Use Disorder..........................................135

Important Supplemental Materials for State-Collected Required BHC Measures derived from CMS 

Medicaid Adult and/or Child Core Set Measures (SAA-AD)..........................................................138

Measure SAA-AD: Adherence to Antipsychotic Medications for Individuals With Schizophrenia,

..........................................................................................................................................................140

Important Supplemental Materials for State-Collected Required BHC Measures derived from CMS 

Medicaid Adult and/or Child Core Set Measures (PCR-AD)..........................................................147

Measure PCR-AD: Plan All-Cause Readmissions,..........................................................................149

Important Supplemental Materials for State-Collected Required BHC Measures derived from CMS 

Medicaid Adult and/or Child Core Set Measures (ADD-CH).........................................................160

Measure ADD-CH: Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity 

Disorder (ADHD) Medication,.........................................................................................................162

Important Supplemental Materials for State-Collected Required BHC Measures derived from CMS 

Medicaid Adult and/or Child Core Set Measures (HBD-AD).........................................................168

Measure HBD-AD: Hemoglobin A1c Control for Patients with Diabetes,......................................170

Important Supplemental Materials for State-Collected Required BHC Measures derived from CMS 
10

Medicaid Adult and/or Child Core Set Measures (IET-AD) ...........................................................176

Measure IET-AD: Initiation and Engagement of Substance Use Disorder Treatment,....................179

Important Supplemental Materials for State-Collected Required BHC Measures derived from CMS 

Medicaid Adult and/or Child Core Set Measures (FUH-AD and FUH-CH)...................................191

Measure FUH-AD: Follow-Up After Hospitalization for Mental Illness: Age 18 and Older,.........193

Measure FUH-CH: Follow-Up After Hospitalization for Mental Illness: Ages 6 to 17,.................197

Important Supplemental Materials for State-Collected Required BHC Measures derived from CMS 

Medicaid Adult and/or Child Core Set Measures (FUM-AD and FUM-CH)..................................201

Measure FUM-AD: Follow-Up After Emergency Department Visit for Mental Illness: Age 18 and 

Older,................................................................................................................................................203

Measure FUM-CH: Follow-Up After Emergency Department Visit for Mental Illness: Ages 6 to 17,

..........................................................................................................................................................208

Important Supplemental Materials for State-Collected Required BHC Measures derived from CMS 

Medicaid Adult and/or Child Core Set Measures (FUA-AD and FUA-CH)...................................212

Measure FUA-AD: Follow-up After Emergency Department Visit for Substance Use: Age 18 and 

Older,................................................................................................................................................214

Measure FUA-CH: Follow-Up After Emergency Department Visit for Substance Use: Ages 13 to 

17,.....................................................................................................................................................219

State-Collected Measures Optional for Submission as Part of CCBHC Demonstration...................224

Important Supplemental Materials for State-Collected Optional BHC Measures derived from CMS 

Medicaid Adult and/or Child Core Set Measures (APP-CH and APM-CH) ...................................225

Measure APP-CH: Use of First-Line Psychosocial Care for Children and Adolescents on 

Antipsychotics,.................................................................................................................................227

Measure APM-CH: Metabolic Monitoring for Children and Adolescents on Antipsychotics,........230

VI. Appendices.....................................................................................................................................232

Appendix A. Glossary of Terms........................................................................................................233

Appendix B. Denominator and Numerator Measurement Periods for BHC Quality Measures.......236

Appendix C. Guidance for Selecting Sample Sizes for Hybrid Measures........................................238

Appendix D. Definitions of Medicaid/CHIP Core Set Practitioner Types........................................239

Appendix E. Core Set Value Set Directory User Manual .................................................................240
11

Introduction

I. INTRODUCTION

Background

This manual provides technical specifications, guidance, and general information related to quality

measures developed or adapted to be used at the Behavioral Health Clinic (BHC) provider level. 

This manual is organized as follows: Chapter I introduces and identifies the BHC quality measures; 

Chapter II provides general information on data collection for and reporting of the measures; 

Chapter III describes the components comprising the technical specification; and Chapters IV and 

V include the technical specifications for the clinic-collected and state-collected BHC measures, 

respectively. Appendices include: A. Glossary of Terms; B. Denominator and Numerator 

Measurement Periods for BHC Quality Measures; C. Guidance for Selecting Sample Sizes for 

Hybrid Measures; D. Definitions of Medicaid/Chip Core Set Practitioner Types; and E. Core Set 

Value Set Directory User Manual.

The measures included in this manual are rooted in the requirements placed on Certified 

Community Behavioral Health Clinics (CCBHCs) as part of the Demonstration Program to 

Improve Community Mental Health Services, found in Section 223 of the federal Protecting 

Access to Medicare Act of 2014 (PAMA), as amended by the Bipartisan Safer Communities 

Act of 2022 (BSCA). The measures in this manual are intended for use by: 

• CCBHCs and states participating in the Section 223 Demonstration, which requires 

reporting of both clinic- and state-collected quality measures; 

• CCBHCs and states involved in implementing independent state CCBHC initiatives 

(outside of the Section 223 Demonstration);

• CCBHC-Improvement and Advancement (IA) grantees and CCBHC-Planning, 

Development, and Implementation (PDI) grantees, that are recipients of grants from 

the Substance Abuse and Mental Health Services Administration (SAMHSA); and 

• Other BHCs if they desire to report the clinic-reported quality measures. 

For more information on the requirements for quality measure reporting applicable to the 

CCBHCs, see Program Requirement 5 of the CCBHC Certification Criteria (2023). A subset 

of these measures may be used by states to make Quality Bonus Payments (QBPs) under the 

Section 223 Demonstration.

Overview of updates to the BHC measures

The original BHC measures were developed by SAMHSA, with inputs from the Assistant 

Secretary for Planning and Evaluation (ASPE) and the Centers for Medicare and Medicaid 

Services (CMS) and published in April 2016. All Section 223 Demonstration CCBHCs were 

required to report nine measures annually; an additional five measures were not required of 

the CCBHCs. At that time, these clinic-reported measures were identified as “clinic-lead 

measures.” In addition, all Section 223 Demonstration states were required to report on 13 

measures annually; five other state measures were prepared but not required to be used by the 

states. The latter 18 measures were identified as “state-lead measures.” 
12

Introduction

In 2022, SAMHSA, in consultation with its federal partners, undertook a lengthy review and 

assessment of the measures to determine which required updates, which should be removed, 

and what might be added, with the twin objectives of relieving some of the reporting burden 

on clinics and bringing the selection of measures up to date. This led to the selection of five 

measures to be required of Section 223 Demonstration CCBHCs, CCBHC-IAs, and CCBHCPDIs, as well as five optional measures for clinic-level reporting. Furthermore, Section 223 

Demonstration states are now required to report on twelve measures and may optionally report 

on two additional measures. Information on the time transition for existing reporting states 

and CCBHCs is provided in a separate document.

Purposes of quality measure reporting 

Data and quality measure reporting has multiple 

purposes. Section 223(E) of PAMA, the 

authorizing statute for the Section 223 

Demonstration, requires “reporting of encounter 

data, clinical data, quality data, and such other 

data as the Secretary [of HHS] requires.” Collection and reporting of this information offers

providers, states, and other stakeholders a method to assess the manner in which care is 

provided and accessed. Quality measures data can be used for BHC internal quality 

improvement (QI) to determine the progress of care delivery and areas for improvement. Some 

quality measure reporting also may be required as part of incentive programs, such as the 

Quality Bonus Measures (QBMs) and QBPs that are part of the Section 223 Demonstration 

Medicaid Prospective Payment System (PPS) methodology. The data and measures reported 

also may be used to supplement program evaluation, as with the national evaluation of the 

CCBHC Demonstration Program. In general, the data collected will help states and the federal 

government to better understand the quality of health care that clients at BHCs receive.

Specification sources

This manual includes technical specifications and guidance for quality measures derived from 

multiple sources, including some developed specifically for BHCs by SAMHSA. In most

cases, however, the measures are derived from other sources, such as original measures that 

were designed for reporting at the state or health plan

level. Each such measure has been re-specified to

enable reporting at the BHC level to capture 

performance by the BHC. This manual includes the

most current version of the measure specifications 

available as of August 2023. For measures sourced 

from the Centers for Medicare and Medicaid (CMS) 

Core Set of Adult Health Care Quality Measures for 

Medicaid (Adult Core Set) or Core Set of Children’s 

Health Care Quality Measures for Medicaid and 

CHIP (Child Core Set), this manual follows the 

Quality Measures & Quality Improvement

Based on an evaluation of the original CCBHC 

Demonstration, we know that implementation 

of the original measures had positive effects on 

the quality of care provided, including 

improving access to and use of evidence-based 

practices.

Consensus-Based Entity (CBE)

The Consensus-Based Entity (CBE), as 

required by section 1890 of the Social 

Security Act, performs various duties 

related to health care performance 

measurement including endorsement and 

maintenance of quality measures. For 

additional information about endorsement 

and maintenance and other CBE work 

funded by CMS, see the Partnership for 

Quality Measurement website.
13

Introduction

Adult or Child Core Set specifications for Federal Fiscal Year (FFY) 2023. For measures

sourced from the Merit-based Incentive Payment System (MIPS), this manual follows the 

applicable MIPS measures for 2023. For the few measures derived from sources other than the 

Core Sets or MIPS, this manual includes the most applicable version of the technical 

specifications available from the measure steward for reporting 2023 data, re-specified where 

necessary at the BHC level. A few measures were developed by SAMHSA specifically for this 

manual rather than from existing measure sources, to address aspects of care important for 

BHCs in general and the CCBHCs specifically. For each measure included in this manual, the 

steward, and/or source, is noted at the top of the specification. Where relevant, information is 

also provided on Consensus-Based Entity (CBE) endorsement. Testing of measures that are not

derived from CBE-endorsed measures is limited. 

The Behavioral Health Clinic Quality Measures

Tables 1 and 2 identify the 2023 BHC measures. Table 1 comprises BHC-collected measures

while Table 2 lists measures where data are collected by the state. The lists of measures in 

Tables 1 and 2 also identify whether they are required or optional for CCBHC or 

Demonstration state reporting. The technical specifications and other guidance in Chapters

IV and V of this manual provide details for each measure. The measures that pertain to QBPs 

that are included in the CCBHC Demonstration will be identified in the CCBHC PPS 

Guidance on the CMS Section 223 website.
Introduction

Table 1. Behavioral Health Clinic, Clinic-Collected Measures

Measure Name and Abbreviation Measure Steward2 CBE ID CMS Medicaid 

Core Set (2023)

MIPS Measure 

(2023)

Required or 

Optional for 

CCBHCs3

Time to Services (I-SERV) SAMHSA NA NA NA R

Depression Remission at Six Months (DEP- REM-6) Minnesota 

Community

Measurement

0711 NA NA R

Preventive Care and Screening: Unhealthy Alcohol

Use: Screening and Brief Counseling (ASC)

NCQA 2152 NA 431 R

Screening for Social Drivers of Health (SDOH) CMS NA NA 487 R

Screening for Clinical Depression and Follow-Up Plan 

(CDF-AD and CDF-CH)

CMS 0418 and 0418e Adult and Child 134, cMS2v12 R

Preventive Care & Screening: Tobacco Use:

Screening & Cessation Intervention (TSC)

NCQA 0028 and 0028e NA 226, 

CMS138v11

O

Major Depressive Disorder: Suicide Risk

Assessment (SRA-A)

MPR 0104e NA 107, 

CMS161v11

O

Child and Adolescent Major Depressive Disorder

(MDD): Suicide Risk Assessment (SRA-C)

MPR 1365e NA 382, 

CMS177v11

O

Weight Assessment and Counseling for Nutrition and 

Physical Activity for Children/Adolescents (WCCCH)

NCQA 0024 Child 239, CMS155v11 O

Controlling High Blood Pressure (CBP-AD) NCQA 0018 Adult 236, CMS165v11 O

Abbreviations: CBE, Consensus-Based Entity; CMS, Centers for Medicare & Medicaid Services; MPR, Mathematica Policy Research; NA, not applicable;

NCQA, National Committee for Quality Assurance; NR, Not required to be a QBM; O, Optional; PCPI, Physician Consortium for Performance 

Improvement; R, Required; SAMHSA, Substance Abuse and Mental Health Services Administration

2The measure steward is the organization responsible for maintaining a particular measure or measure set. Responsibilities of the measure steward include updating 

the codes that are tied to technical specifications and adjusting measures as the clinical evidence changes. 

3The designation of required or optional for clinic-reported measures applies to CCBHCs in the Section 223 Demonstration and to any CCBHC-IAs or CCBHC-PDIs that are 

required to report measures. For CCBHCs that were part of the original Demonstration, and states with independent programs that may require reporting by nonDemonstration clinics, however, it must be determined by that state whether or not to require CCBHCs to report optional measures that formerly were required to be 

reported under the 2016 criteria. 14 
Introduction

Table 2. Behavioral Health Clinic State-Collected Measures

Measure Name and Abbreviation Measure Steward

2

CBE ID CMS Medicaid Core 

Set (2023)

MIPS Measure 

(2023)

Required or 

Optional for 

CCBHCs3

Patient Experience of Care Survey (PEC) SAMHSA NA No NA R

Youth/Family Experience of Care Survey (YFEC) SAMHSA NA No NA R

Antidepressant Medication Management (AMM-AD) NCQA 0105 Adult 009, CMS128v11 R

Use of Pharmacotherapy for Opioid Use Disorder (OUD-AD) CMS 3400 Adult NA R

Adherence to Antipsychotic Medications for Individuals with 

Schizophrenia (SAA-AD) 

CMS 1879 Adult 383 R

Plan All-Cause Readmissions Rate (PCR-AD) NCQA 1768 Adult NA R

Follow-Up Care for Children Prescribed Attention-Deficit 

Hyperactivity Disorder (ADHD) Medication (ADD-CH)

NCQA 0108 Child 366, CMS136v12 R

Hemoglobin A1c Control for Patients with Diabetes (HBDAD)NCQA 0059/0575 Adult NA R

Initiation and Engagement of Alcohol and Other Drug 

Dependence Treatment (IET-AD) 

NCQA 0004 Adult 305, CMS137v11 R

Follow-Up After Hospitalization for Mental Illness (FUH-CH 

and FUH-AD)

NCQA 0576 Adult & Child 391 R

Follow-Up After Emergency Department Visit for Mental 

Illness (FUM-AD and FUM-CH)

NCQA 3489 Adult & Child 391 R

Follow-Up After Emergency Department Visit for Alcohol and 

Other Drug Dependence (FUA-AD and FUA-CH)

NCQA 3488 Adult & Child NA R

Use of First-Line Psychosocial Care for Children and 

Adolescents on Antipsychotics (APP-CH)

NCQA 0717 Child NA O

Metabolic Monitoring for Children and Adolescents on 

Antipsychotics (APM-CH)

NCQA 2800 Child NA O

Abbreviations: CBE, Consensus-Based Entity; CMS, Centers for Medicare & Medicaid Services; NA, not applicable; NCQA, National Committee for Quality 

Assurance; NR, Not required to be a QBM; O, Optional; R, Required; SAMHSA, Substance Abuse and Mental Health Services Administration

2The measure steward is the organization responsible for maintaining a particular measure or measure set. Responsibilities of the measure steward include 

updating the codes that are tied to technical specifications and adjusting measures as the clinical evidence changes. 

3The designation of required or optional for state-collected measures applies to states in the Section 223 Demonstration and to any CCBHC-IAs or CCBHCPDIs that are required to report measures. For CCBHCs that were part of the original Demonstration, and states with independent programs that may require 

reporting by non-Demonstration clinics, however, it must be determined by that state whether or not to require CCBHCs to report optional measures that

formerly were required to be reported under the 2016 criteria. 

15
16

Data Collection and Reporting

II. DATA COLLECTION AND REPORTING OF THE BEHAVIORAL

HEALTH CLINIC QUALITY MEASURES

This chapter provides general guidelines for data collection, preparation, and reporting.

Technical specifications and related guidance, with detailed information on how to calculate each 

measure, are presented in Chapters IV and V. For technical assistance with calculating and 

reporting these measures, please use the measure submission mailbox for the Section 223 

Demonstration at CCBHCMeasuresSubmission@samhsa.hhs.gov.

Data Collection and Preparation for Reporting

Measurement years and measurement periods

Measurement Years. Measurement Years are the 

period of time that calculated quality measures assess.

For reporting related to the Section 223

Demonstration, the Measurement Year originally was

defined as the 12 month Demonstration Year (DY) 

(e.g., DY5). When the updated specifications are implemented, all reporting will transition to a 

Measurement Year that corresponds with the calendar year; for example, calendar year 2025 data.

• Reporting: For all measures, reporters should indicate the Measurement Year using

Section A (Measurement Year) of the data-reporting templates. The data-reporting

templates are discussed in detail below.

Measurement Periods. Data collection also involves Measurement Periods, which identify the 

time periods for which data must be used to calculate a measure. Measurement Periods may 

correspond with the Measurement Year, but many Measurement Periods do not. Rather, they may 

be indexed to a specific date or event or may require some other modification to time periods for 

actual data collection (e.g., Preventive Care and Screening: Unhealthy Alcohol Use: Screening & 

Brief Counseling (ASC), where the numerator measures whether alcohol use screening occurred in 

the past 12 months, requiring a numerator Measurement Period that includes both the 

Measurement Year and the prior 12 months to capture past year screening for individuals seen 

early in the Measurement Year). States and BHCs should adhere to the Measurement Periods 

identified in the technical specification for each 

measure. Measurement Periods also are summarized 

in Appendix B. 

• Reporting: For all measures, reporters should

indicate start and end dates for the

Measurement Period for the denominator and

numerator in Section C (Date Range for

Measurement Period) of the data-reporting

templates.

Measurement Years

Beginning with the implementation of 

these updated technical specifications, 

CCBHCs will start using the calendar 

year as their Measurement Year. This 

replaces the Demonstration Year.

Measurement Periods

A measure is calculated using the data 

from a specific period of time, known as 

the Measurement Period. There may be 

distinct Measurement Periods for the 

numerator and denominator and they may 

or may not be the same as the 

Measurement Year.
17

Data Collection and Reporting

Reporting at the BHC level

The unit or level of reporting for these measures is always the BHC. The measures are specified 

at the clinic/clinician office setting level. This means that both states and BHCs should collect

data across all clients that are served by the BHC. In the case of the Section 223 Demonstration 

CCBHCs, the unit of reporting is determined at the CCBHC level regardless of how many clinics 

or entities comprise a single CCBHC. Depending on the data required for the measure and the 

structure of a Section 223 Demonstration CCBHC, data from Designated Collaborating 

Organizations (DCOs) also may be required (e.g., a DCO might be the entity undertaking 

screening for Hemoglobin A1c and the DCO data would be needed for computation of the 

related diabetes quality measure).

For state-collected measures in particular, reporting 

measures at the CCBHC level is different than the 

norm for most state reporting, as states tend to report 

numbers aggregated from multiple sources

encompassing the state’s Medicaid program or health 

plans. Therefore, the state must be able to identify and 

attribute data to specific clinics and their clients, for 

example, by assigning a unique identification number 

to each clinic. 

The population to be measured

Client attribution. States or other entities requiring reporting may decide how to attribute clients to 

BHCs depending on the specific impetus for data reporting. For the Section 223 Demonstration,

attribution of clients for purposes of data reporting required by the CCBHC criteria requires only one 

visit by a person to the CCBHC during the Measurement Year. The state is responsible for providing 

guidance to clinics on what activities constitute a visit that should be enumerated (for example, a 

person seen only once for primary care services that are outside the scope of services required as part 

of the CCBHC certification criteria). Attribution to a CCBHC requires one enumerated visit that falls 

within the CCBHC scope of services (whether or not provided within the four walls of the clinic). It is 

possible that a client may visit more than one CCBHC during a year; in such cases, the client will be 

attributed to both unless one is a DCO for the other.

Population eligible for measurement. In the broadest sense, the eligible population for these measures 

is all clients served by a BHC provider. The denominator for a specific measure, however, includes

only the BHC clients who satisfy measure-specific eligibility criteria. These may include requirements

such as age or continuous Medicaid enrollment. The specifications in Chapters IV and V indicate the 

population eligible to be included in each measure.

Clinic Site Identifiers

Section 5.a.3 of the CCBHC certification 

criteria updated in 2023 require that 

“Medicaid claims and encounter data 

provided by the state to the national 

evaluation team, and to CMS through TMSIS, should include a unique identifier 

for each person receiving services, 

unique clinic identifier, date of service, 

CCBHC-covered service provided, units 

of service provided and diagnosis. Clinic 

site identifiers are very strongly 

preferred.”
18

Data Collection and Reporting

Population stratification. The technical specifications also 

state what population stratifications are required for each 

measure. Stratification requirements might include race 

and/or ethnicity. However, except for the two statecollected patient experience of care measures (PEC and 

Y/FEC), there always will be a stratification by payer. 

Stratification by payer serves two purposes: (1) for evaluation, ASPE needs information on the 

population served to the greatest extent possible; and (2) CMS uses this information to determine the 

population to which the Quality Bonus Payments may apply.

• For Section 223 Demonstration CCBHCs, stratification by payer requires identification 

of clients as either: (1) Medicaid beneficiaries, including Title 19-eligible CHIP 

beneficiaries, or (2) Others, including those dually enrolled under Medicare and

Medicaid, Title 21-eligible CHIP beneficiaries, those reliant on other payment sources, 

and people who lack insurance. The distinction between Title 21 and Title 19-eligible

CHIP beneficiaries is based upon the restrictions found in PAMA Section 223 

(d)(5)(A). 

• Section 223 Demonstration states also are required to report data stratified for 

Medicaid beneficiaries, including Title 19-eligible CHIP beneficiaries, and, to the 

extent possible, clinic users who are dually eligible for Medicare and Medicaid. If a 

state cannot access the dual eligibility data, it should indicate in the data-reporting 

templates that it is excluding some or all data for the dually eligible group. 

Continuous Medicaid enrollment requirements apply to determining the eligible population for

some measures. If a measure specification does not include requirements for continuous 

enrollment, the insurance status at the time of the first visit during the Measurement Year will 

be applied for the entire year for purposes of stratification. For any measure with a continuous 

enrollment requirement that is clinic-collected, Medicaid and CHIP enrollees should be counted

if applicable within those categories if they satisfy the continuous enrollment criteria. Those who 

do not satisfy those criteria are to be stratified into the “Other” category.

Implication of payer stratification for quality bonus measures (QBMs). For purposes of

CCBHC QBM/QBP reporting and payment, only clients who are Medicaid beneficiaries, 

including Title 19-eligible Medicaid expansion CHIP beneficiaries, are counted towards 

payment. Data will be drawn from the stratified rates for those groups. Stratification by payer 

category is required for all non-experience of care measures.

• Reporting: Section E of the data-reporting template (Adherence to Measure 

Specifications) provides space for the state or BHC to report nonadherence to measure 

specification; for instance, if only certain client/payer categories are included in the 

measure calculation, including if the state lacks access to data for individuals dually 

enrolled in Medicare and Medicaid.

Stratification

Some stratification is required for all 

measures except the two state-collected 

patient experience of care measures 

(PEC and Y/FEC). Stratification details 

for each measure are included in the 

measure specification.
19

Data Collection and Reporting

Representativeness of data. States and BHC providers should use the most complete data available 

and ensure that the rates reported are representative of the entire population served by the BHC. To 

achieve this with a measure based on administrative data, all BHC clients who meet the eligible 

population requirements for the measure should be included. For a measure based on a sampling 

methodology, states and BHC providers should ensure that the sample used to calculate the measure is 

representative of the entire BHC eligible population for the measure.

Population size requirements for reporting

For purposes of the CCBHC Demonstration Program, all measures must be reported to 

SAMHSA regardless of the size of the specified eligible population for a given measure in a 

CCBHC.

• However, if the eligible population and denominator exclusions for a given measure in a 

CCBHC result in a denominator less than 30, results should not be used for any public

reporting or for purposes of the national evaluation

• For the Plan All-Cause Readmissions (PCR-AD) state-collected measure, the 

denominator is the Count of Index Hospital Stays among non-outlier members (outliers 

should not be considered). For that measure, a Count of Index Hospital Stays less than 

150 should not be used for any public reporting or for purposes of the national 

evaluation.

For reporting that is not related to the CCBHC Demonstration Program, if a measure has a

denominator less than 30 and the state and BHCs choose not to report the measure due to small 

numbers, this decision is to be noted in Section E of the data-reporting template (Adherence to 

Measure Specifications) and the denominator size should be provided.

Data sources or collection methods

The measures included in this manual have four possible data sources/collection methods: (1) 

administrative, (2) medical records (including electronic health records (EHRs)), (3) hybrid,

and (4) survey. The specifications for each measure indicate which is to be used. If a measure 

includes a choice of sources or methods, any identified in the specification may be used.

Administrative data. The administrative method uses transaction data (for example, claims or 

encounters) or other administrative data sources to calculate the measure. Administrative data 

can be used in cases where such data are known to be complete, valid, and reliable. When 

administrative data are used, the entire eligible population, as specified for the measure, is

included in the denominator.

Medical record data. The medical records method uses the BHC medical records or other 

clinic transaction data sources, such as electronic health records (EHRs), paper medical 

records, clinic registries, or scheduling software.

EHR medical records: The electronic specification method uses EHR data to calculate 

the measure. A link to electronic specifications is included in the following measure 

specifications: ADD-CH, AMM-AD, CBP-AD, CDF-AD, CDF-CH, HBD-AD, IET-
Data Collection and Reporting

AD, SRA-C, SRA-A, and WCC-CH. Use the version current for the year being 

reported.

• Reporting: States or BHCs that use electronic specifications should indicate this by

selecting “Electronic Health Records” in the Data Source section (section B) of the

Data Reporting Template.

Hybrid. The hybrid method uses data from both administrative sources and medical records

(paper or EHRs or registry) determine the numerator. The denominator consists of a systematic 

sample of beneficiaries drawn from the measure’s eligible population. Administrative data are 

reviewed to determine if clients in the sample received the service, and medical record data are 

reviewed for clients who do not meet the numerator criteria through administrative data. The 

hybrid method, when available, should be used when administrative data and EHR data are 

incomplete or may be of poor quality, or the data elements for the measure are not reliably 

captured in administrative data. Samples should be representative of the eligible population, 

including, when stratified by age, the relevant age groups. Only three BHC measures include an 

hybrid option: CBP-AD, HBD-AD, and WCC-CH. Only HBD-AD is a required measure; other 

options for calculation are available for each of these three measures.

Sampling: For measures that use the hybrid method and that require sampling, 

guidance is included in the technical specification and as described below. Sampling

should be systematic and random to ensure that all eligible individuals have an equal 

chance of inclusion. The sample should be representative of the eligible population, and, 

in situations where reporting is by age group, random samples should be selected within

each specified age group, to insure sufficient sample size of each age group.

Technical Assistance: Additional applicable guidance on sampling for hybrid measures 

is available in the following CMS technical assistance brief: “Approaches to Using the

Hybrid Method to Calculate Measures from the Child and Adult Core Sets” (October 

2014).4

• Reporting: States and BHC providers should describe the sampling approach used for

each hybrid measure in Section F (Additional Notes) and the sample size and the size of

the measure-eligible population in Section B (Data Source) in the data-reporting

template.

Survey. The survey method uses data collected through a survey to calculate the measure. This 

data collection method applies only to the PEC and Y/FEC measures.

• Reporting: The method used should be reported in Section B of the data-reporting

template (Data Source).

Alternative data collection methods and data sources. States and BHCs should report the measures 

4Medicaid Core Measure Technical Assistance briefs can be found at the Adult and Child Health Care Quality Measures website.

20
21

Data Collection and Reporting

using the methods listed in the specifications to the extent possible, but if that is not feasible, they may 

use an alternative method (e.g., medical record review without systematic sample) or data source.

• Reporting: Any deviations from the measure specifications should be explained in

Section E of the data-reporting template (Adherence to Measure Specification) and, if

necessary, in Section F (Additional Notes).

Includable claims

Inclusion of paid, suspended, pending, and denied claims. A key aspect of the assessment of quality for 

some measures is to capture whether or not a service was provided. For some measures, the Guidance 

for Reporting within each measure's technical specification indicates which claims (paid, suspended, 

pending, and/or denied) should be included. This applies to the following measures if administrative 

data sources are used: ADD-CH, AMM-AD, APP-CH, APM-CH, CBP-AD, CDF-AD, CDF-CH, FUAAD, FUA-CH, FUH-AD, FUH-CH, FUM-AD, FUM-CH, HBD-AD, IET-AD, PCR-AD, SAA-AD, and 

WCC-CH.

Telehealth. Unless specifically stated otherwise, synchronous telehealth visits, which require real-time 

interactive audio and video telecommunications are to be treated as are in-person visits. Measures will 

specify if telephone-only or asynchronous telehealth are to be counted.

Code and medication lists

Value sets and codes. Many measures require the use of billing or diagnostic codes for calculation and

many specifications list value sets to identify codes required for calculation. A value set is a separate 

and complete set of codes used to identify a service or condition included in a measure. Where 

required, either value set references or actual codes are included for all technical specifications in this 

manual. Value set references are underlined in the specifications (e.g., Schizophrenia Value Set).

ICD-9/ICD-10 Conversion. In compliance with the CMS mandate to use ICD-10 codes for services 

provided on or after October 1, 2015, measures should be calculated using ICD-10 codes for claims 

with a date of service or date of discharge on or after October 1, 2015. Pertinent ICD-10 codes are 

available in the specification or in the corresponding value set. ICD-9-CM and ICD-9-PCS codes are 

still included in measures where the lookback period plus one year prior includes services before 

October 1, 2015. ICD-9 codes are still referenced in the following measures: ADD-CH, CBP-AD, DEPREM-6, PCR-AD, and SAA-AD.

Medication Lists. Several BHC measures derived from Medicaid Core Set measures reference 

medication lists, which are a list of codes and medications used to identify dispensed medications. The 

Medication List Directory is available to order free of charge in the NCQA Store. Once ordered, it can 

be downloaded from the NCQA Download Center. This applies to the following measures: ADD-CH, 

AMM-AD, APM-CH, APP-CH, CBP-AD, FUA-AD, FUA-CH, HBD-AD, IET-AD, and SAA-AD. Use 

the version that is current for the year being reported.
22 

Data Collection and Reporting

Risk adjustment

Among the measures that are part of the Medicaid Core Sets, one measure — the Plan All-Cause 

Readmissions (PCR-AD) — requires risk adjustment. Risk adjustment guidelines are included in 

the specification for the measure.

Reporting and Submission of Measures

Who collects and reports the data

Measures included in this technical specification 

manual are designed to be calculated and reported by 

either the BHC or the state, but all of them are 

specified to capture information at the BHC level 

rather than at a higher level of aggregation. For the 

Section 223 Demonstration, the responsibility for calculation and reporting reflects the fact that 

some measures require access to data that the clinics may not have (e.g., Follow-Up After 

Emergency Department Visit for Mental Illness (FUM-AD and FUM-CH)).

• Clinic responsibilities: For clinic-collected measures (Table 1), the BHC should report

the measures to the entity that requested it. In the case of the Section 223

Demonstration, CCBHCs report the required measures to their designated state agency

and the state agency reports them to SAMHSA. This is true for all required measures,

including the QBMs, although QBPs based on those measures will be calculated only

from clients who are Medicaid eligible, including Title 19-eligible Medicaid expansion

CHIP program beneficiaries (but not Title 21-eligible CHIP beneficiaries).

• State responsibilities: The state should report the measures that it collects and/or

calculates (whether received from the BHCs (Table 1) or calculated by the state using

administrative or other data (Table 2)) to the entity that requested it. In the case of the

Section 223 Demonstration, any data that the state is required to report (either on its own

or as a conduit for the CCBHCs) should be reported to SAMHSA. The data submitted

to SAMHSA will be reported for each CCBHC separately using the data-reporting

templates.

Data-reporting templates 

Data-reporting templates have been developed for each measure. For the Section 223 

Demonstration, CCBHCs and states reporting the measures must use the templates to submit the 

measure results. The templates are not part of an automated electronic system. Rather, the 

templates are worksheets that are to be completed and submitted by email to 

CCBHCMeasuresSubmission@samhsa.hhs.gov. 

In addition to guidance and technical specifications provided in this manual, instructions for 

completion of the templates are included in the template document. For purposes of the Section 

Level of Data Collected and Reported

Regardless of whether it is a clinic or 

state collecting and reporting the BHC 

measure data, the measures are always 

calculated at the BHC level, not at the 

state level.
23 

Data Collection and Reporting

223 Demonstration, CCBHCs and states should complete every field for each measure to meet 

reporting requirements and to ensure consistent reporting across CCBHCs and states. The

templates are separated into clinic-collected and state-collected measures; both have the same

fields. Clinics also are provided a worksheet to report on caseload characteristics. A final rollup worksheet automatically includes the results for all measures.

• Reporting: States and BHC providers are strongly encouraged to use the methods and

data sources listed in the specification for each measure; however, if states or BHC

providers use alternative methods or data sources, the deviations should be indicated in

Section E (Adherence to Measure Specification) of the pertinent data-reporting template.

Data auditing

Individual states may have specific data auditing requirements.

• Reporting: If the state has current mechanisms for external quality review reporting, or if

the state validates its measures, the states should note these processes in Section F

(Additional Notes) of the data-reporting template.

Changes to aspects of Quality Bonus Programs

If a Section 223 Demonstration state makes any changes to factors surrounding its QBP, such as 

any change that may differ from descriptions provided in the state’s original CCBHC 

Demonstration application regarding the methodology by which QBPs are made, factors that 

trigger payment, amount of payment, or how often payment is made, the state should report that 

with their submission. 

• Reporting: Changes related to the QBP must be reported as part of quality measure

reporting, either in Section F (Additional Notes) of the data-reporting template, or by

providing a separate attachment to the submission.

Submission deadlines

For non-CCBHC reporting, data must be submitted to 

the state or other entity that requires it.

For the Section 223 Demonstration Program, results for

the clinic-collected measures must be submitted to the 

state no later than nine months after the end of the 

Measurement Year. In turn, the state must submit both 

its state-collected measures and the previously received 

clinic-collected measures for that Measurement Year to 

SAMHSA no later than 12 months after the end of the Measurement Year. The completed 

reporting templates from the Section 223 Demonstration states should be submitted to SAMHSA 

using the following email address: CCBHCMeasuresSubmission@samhsa.hhs.gov. Submitted 

data should be complete and final at the submission deadline. The state may set separate

timeframes for the submission of data by CCBHCs that support the Quality Bonus Payments.

State and Clinic CCBHC Submission 

Deadlines

For purposes of the CCBHC Section 223 

Demonstration, CCBHCs report their 

measures to their state nine months after 

the end of the Measurement Year. States, 

in turn, report both those clinic-collected 

measures and their state-collected 

measures to SAMHSA 12 months after 

the end of the Measurement Year.
24

Data Collection and Reporting

For CCBHC-IAs and CCBHC-PDIs that are part of the Section 223 Demonstration, measures 

must be reported as required for all Demonstration CCBHCs. Additionally, those CCBHC-IAs 

and CCBHC-PDIs that are required by the terms of their SAMHSA grants to report measures 

(whether in the Section 223 Demonstration or not), must report to SAMHSA their most recent 

complete data no later than 90 days after the end of each 12-month grant budget period. 
25

Data Collection and Reporting

III. TECHNICAL SPECIFICATION COMPONENTS

This chapter presents the technical specification 

components for the BHC measures. Each 

specification includes a description of the 

measure and information about the eligible 

population, key definitions, data collection 

method(s), instructions for calculating the 

measure, and other relevant information. A brief 

introduction to each component of the 

specifications follows this paragraph, with the 

technical specifications themselves found in 

Chapters IV (Clinic-Collected) and V (StateCollected).

Description

The description section in each specification includes a narrative description of the 

measure, the applicable data source or collection method, guidance on reporting, and an 

explanation of the Measurement Period. Topics included in guidance on reporting vary by 

measure, but they typically address the following information on: 1) stratifications 

required for the measure; 2) the multiple rates included in the measure, if applicable; 3) 

potential sources of data for clinic-reported measures (i.e., administrative, hybrid, medical 

records, survey); 4) value sets if the measure relies on administrative data; 5) a reminder

to refer to the data-reporting template pertinent to the measure; and 6) any additional

information. The explanation of the Measurement Period provides information on the 

time period(s) for data used to compute the denominator and numerator, respectively.

Definitions

This section of each specification defines key terms relevant to the measure.

Eligible Population

The section defining the eligible population provides information needed for 

computation of the denominator, including requirements regarding the client’s 

relationship to the clinic, age, and insurance (the latter for claims-based data), and a stepby-step guide for determining the eligible population.

• Age requirements: The age criteria vary by measure. States and BHCs should

calculate and report rates for the total age-eligible population.

• Insurance requirements: Some measures include requirements related to

Important Information

For measures derived from the CMS 

Medicaid Adult and Child Core Sets, 

this manual incorporates: 

(1) the actual technical specification

generated by CMS with minor

annotations in that specification, and

(2) supplemental information that we

believe will be useful to reporters,

including very critical information

such as additional required

stratifications beyond those in the

CMS document.
26

Data Collection and Reporting

continuous enrollment in Medicaid or dual enrollment in Medicare and 

Medicaid, allowable insurance gaps, and an anchor date.

o Continuous enrollment: This requirement refers to the period of time

during which a client must be enrolled for Medicaid or CHIP benefits

or dually eligible for Medicare and Medicaid benefits to be included in

the eligible population for certain measures using administrative data. It

ensures that the provider has enough time to render services during the

Measurement Period. If applicable, the technical specifications provide

the continuous enrollment requirement for the measure. To be

considered continuously enrolled, a client must also be continuously

enrolled with the benefit specified for each measure (e.g., pharmacy or

mental health), accounting for any allowable gap. States should

combine data across programs (e.g., Medicaid and CHIP), delivery

systems (e.g., managed care and fee-for-service), and managed care

plans when analyzing continuous enrollment for a client. For example,

a client might switch between Medicaid programs or between managed

care plans, and should be counted for the measure as long as the

continuous enrollment criteria in the measure specification are met.

o Allowable gap: Some measures specify an allowable gap that can occur

during continuous enrollment for Medicaid or CHIP, or for dually eligible

Medicare and Medicaid enrollment. For example, the CBP-AD measure

requires continuous enrollment throughout the Measurement Year (January 1–

December 31) and allows one gap in Medicaid and CHIP enrollment of up to

45 days. Thus, a client who enrolls for the first time on February 8 of the

Measurement Year is considered continuously enrolled as long as there are no

other gaps in enrollment throughout the remainder of the Measurement Year,

because this client has one 38-day gap (January 1–February 7). A client who

switches between Medicaid or CHIP programs, delivery systems, or managed

care plans should be included in a measure as long as there is no gap in

Medicaid or CHIP coverage that exceeds the allowable gap specified in the

measure.

o Anchor date: Some measures include an anchor date, which is the

date that an individual must be enrolled in Medicaid or CHIP and

have the required benefit to be eligible for the measure. If a measure

requires a Medicaid beneficiary, or a dually eligible Medicare and

Medicaid beneficiary, to be enrolled and to have a benefit on a

specific date, the allowable gap must not include the anchor date.
27

Data Collection and Reporting

• Reporting: States and BHCs should note any deviations from the specifications 

in Section E of the data-reporting template (Adherence to Measure

Specifications) and, if necessary, Section F (Additional Notes).

Measure Specification

The measure specification explains how to compute: 1) the denominator (the eligible 

population with any relevant exclusions) and 2) the numerator (some subset of the

denominator that typically has received the service or achieved the outcome being

measured). If the measure requires reporting of multiple rates or other types of measures, 

specifications for each are included. Relevant Measurement Periods also are addressed

within the specification.

• Required and optional exclusions: Some measure specifications contain

required or optional exclusions. A BHC client who meets required exclusion 

criteria should be removed from the eligible population as stated in the technical 

specification. Most exclusions are to the denominator and numerator, but some 

apply only to the numerator. 

• Reporting: If an optional exclusion is used, this fact should be so stated

in Section E (Adherence to Measure Specification) of the data-reporting 

template.

• Hospice exclusion: Some measures include a required hospice exclusion: ADDCH, AMM-AD, APM-CH, APP-CH, ASC, CBP-AD, DEP-REM-6, FUA-AD, 

FUA-CH, FUH-AD, FUH-CH, FUM-AD, FUM-CH, HBD-AD, IET-AD, PCRAD, SAA-AD, TSC, and WCC-CH. For these measures, states should exclude 

BHC clients who use hospice services or elect to use a hospice benefit any time 

during the measurement year, regardless of when the services began. These 

clients may be identified using various methods, which may include but are not 

limited to, enrollment data, medical record, or claims/encounter data, or 

supplemental data for this required exclusion.

States should remove BHC clients under the hospice exclusion while they are 

determining the measure’s eligible population. For measures calculated using 

the hybrid process, states should remove these clients before drawing the 

sample. If a client is found to be in hospice or using hospice services during the 

medical record review portion if using the hybrid approach, the client is 

removed from the sample and replaced by a client from the oversample. If the 

documentation shows that a client is near the end of life (e.g., comfort care, Do 

Not Resuscitate [DNR], Do Not Intubate [DNI]), or is in palliative care, but is 
28

Data Collection and Reporting

not in hospice, the client does not meet criteria for the hospice exclusion and 

therefore must not be removed from the sample on that basis.

Supplemental data can be used for the hospice exclusion for all applicable 

measures, including for the PCR-AD measure which otherwise says

“supplemental data may not be used for the measure.”

• Deceased client exclusion: Some measures include a deceased client exclusion: 

ADD-CH, AMM-AD, APM-CH, APP-CH, CBP-AD, FUA-AD, FUA-CH, 

FUH-AD, FUH-CH, FUM-AD, FUM-CH, HBD-AD, IET-AD, SAA-AD, and 

WCC-CH. For these measures, if a state can identify BHC clients who die 

during the Measurement Year, these clients should be excluded consistently 

from the measures. Deceased clients may be identified using various methods 

that include, but are not limited to, enrollment data, medical record review, 

claims/encounter data, or supplemental data.

For a measure where hybrid data are being used, if a state excludes deceased

clients, it should attempt to remove them while it is determining the eligible 

population and before drawing the sample for hybrid measures. If, during 

medical record review, a client is found to be deceased, the client can be 

removed from the sample and replaced by a client from the oversample.

The deceased client exclusion is a client-level exclusion. For episode-based 

measures, if one event does not meet numerator criteria and the state chooses to 

use this optional exclusion, remove all client events/episodes from the measure.

Additional Notes

This section contains additional information relevant to the measure.

Frequently Asked Questions

These are questions that have been asked in the past and potential future questions with their 

answers.
29

Clinic-Collected Measure Technical Specifications

IV. CLINIC-COLLECTED MEASURE TECHNICAL 

SPECIFICATIONS

Section IV contains the technical specifications and other guidance for the Clinic-Collected BHC 

measures, including five measures that are required as part of the Section 223 CCBHC 

Demonstration and for SAMHSA CCBHC-IA and CCBHC-PDI grantees, and five measures that 

are optional. These are:

Required Measures: 

1. Time to Services (I-SERV)

2. Depression Remission at Six Months (DEP- REM-6)

3. Preventive Care and Screening: Unhealthy Alcohol Use: Screening and Brief Counseling 

(ASC)

4. Screening for Social Drivers of Health (SDOH)

5. Screening for Clinical Depression and Follow-Up Plan (CDF-AD and CDF-CH)

Optional Measures:

1. Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention (TSC)

2. Major Depressive Disorder: Suicide Risk Assessment (SRA-A)

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

(SRA-C)

4. Weight Assessment and Counseling for Nutrition and Physical Activity for 

Children/Adolescents (WCC-CH)

5. Controlling High Blood Pressure (CBP-AD)
30

Clinic-Collected Measures Required for Submission as Part of CCBHC Demonstration

Clinic-Collected Measures Required for Submission as Part of CCBHC 

Demonstration

This section of Chapter IV includes the following Clinic-Collected required measures:

1. Time to Services (I-SERV)

2. Depression Remission at Six Months (DEP- REM-6)

3. Preventive Care and Screening: Unhealthy Alcohol Use: Screening and Brief Counseling 

(ASC)

4. Screening for Social Drivers of Health (SDOH)

5. Screening for Clinical Depression and Follow-Up Plan (CDF-AD and CDF-CH) —

including supplemental materials
31

Time to Services (I-SERV)

Time to Services (I-SERV)5

SAMHSA-Developed Measure

A. DESCRIPTION 

The I-SERV measure calculates the Average time for clients to access three different types of 

services at Behavioral Health Clinics (BHCs) reporting the measure. The I-SERV measure is 

comprised of three sub-measures of time until provision of: (1) initial evaluation, (2) initial 

clinical services, and (3) crisis services. 

Data Source: Medical Records

Important Reporting Guidance: 

This section of the specification includes important guidance for reporting the I-SERV 

measure. Also refer to section I for Frequently Asked Questions.

• I-SERV is a three-part measure. Each submeasure requires a separate calculation. 

• Providers will rely on medical records to compile the submeasures. There are several 

potential data sources that may be used individually or together to compile the 

submeasures: 

o An electronic scheduling or case management system that is used to schedule 

and monitor appointments and critical time frames 

o Electronic health records (including billing records) 

o Paper health records 

o A registry 

• I-SERV is stratified separately based on whether the client is:

o an adolescent (12–17 years of age) or an adult (18 years of age and older) 

AND 

o Medicaid only or Other (including those dually eligible for Medicare and 

Medicaid)

AND

o a member of which of the following ethnic groups: Not Hispanic or Latino, 

Hispanic or Latino, or Unknown

AND

5This measure differs from the previous I-EVAL measure. It incorporates part of that measure and adds 

submeasures related to time to Initial Clinical Services and time until provision of Crisis Services.
32

Time to Services (I-SERV)

o a member of which of the following racial groups: White or Caucasian, Black 

or African American, American Indian or Alaska Native, Asian, Native 

Hawaiian or Pacific Islander, More than one race, or Unknown

• Refer to the specific data-reporting template for the reporting requirements applicable 

to each measure.

Measurement Period: The Measurement Period is the period for which data are required for 

reporting purposes.

For Submeasures 1 and 2: The Measurement Period for the denominator is the 

Measurement Year, excluding the final month of that year, and including the 6 months 

preceding the Measurement Year. The Measurement Period for the numerator is the 

Measurement Year. See Figure 1 for visual depiction of Measurement Year and 

Measurement Periods for Submeasures 1 and 2.

Figure 1. Visual of Measurement Year and Measurement Periods for Submeasures 1 and 2

6 Months First Eleven Months of MY Last 30 Days of 

MY

Measurement Year (MY): 12-month reporting period

Denominator Measurement Period: First 11 months of MY + 6 months before the MY

Numerator Measurement Period: The MY

Key: MY: Measurement Year.

For Submeasure 3: The Measurement Period for the denominator is the Measurement Year, 

excluding the last 24 hours, and including the 24 hours immediately preceding the Measurement 

Year. The Measurement Period for the numerator is the Measurement Year. See Figure 2 for 

visual depiction of Measurement Year and Measurement Periods for Submeasure 3.

Figure 2. Visual of Measurement Year and Measurement Periods for Submeasure 3

24 H One Year (excluding final 24 H) 24 H

Measurement Year (MY): 12 month reporting period

Denominator Measurement Period: 24 hours before MY and MY (excluding last 24 hours)

Numerator Measurement Period: The MY

Key: H: Hours; MY: Measurement Year

B. DEFINITIONS 

TERM DEFINITION 

Average

The Average in this measure is calculated by dividing the 

sum of observations in the numerator by the number of 

observations in the denominator (N/D).

Business Days Monday through Friday, excluding state and federal 

holidays (regardless of days of operation) 

Crisis Episode or Crisis Service 

Episode

A Crisis Service Episode begins when an individual or 

someone acting on their behalf contacts the Crisis Service 

provider (whether a CCBHC or its crisis Designated 
33

Time to Services (I-SERV)

TERM DEFINITION 

Collaborating Organization (DCO)) requesting Crisis 

Services for the first time in a 24-hour period. 

Crisis Service or Crisis 

Management Service

Crisis Services such as those provided by CCBHCs in 

accordance with CCBHC certification criteria 2.C.

Designated Collaborating 

Organization (DCO)

A Designated Collaborating Organization is an entity that is 

not under the direct supervision of the CCBHC but is 

engaged in a formal relationship with the CCBHC and 

delivers services under the same requirements as the 

CCBHC. See Appendix A of CCBHC Certification Criteria 

for further information.

First Contact (for Purposes of 

Initial Evaluation or Clinical 

Service)

First Contact represents the first time that an individual or 

guardian contacts a BHC to obtain services for the 

individual in a six-month period. First Contact may be by 

telephone. First Contact for a CCBHC should include the 

required preliminary screening and risk assessment and 

collection of basic data about the person that includes 

insurance information. A referral from a primary care 

physician or other provider is not a First Contact (contact 

must be between the prospective client and the 

CCBHC).Only one contact in a six-month period will count 

(with six months being used to determine if the person is a 

New Client). 

Note: The idea of First Contact does not apply to 

submeasure 3 regarding Crisis Services.

Initial Clinical Service

Some certification standards, such as the CCBHC 

certification criteria, require that Initial Clinical Services be 

carried out for New Clients within a specified time frame 

based on the acuity of needs. In the case of a CCBHC, 

Initial Clinical Services occur after a preliminary screening 

and risk assessment to determine acuity of needs and after 

or at the time of an Initial Evaluation. CCBHC criteria 

require the Initial Clinical Services to occur within 10 

Business Days of First Contact for those who present with 

“routine” non-emergency or non-urgent needs. That 

standard is used in this specification. Other standards may 

exist for other entities and this specification can be adapted 

accordingly.

Initial Evaluation 

Some certification standards, such as the CCBHC 

certification criteria, require that an Initial Evaluation be 

carried out for New Clients within a specified time frame 

based on the acuity of needs. In the case of a CCBHC, the 

Initial Evaluation is due within 10 Business Days of First 

Contact for those who present with “routine” nonemergency or non-urgent needs. That standard is used in 
34 

Time to Services (I-SERV)

TERM DEFINITION 

this specification. Other standards may exist for other 

entities and this specification can be adapted accordingly. 

Measurement Period

The specific time period for which data are needed for the 

numerator and denominator of a given measure. The 

Measurement Period may differ for the numerator and 

denominator and for each measure and is specified in 

section A above.

Measurement Year The standard 12-month reporting period common to all 

measures being reported by the Provider Entity.

New Client An individual not seen at the clinic in the past 6 months 

Provided 

As used in the context of the measured services being 

“Provided” by the clinic, the word “Provided” means 

“received.” 

Provider Entity The Provider Entity that is being measured (i.e., BHC) 

Seeking Crisis Services

Seeking Crisis Services includes instances when a client 

actively seeks crisis services or when others seek services 

on a client’s behalf.

Submeasure

I-SERV is comprised of calculations for three different

services, with each calculated average time to service being

a submeasure.

C. ELIGIBLE POPULATION FOR SUBMEASURES 1 AND 2

CRITERIA REQUIREMENTS 

Event/Age

Follow the steps below to identify the eligible population: 

Step 1 

Identify New Clients who contacted the Provider Entity 

seeking services during the Measurement Year. 

Note: New Clients are those who have not been served at 

the clinic in the past six months.

Step 2 

Identify clients from step 1 of ages 12 years and older as of 

the end of the Measurement Year. 

D. ELIGIBLE POPULATION FOR SUBMEASURE 3

CRITERIA REQUIREMENTS 

Event/Age

Follow the steps below to identify the eligible population: 

Step 1 

Identify clients who contacted the Provider Entity or its 

crisis DCO Seeking Crisis Services for a new Crisis 

Episode during the Measurement Year. 
35

Time to Services (I-SERV)

CRITERIA REQUIREMENTS 

Note: A Crisis Service Episode begins when the Crisis 

Service provider (whether a CCBHC or its crisis DCO) 

receives a contact related to needed Crisis Services for a 

client for the first time in 24 hours.

Note: A single individual may have multiple Crisis Service 

Episodes over the course of the Measurement Year and each 

such episode is counted. 

Step 2 

Identify clients from step 1 of ages 12 years and older as of 

the end of the Measurement Year. 

E. SUBMEASURE SPECIFICATION #1 

The Average number of days until Initial Evaluation for New Clients (see Figure 3 for visual) 

Denominator 

The number of clients in the eligible population (Section C). 

Denominator Exclusions 

Exclude from the Submeasure #1 denominator all eligible New Clients who never 

received an Initial Evaluation. Indicate in Additional Notes in the data reporting template 

the number so excluded. 

Note: The Measurement Period for the denominator is the Measurement Year excluding the last 

month of the Measurement Year and including the 6 months preceding the Measurement Year. 

Numerator 

The total number of days between First Contact and Initial Evaluation for all members of the 

Section E denominator population (after exclusions) 

Note: The Measurement Period for the numerator is the Measurement Year. Any who received 

an Initial Evaluation after the last day of the Measurement Year are treated as having been 

evaluated 31 days after First Contact. 
36

Time to Services (I-SERV)

Figure 3. Visual of Submeasure 1 Specification

Key: MP: Measurement Period; MY: Measurement Year.

F. SUBMEASURE SPECIFICATION #2

The Average number of days until Initial Clinical Service for New Clients (see Figure 4 for 

visual)

Denominator 

The number of clients in the eligible population (Section C).

Denominator Exclusions 

Exclude from the Submeasure #2 denominator all eligible New Clients who never 

received a clinical service. Indicate in Additional Notes in the data reporting template the 

number excluded.

Note: The Measurement Period for the denominator is the Measurement Year excluding the last 

month of the Measurement Year and including the 6 months preceding the Measurement Year.

Numerator 

The total number of days between First Contact and Initial Clinical Service for all members of 

the Section F denominator population (after exclusions) 

Denominator MP🡺 First 11 months of MY + 6 months before the MY

1. The number of all New Consumers during the MY (those with First Contact during the MY and not seen 

during the prior 6 months)

2. Exclude those who would be New Consumers but who had First Contact during the last 30 days 

of the MY

3. Exclude those age 11 years or younger as of the last day of the MY

4. Exclude those who never received an Initial Evaluation (specify the number 

excluded for this reason in the Additional Notes)

Equals (=) Denominator

Numerator MP🡪 12 month MY

In the Denominator population, total number of days between First Contact and Initial 

Evaluation (if Initial Evaluation after MY, count as 31 days)

Equals (=) Numerator
37

Time to Services (I-SERV)

Note: The Measurement Period for the numerator is the Measurement Year. Any who received 

an Initial Clinical Service after the last day of the Measurement Year are treated as having been 

served 31 days after First Contact. 

Figure 4. Visual of Submeasure 2 Specification

Key: MP: Measurement Period; MY: Measurement Year. 

G. SUBMEASURE SPECIFICATION #3

The Average number of hours until provision of Crisis Services following a first Crisis Episode 

contact (see Figure 5 for visual). 

Note: This submeasure applies to face to face crisis services (e.g. mobile crisis) but not to crisis 

hotlines. 

Denominator 

The number of clients in the eligible population (Section D). 

Note: A single individual may have multiple Crisis Service Episodes over the course of the 

Measurement Year and each such episode is counted. Additionally, the concept and definition of 

First Contact do not apply to submeasure 3. 

Denominator Exclusions 

Exclude from the Submeasure #3 denominator all clients who never received a Crisis 

Service in response to a Crisis Episode contact. Indicate in Additional Notes in the data 

reporting template the number so excluded. 

Denominator MP🡺 First 11 months of MY + 6 months before the MY

1. The number of all New Consumers during the MY (those with First Contact during the MY and not seen

during the prior 6 months)

2. Exclude those who would be New Consumers but who had First Contact during the last 30 days

of the MY

3. Exclude those age 11 years or younger as of the last day of the MY

4. Exclude those who never received an Initial Clinical Service (specify the 

number excluded for this reason in the Additional Notes)

Equals (=) Denominator

Numerator MP🡪 12 month MY

In the Denominator population, total number of days between First Contact and Initial Clinical 

Service (if Initial Clinical Service after MY, count as 31 days)

Equals (=) Numerator
38

Time to Services (I-SERV)

Note: The Measurement Period for the denominator is the Measurement Year excluding the last 

24 hours of the Measurement Year and including the 24 hours immediately preceding the 

Measurement Year. 

Numerator 

The total number of hours between Crisis Episode contact and related provision of a Crisis 

Service for all members of the Section G denominator population (after exclusions) 

Note: The Measurement Period for the numerator is the Measurement Year. Any who received a 

Crisis Service after the last day of the Measurement Year in response to a Crisis Episode contact 

during the Measurement Year are treated as having been served 24 hours after the Crisis Episode 

contact. 

Figure 5. Visual of Submeasure 3 Specification

Key: MP: Measurement Period; MY: Measurement Year.

H. ADDITIONAL NOTES 

This measure is designed to require provider-level reporting. 

Interpretation of scores: 

Mean number of days until Initial Evaluation or Initial Clinical Services for New 

Clients: Better quality = Lower number

Mean number of hours until receipt of Crisis Services after a Crisis Episode contact:

Better quality = Lower number

Denominator MP🡺 24 hours before MY and MY (excluding last 24 hours of MY)

1. The number of consumers who sought Crisis Services for a new Crisis Episode during the MY (a new Crisis 

Episode is one that has not involved crisis contact with the CCBHC during the prior 24 hours)

2. Exclude those consumers included in step 1 immediately above who had the Crisis Episode 

contact during the last 24 hours of the MY

3. Exclude those age 11 years or younger as of the last day of the MY

4. Exclude those who never received a Crisis Service related to the Crisis Episode 

contact (specify the number excluded for this reason in the Additional Notes )

Equals (=) Denominator

Numerator MP🡪 12 month MY

In the Denominator population, total number of hours between Crisis Episode contact and 

related provision of Crisis Service (if Crisis Service provided after MY, count as 24 hours)

Equals (=) Numerator
39

Time to Services (I-SERV)

I. FREQUENTLY ASKED QUESTIONS

Questions Regarding Age: 

Q: Why is this measure not reported for children younger than 12 years of age?

A: Ensuring timely access for younger children is important. If BHCs wish, they may report this 

measure for children younger than age 12 years of age but that information should be included in 

the additional notes in the bottom of the I-SERV data reporting template.

Questions Regarding Clients Who Do Not Attend Appointments within 10 Days:

Q: Why should we be penalized for clients who do not attend appointments within 10 days of 

First Contact?

A: For Submeasures 1 and 2, it is likely that some New Clients will not have an appointment 

within 10 days because of their own schedules, non-urgent needs, and/or rescheduling. This 

situation is a recognized limitation of this measure that will affect all clinics. Trying to adjust for 

New Clients who are offered but do not accept an appointment within 10 Business Days 

complicates the calculation. The same is true for clients who are referred only for forensic 

evaluation or who only seek service during a crisis but may go elsewhere for additional services. 

We suggest that, if you see patterns over time, you report in the space for additional notes in the 

bottom of the I-SERV data reporting template.

Questions Regarding Clients Who Do Not Receive Crisis Services within 24 Hours of Contact:

Q: Why should we be penalized for clients who contact us in crisis but are not seen within 24 

hours of a Crisis Episode contact for no fault of ours?

A: Submeasure 3 is just a measure of your average time to provision of Crisis Services. The 24-

hour time period is used only to indicate a new crisis episode and for no other reason. Moreover, 

for a variety of reasons, it is likely that some clients will not receive Crisis Services as promptly 

as others, which is why we are using an average over the course of a year. 

Questions regarding multiple Crisis Episodes:

Q: If a client has multiple Crisis Episodes during the Measurement Year, is each episode counted 

in submeasure 3?

A: Yes, each episode is counted, provided there are more than 24 hours between episodes. 
40 

Depression Remission at Six Months (DEP-REM-6)

Depression Remission at Six Months (DEP-REM-6)6

Based on CMS MIPS CQMS #370 (2023), stewarded by MN Community Measurement (CBE

#0710), modified for Depression Remission at Six Months (CBE #0711)

A. DESCRIPTION

The DEP-REM-6 measure calculates the Percentage of clients (12 years of age or older) with 

Major Depression or Dysthymia who reach Remission Six Months (+/- 60 days) after an Index 

Event Date.

Data Source: Medical Records 

Important Reporting Guidance:

This section of the specification includes important guidance for reporting the DEP-REM-6 

measure. Also refer to section (F) on Frequently Asked Questions.

• This measure is to be reported once per Measurement Year for clients seen during the

Measurement Year with a diagnosis of Major Depression or Dysthymia and an initial

Patient Health Questionnaire – 9 item version (PHQ-9) or Patient Health Questionnaire –

9 Modified for Teens and Adolescents (PHQ-9M) greater than nine (Index Event).

• Providers will rely on medical records to compile this information. There are several

potential sources of information that may be used individually or together:

o Electronic health records (including billing records)

o Paper health records

o A registry

• G or M codes are not available for this measure. Instead, a Provider may rely on an

equally reliable source of information to indicate numerator compliance.

• DEP-REM-6 is stratified separately based on whether the client is:

o an adolescent (12-17 years of age) or an adult (18 years of age and older,

AND

o Medicaid only or Other (including those dually eligible for Medicare and

Medicaid)

AND

o a member of which of the following ethnic groups: Not Hispanic or Latino,

Hispanic or Latino, or Unknown

AND

6This measure differs from the 2016 Behavioral Health Clinic measure (DEP-REM-12) which looked at remission at 

12 months. This measure only requires measurement of remission at six months.
41 

Depression Remission at Six Months (DEP-REM-6)

o a member of which of the following racial groups: White or Caucasian,

Black or African American, American Indian or Alaska Native, Asian,

Native Hawaiian or Pacific Islander, More than one race, or Unknown

o Refer to the specific data-reporting template for the reporting requirements applicable to

each measure.

Measurement Period: The Measurement Period is the period for which data are required for 

reporting purposes. The Measurement Period for the denominator is the Measurement Year. 

The Measurement Period for the numerator begins four months after the beginning of the 

Measurement Year and extends eight (8) months past the end of the Measurement Year; this 

allows capture of Remission in the period 4 to 8 months after an Index Event Date that may 

occur at any point during the Measurement Year (6 months (+/- 60 days)). This equates to a four 

month window around the six month calendar date from the Index Event Date (+/- 60 days). See 

Figure 1 for visual depiction of Measurement Year, Measurement Periods, Index Event Dates 

and Measure Assessment Period.

Figure 1. Visual of Measurement Year, Measurement Periods, and Index Event Dates for 

Remission at Six Months

Key: IED: Index Event Date; MY: Measurement Year; MP: Measurement Period; R: Six Month Remission may be 

measured, depending on date, 4-8 months after IED (6 months (+/- 60 days)).

B. DEFINITIONS

TERM DEFINITION 

Index Event 

Date 

The date on which the first instance of elevated PHQ-9 or PHQ-9M greater than nine 

AND diagnosis of Depression or Dysthymia occurs during the Measurement Year. 

Clients may be screened using PHQ-9 or PHQ-9M up to seven days prior to the 

encounter (including the day of the encounter).
42

Depression Remission at Six Months (DEP-REM-6)

TERM DEFINITION 

Measure 

Assessment 

Period7

The Index Event Date marks the start of the Measure Assessment Period for each 

client, which is 14 months (12 months +/- 60 days). This period is fixed and does not 

“start over” with a higher PHQ-9 or PHQ-9M that may occur after the Index Event 

Date. The Measure Assessment Period is held constant to accommodate both the six 

and twelve month depression outcome measures, if both are being used, so that the 

client does not re-index after the Six Month assessment. The window for assessing 

the Six Month measure, however, is at 6 months (+/- 60 days) or 4 to 8 months after 

Index Event Date. 

Measurement 

Period

The specific time period for which data are needed for the numerator and 

denominator of a given measure. The Measurement Period may differ for the 

numerator and denominator and for each measure and is specified in section A 

above.

Measurement 

Year

The standard 12-month reporting period common to all measures being reported by 

the Provider.

Percentage A Percentage is calculated as follows: numerator divided by denominator (n/d).

PHQ-9 The Patient Health Questionnaire (PHQ-9) tool is a widely accepted, standardized 

patient reported outcome tool that is completed by the client, ideally at each visit, 

and utilized by the provider to monitor treatment progress. It is available in many 

languages and was developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt 

Kroenke, et al. It is in the public domain and can be obtained for free use on the 

Patient Health Questionnaire (PHQ) Screeners website at Link to PHQ-9. More than 

75 language versions are available.

PHQ-9M The PHQ-9M is a modification of the PHQ-9 geared for use with adolescents and, 

although it has not been validated, is widely used. This tool is similar to the PHQ-9 

with only a few minor age-related wording modifications (e.g., schoolwork instead 

of newspaper) and scores with the same cut-points as the PHQ-9. The tool developer 

approved the minor wording changes. According to the measure developer, the 

American Psychiatric Association (APA) recommends using the PHQ-9M for 

children ages 11 to 17 to assess depression symptom severity (APA, 2015. Online 

Assessment Measures. Severity Measure for Depression, Child Age 11 to 17 (PHQ9 modified for Adolescents [PHQ-A], Adapted) at Link to PHQ-9M.

Provider The Provider entity that is being measured (i.e., BHC) 

Remission A PHQ-9 or PHQ-9M score of less than five 

Six Months The point in time from the Index Event Date extending out “Six Months” and then 

allowing a grace period of sixty days prior to and sixty days after this date. The most 

recent PHQ-9 or PHQ-9-M score less than five obtained during this four-month 

period is deemed Remission at Six Months; values obtained prior to or after this 

period are not counted as numerator compliant (Remission).

C. ELIGIBLE POPULATION 

CRITERIA REQUIREMENTS 

Event/Age Follow the steps below to identify the eligible population:

Step 1

7The Measure Assessment Period is only applicable to Providers reporting both a Six Month and Twelve Month 

Depression Remission outcome measure.
43

Depression Remission at Six Months (DEP-REM-6)

CRITERIA REQUIREMENTS 

Identify clients seen at the Provider during the Measurement Year.

Step 2

Identify clients from step 1 who were aged 12 years or older at the Index Event Date.

Step 3

Identify clients from step 2 who:

• Have an active diagnosis of Major Depression or Dysthymia (ICD-10-CM): 

F32.0, F32.1, F32.2, F32.3, F32.4, F32.5, F32.9, F33.0, F33.1, F33.2, F33.3, 

F33.40, F33.41, F33.42, F33.9, F34.1

• At a client encounter during the Measurement Year (CPT or HCPCS): 

90791, 90792, 90832, 90834, 90837, 99202, 99203, 99204, 99205, 99211, 

99212, 99213, 99214, 99215, G0402, G0438, G0439, 99384*, 99394*, 

99421, 99422, 99423, 99441, 99442, 99443, 96156, 96158, 96159

NOTE #1: The diagnosis of Major Depression or Dysthymia may be in any 

diagnostic field and need not be the primary diagnosis.

NOTE #2: Client encounters for this measure conducted via telehealth (e.g., 

encounters coded with GQ, GT, 95, or POS 02 modifiers) are allowable.

NOTE #3: *Signifies that this CPT Category I code is a non-covered service under 

the Medicare Part B Physician Fee Schedule (PFS). These non-covered services 

should be counted in the eligible population.

Step 4

Identify clients from step 3 who have an Index Event Date PHQ-9 or PHQ-9M score 

greater than nine (9) documented during the denominator Measurement Period (as 

specified in Section A). 

NOTE #1: To be considered denominator eligible for this measure, the client must 

have both the diagnosis of Depression or Dysthymia and a PHQ-9 or PHQ-9M score 

greater than nine (9) documented on the same date or up to seven (7) days prior to 

encounter (Index Event) and this date occurs during denominator Measurement 

Period (as specified in Section A).

D. MEDICAL RECORD SPECIFICATION 

DENOMINATOR: 

All clients (aged 12 years or older with Major Depression or Dysthymia and an initial PHQ-9 or 

PHQ-9M score greater than nine on the Index Event Date (see Figure 2 for visual).

NOTE #1: The diagnosis of Major Depression or Dysthymia may be in any diagnostic field and 

need not be the primary diagnosis.
44

Depression Remission at Six Months (DEP-REM-6)

Denominator Criteria:

All clients in the Eligible Population (section C)

AND NOT

Denominator Exclusions: 

Clients with an active diagnosis of Bipolar Disorder any time prior to the end of their 

numerator Measurement Period or, if the Provider also is reporting the Twelve Month 

Remission measure, their Measure Assessment Period:

o The following codes would be sufficient to define the Denominator Exclusion 

of Bipolar Disorder: 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 or F31.9

o For historical reference purposes, these ICD-9 codes, if documented, would be 

sufficient to define the Denominator Exclusion of Bipolar Disorder: 296.00, 

296.01, 296.02, 296.03, 296.04, 296.05, 296.06, 296.10, 296.11, 296.12, 

296.13, 296.14, 296.15, 296.16, 296.40, 296.41, 296.42, 296.43, 296.44, 

296.45, 296.46, 296.50, 296.51, 296.52, 296.53, 296.54, 296.55, 296.56, 

296.60, 296.61, 296.62, 296.63, 296.64, 296.65, 296.66, 296.7, 296.80, 

296.81, 296.82 or 296. 89

OR

Clients with an active diagnosis of Personality Disorder any time prior to the end of their 

numerator Measurement Period or, if the Provider also is reporting the Twelve Month 

Remission measure, their Measure Assessment Period:

o The following codes would be sufficient to define the Denominator Exclusion 

of Personality Disorder: F34.0, F60.3, F60.4, F68.10, F68.11, F68.12 or 

F68.13

o For historical reference purposes, these ICD-9 codes, if documented, would be 

sufficient to define the Denominator Exclusion of Personality Disorder: 

301.13, 301.50, 301.51 or 301.83

OR

Clients with an active diagnosis of Schizophrenia or Psychotic Disorder any time prior to 

the end of their numerator Measurement Period or, if the Provider also is reporting the 

Twelve Month Remission measure, their Measure Assessment Period:

o The following codes would be sufficient to define the Denominator Exclusion 

of Schizophrenia or Psychotic Disorder: F20.0, F20.1, F20.2, F20.3, F20.5, 

F20.81, F20.89, F20.9, F21, F23, F25.0, F25.1, F25.8, F25.9, F28 or F29

o For historical reference purposes, these ICD-9 codes, if documented, would be 

sufficient to define the Denominator Exclusion of Schizophrenia or Psychotic 

Disorder: 295.00, 295.01, 295.02, 295.03, 295.04, 295.05, 295.10, 295.11, 
45

Depression Remission at Six Months (DEP-REM-6)

295.12, 295.13, 295.14, 295.15, 295.20, 295.21, 295.22, 295.23, 295.24, 

295.25, 295.30, 295.31, 295.32, 295.33, 295.34, 295.35, 295.40, 295.41, 

295.42, 295.43, 295.44, 295.45, 295.50, 295.51, 295.52, 295.53, 295.54, 

295.55, 295.60, 295.61, 295.62, 295.63, 295.64, 295.65, 295.70, 295.71, 

295.72, 295.73, 295.74, 295.75, 295.80, 295.81, 295.82, 295.83, 295.84, 

295.85, 295.90, 295.91, 295.92, 295.93, 295.94, 295.95, 298.0, 298.1, 298.4, 

298.8 or 298.9

OR

Clients with an active diagnosis of Pervasive Developmental Disorder any time prior to 

the end of their numerator Measurement Period or, if the Provider also is reporting the 

Twelve Month Remission measure, their Measure Assessment Period:

o The following codes would be sufficient to define the Denominator Exclusion 

of Pervasive Developmental Disorder: F84.0, F84.3, F84.8 or F84.9

o For historical reference purposes, these ICD-9 codes, if documented, would be 

sufficient to define the Denominator Exclusion of Pervasive Developmental 

Disorder: 299.00, 299.01, 299.10, 299.11, 299.80, 299.81, 299.90 or 299.91

OR

Clients who died any time prior to the end of their numerator Measurement Period or, if 

the Provider also is reporting the Twelve Month Remission measure, their Measure 

Assessment Period

OR

Clients who received hospice or palliative care service any time during the numerator 

Measurement Period or, if the Provider also is reporting the Twelve Month Remission 

measure, their Measure Assessment Period:

o The following code would be sufficient to define the Denominator Exclusion 

of hospice or palliative care: Z51.5

NUMERATOR: 

All clients in the denominator who achieved Remission at Six Months as demonstrated by a 

Six Month (+/- 60 days) PHQ-9 or PHQ-9M score of less than five (5) (see Figure 2 for 

visual)

Numerator Options:

Performance Met: Client identified as achieving Remission at Six Months as demonstrated 

by a Six Month (+/- 60 days) PHQ-9 or PHQ-9M score of less than 5 

OR

Performance Not Met: Remission at Six Months NOT demonstrated by:

• A Six Month (+/- 60 days) PHQ-9 or PHQ-9M score of less than five 

OR

• PHQ-9 or PHQ-9M score was not assessed during the allowed time period 
46

Depression Remission at Six Months (DEP-REM-6)

NOTE #1: The Measurement Period for the numerator begins four months after the 

beginning of the Measurement Year and extends eight (8) months past the end of the 

Measurement Year; this allows capture of Remission in the period 4 to 8 months after an 

Index Event Date (6 months (+/- 60 days)), as the Index Event Date may occur at any point 

during the Measurement Year. The Measure Assessment Period is held constant to 

accommodate both six and twelve month depression outcome measures for those who choose 

or are required to use both. Thus, the total Measure Assessment Period is 14 months so that 

the client does not re-index after the six month assessment.

NOTE #2: If more than one PHQ-9 or PHQ-9M is administered during the Measurement 

Period for the numerator, the most recent (latest) occurring within the Measurement Period is 

used.
47

Depression Remission at Six Months (DEP-REM-6)

Figure 2. Visual of DEP-REM-6 Specification

Key: MP: Measurement Period; MY: Measurement Year. 

a The Numerator MP is the total potential time for which data must be available to compute the numerator. 

The reporter does not have 20 months to meet remission for Clients. Rather, this MP is for the entire group of 

Clients in the denominator, with the individual’s remission measured depending on when the Index Event 

occurred in the 12 month MY.

E. ADDITIONAL NOTES

Both this and the source measure were specified at the provider level. This measure is not risk 

adjusted, although the source measure when reported to the state of Minnesota is. The source 

measure was assessed for reliability and validity for clinics with ≥ 30 clients in the denominator. 

This measure is modified from the source measure to provide a specification consistent in format 

to other measures in this set of BHC measures. The substance of the measure is unchanged. 

Interpretation of scores: Better quality = Higher Percentage

F. FREQUENTLY ASKED QUESTIONS

Questions Related to Screening Tools Required to be Used:

Q: Must we use the PHQ-9 or PHQ-9M?

A: Yes, you must use one of those two instruments/screening tools. The developers of the 

source measure reviewed 21 additional tools against standardized criteria and concluded very 

few had cut-points for severity levels of depression or Remission. Further, using patient-reported 

outcome tools with significantly different numbers of questions could impact the response 

measures in addition to adversely affecting denominator comparability. 

Denominator MP🡺 12 month MY

1. The number of all clients seen during the MY who have an active diagnosis of Major Depression or 

Dysthymia and a PHQ-9 or PHQ-9M score greater than nine (9) at an encounter during the MY (Index Event)

2. Exclude those age 11 years or younger at the Index Event Date

3. Exclude those with any of these active diagnoses: Bipolar Disorder, Personality Disorder, Schizophrenia or 

Psychotic Disorder, or Pervasive Developmental Disorder, or who died prior to the end of their numerator 

Measurement Period; or who received hospice or palliative care ay any time during their numerator MP

Equals (=) Denominator

Numerator MP🡪a 12 month MY 8 months after MY

In the Denominator population, all those who achieved Remission at Six Months as 

demonstrated by a Six Month (+/- 60 days) PHQ-9 or PHQ-9M score of less than five (5)

Equals (=) Numerator
48

Depression Remission at Six Months (DEP-REM-6)

Q: Do we have to pay for the PHQ-9 or PHQ-9M?

A: No, these tools are in the public domain and require no further permission for use. More 

information can be obtained from the tool developer. To obtain a copy of the PHQ-9 tool or 

additional language translations, please visit www.phqscreeners.com. 

Q: Is the PHQ-9M required to be used for adolescents? 

A: No. Providers may elect to use either tool (the PHQ-9 or PHQ-9M); there is no measure 

construct restriction for age. According to MN Community Measurement, the PHQ-9 is validated 

for use for ages 13 years and older, however a provider group can elect to administer this tool for 

twelve-year-old clients as well. The depression measure development workgroup decided not to 

restrict the measure construct by age and supports the most efficient use of tools depending on 

the population of clients in each clinic.

Questions Related to How and When Screening Tools are Used and Scored:

Q: Some of our clinics have not used the PHQ-9 in the past, so clients currently being seen by 

the clinics for Major Depressive Disorder/Dysthymia do not have PHQ-9 or PHQ-9M scores. Do 

these clinics need to screen all their current clients using the PHQ-9 or PHQ-9M at the first visit 

during the DY? 

A: The measure requires that BHC include in the denominator clients who (1) were seen at the 

BHC during the MY; (2) had a diagnosis of Major Depressive Disorder/Dysthymia; (3) were age 

12 years or older, and (4) had a PHQ-9 or PHQ-9M score greater than 9 on the day they 

presented (or up to seven days prior). Careful examination of the metric indicates that the 

measure does not require universal population screening with a PHQ-9/PHQ-9M of all patients, 

however, when screening does occur and results in a score greater than nine, indicating a need 

for treatment, the patient is included in the denominator with an expectation for assessing for the 

outcome of remission at six months.

Q: Can someone other than the client complete the PHQ-9 or PHQ-9M (i.e., a proxy)?

A: No, the client must complete it themselves.

Q: Must the PHQ-9 or PHQ-9M be collected in a face to face office visit?

A: According to MN Community Measurement, acceptable methods for obtaining PHQ-9/PHQ9M scores include traditional paper or electronic versions and they can be collected via:

• Office visit/in-person

• Telephone encounter

• E-visit

• Mail (post)

• Electronic administration (email, client portal, iPad/tablet, client kiosk)

Q: Who can administer the PHQ-9 or PHQ-9M?

A: According to MN Community Measurement, anyone can administer these tools, including 

office staff, the care team, receptionists, medical assistants, etc. For purposes of insurance 

billing, however, the Index Visit must be with an insurance-eligible provider.
49

Depression Remission at Six Months (DEP-REM-6)

Q: Can the PHQ-9 or PHQ-9M be changed to better fit our practice?

A: Regardless of mode of administration, the content of all tools must be kept intact including 

question text, order, and scoring. Tools that are altered from their original form are invalid.

Q: What if a client does not complete all nine questions or provides multiple responses? How 

should we score the PHQ-9 or PHQ-9M? 

A: According to MN Community Measurement, the PHQ-9/9M tool contains nine items, each 

item earning a score from zero to three, providing a zero to 27 total severity score. Valid scores 

are whole numbers 0 – 27. If a client chooses more than one answer, select the “worst” of the 

answers which will be the higher score. The client must answer ALL nine questions for the score 

to be valid. If the PHQ-9/ 9M result is missing, invalid or incomplete, do NOT submit zero for 

these encounters. Tools that are not complete are invalid.

Questions Related to Diagnoses:

Q: In the past, the Depression or Dysthymia diagnosis had to be the primary diagnosis. Is that 

still true?

A: No, the diagnosis may be in any diagnostic field or order if a client has multiple diagnoses.

Questions Related to Index Event Dates: 

Q: Is the Index Event Date for the measure the date of the first PHQ-9 or PHQ9M screening that 

resulted in a diagnosis of depression in the MY (or the seven (7) days prior)? 

A: Yes.

Q: What if a client comes to intake and Major Depressive Disorder is diagnosed based on 

previous history, previous psychiatric hospitalization, or transfer from one CCBHC to our 

CCBHC, etc, and the current PHQ score is 9 or less. Then several weeks later, the client 

completes the PHQ9 and the score is greater than 9. Would this count as the Index Event Date 

even though the MDD diagnosis was not diagnosed on the same date the PHQ-9 score was 

greater than 9? 

A: The point at which there is the first (in this case first known) PHQ-9 greater than 9 and a 

documented dx of MDD (not necessarily a new diagnosis, but an active diagnosis) is when the 

Index Event Date occurs. So, in this example, it will be at the point “several weeks later.”

Questions Related to Multiple Visits: 

Q: If there are multiple PHQ-9 scores submitted for an indexed client that fall within that client's 

Remission at Six Months “window” (the period 6 months after the Index Event Date (+/- 60 

days), which score is evaluated for numerator compliance? 

A: The most recent PHQ-9 or PHQ-9-M score less than five obtained during this four-month 

period is deemed Remission at Six Months for the numerator.
50

Depression Remission at Six Months (DEP-REM-6)

Questions Related to Capturing Remission at Six Months: 

Q: How do you recommend clinics handle the situation where a client has finished treatment 

prior to the Remission at Six Months “window” and is no longer being seen by the clinic because 

they are in Remission? Should a follow-up appointment around 6 months be scheduled, even 

though the client is finished with treatment? Should the clinic note the number of people who 

achieved Remission prior to 6 months? 

A: The measure does require such an appointment. We know it may be difficult to get people in 

if they do not otherwise need service. However, we ask that BHCs try, and, if they do not 

succeed, to treat failure to do so as not satisfying the numerator. Although it is not necessary,

BHCs are free to indicate in the additional notes of the reporting template, the number of clients 

who do not appear in the Six-Month “window” but who are known to have achieved Remission 

prior to that point. 

Questions Related to Measure Calculation: 

Q: How do we handle missing data when we cannot assess someone at Six Months (± 60 days)?

A: According to MN Community Measurement, missing data (in this case follow-up PHQ-9/9M 

assessment) is not an issue as those clients who are not reassessed in follow-up remain in the 

denominator and are treated as if they are not in Remission. 

Q: The DEP-REM-6 measure indicates that the numerator Measurement Period spans MY1 and 

8 months into MY2 and the denominator Measurement Period encompasses MY1 only. Is this 

measure not required to be reported annually? If not, when will we be required to report on this 

measure? 

A: For purposes of the CCBHC demonstration program, this measure is to be reported annually 

and, because it is a clinic-collected measure, it is reported by CCBHCs within 9 months of the 

end of the demonstration year (DY) for their state. This means that the data included in the 

numerator would, at the latest, end one month before the reporting due date.
51

Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief 

Counseling (ASC)

Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief 

Counseling (ASC)9

Based on CMS MIPS CQMS #431 (2023), which is derived from a measure stewarded by the 

National Committee for Quality Assurance (NCQA)8

A. DESCRIPTION 

The ASC measure calculates the Percentage of clients aged 18 years and older who were 

screened for unhealthy alcohol use using a Systematic Screening Method at least once within the 

last 12 months AND who received brief counseling if identified as an unhealthy alcohol user. 

Data Source: Medical Records 

Important Reporting Guidance: 

This section of the specification includes important guidance for reporting the ASC measure. 

Also refer to section F for Frequently Asked Questions.

• The MIPS CQMS measure 431 on which this measure is based contains three 

submeasures or submission criteria, with the third designed to allow comparison of 

performance to published versions of the measure prior to the MIPS 2021 performance 

year, when the measure had a single performance rate. We include all three but 

submeasure 3 is optional for newer reporters who are not also reporting MIPS.

• This measure is to be reported once per Measurement Year for clients seen during the 

Measurement Year. 

• Providers will rely on medical records to compile this information. There are several 

potential sources of information that may be used individually or together: 

o Electronic health records (including billing records) 

o Paper health records 

o A registry 

• A Provider that does not use the G or M codes noted in the specifications below may rely 

on an equally reliable source of information (designated as “equivalent information 

source” in the specifications).

8The NCQA HEDIS® measure specification has been adjusted pursuant to NCQA’s Rules for Allowable 

Adjustments of HEDIS.

9Note: The National Quality Forum (NQF) endorsed version of ASC (#2152) contains different requirements, 

including screening only every 24 months and different AUDIT and Single Question Screening scores for unhealthy 

alcohol use. The 2016 version of this Behavioral Health Clinic (BHC) measure relied on the NQF version of the 

measure. This 2023 version aligns, instead, with the MIPS version which requires screening and brief counseling 

services during the Measurement Year or within the prior 12 months.
52

Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief 

Counseling (ASC)

• For the purposes of the measure, the most recent denominator eligible encounter should 

be used to determine if the numerator action for the submeasure was performed within 

the 12-month look back period.

• ASC is stratified separately based on whether the client is:

o Medicaid only or Other (including those dually eligible for Medicare and 

Medicaid)

AND

o A member of which of the following ethnic groups: Not Hispanic or Latino, 

Hispanic or Latino, or Unknown

AND

o A member of which of the following racial groups: White or Caucasian, Black or 

African American, American Indian or Alaska Native, Asian, Native Hawaiian or 

Pacific Islander, More than one race, or Unknown

• Refer to the specific data-reporting template for the reporting requirements applicable to 

each measure.

Measurement Period: The Measurement Period is the period for which data are required for 

reporting purposes. The Measurement Period for the denominator is the Measurement Year and, 

for the numerator, is the Measurement Year and the prior year. See Figure 1 for visual depiction 

of Measurement Year and Measurement Periods.

Figure 1. Visual of Measurement Year and Measurement Periods

Year before Measurement Year Measurement Year

Measurement Year (MY): 12 month reporting 

period

Denominator Measurement Period (MP): 12 month 

MY

Numerator Measurement Period: MY and previous year

Key: MY: Measurement Year; MP: Measurement Period.

B. DEFINITIONS 

TERM DEFINITION 

AUDIT and AUDIT-C The AUDIT is the Alcohol Use Disorders Identification Test, and 

the AUDIT-C is an abbreviated version of the AUDIT. Both were 

developed by the World Health Organization. 

Brief Counseling Brief Counseling for unhealthy alcohol use refers to one or more 

counseling sessions, a minimum of 5-15 minutes, which may 

include: feedback on alcohol use and harms; identification of highrisk situations for drinking and coping strategies; increased 

motivation and the development of a personal plan to reduce 

drinking.

Measurement Period The specific time period for which data are needed for the 

numerator and denominator of a given measure. The Measurement 
53

Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief 

Counseling (ASC)

TERM DEFINITION 

Period may differ for the numerator and denominator and for each 

measure and is specified in section A above.

Measurement Year The standard 12-month reporting period common to all measures 

being reported by the Provider.

Percentage A Percentage is calculated as follows: numerator divided by 

denominator (n/d).

Provider The Provider entity that is being measured (i.e., BHC) 

Submeasure ASC is comprised of calculations for three different approaches to 

assessing rates of screening and brief counseling.

Systematic Screening 

Method10

For purposes of this measure, one of the following systematic 

methods to assess unhealthy alcohol use must be utilized. 

Systematic Screening Methods and thresholds for defining 

unhealthy alcohol use include: 

• AUDIT Screening Instrument (score ≥ 8) 

• AUDIT-C Screening Instrument (score ≥4 for men; score ≥3 

for women) 

• Single Question Screening - How many times in the past year 

have you had 5 (for men) or 4 (for women and all adults older 

than 65 years) or more drinks in a day? (response ≥1) 

C. ELIGIBLE POPULATION 

CRITERIA REQUIREMENTS 

Event/Age Follow the steps below to identify the eligible population:

Step 1

Identify clients seen at the Provider during the Measurement Year.

Step 2

Identify clients from step 1 who were aged 18 years and older on 

the date of service during the Measurement Year.

Step 3

1. Had at least two encounters at the Provider during the 

Measurement Year. Relevant codes (Current Procedural 

Terminology [CPT®] or Healthcare Common Procedure 

Coding System [HCPCS]) include: 90791, 90792, 90832, 

90834, 90837, 90845, 92002, 92004, 92012, 92014, 92521, 

92522, 92523, 92524, 92540, 92557, 92625, 96156, 96158, 

10Please note that the scores for the third bullet has changed in the source measure since the 2016 BHC measures 

were published. The response for the Single Question Screening for women and adults older than 65 years 

decreased from ≥2 to ≥1.
54

Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief 

Counseling (ASC)

CRITERIA REQUIREMENTS 

97161, 97162, 97163, 97165, 97166, 97167, 97168, 97802, 

97803, 97804, 99024, 99202, 99203, 99204, 99205, 99212, 

99213, 99214, 99215, 99341, 99342, 99344, 99345, 99347, 

99348, 99349, 99350, G0270, G0271

 OR

2. Had one preventive care visit. Relevant codes (Current 

Procedural Terminology [CPT®] or Healthcare Common 

Procedure Coding System [HCPCS]) include: 99385*, 99386*, 

99387*, 99395*, 99396*, 99397*, 99401*, 99402*, 99403*, 

99404*, 99411*, 99412*, 99429*, G0438, G0439

NOTE #1: *Signifies that this CPT Category I code is a noncovered service under the Medicare Part B Physician Fee Schedule 

(PFS). These non-covered services should be counted in the 

eligible population. 

NOTE #2: Client encounters for this measure conducted via 

telehealth (e.g., encounters coded with GQ, GT, 95, or POS 02 

modifiers) are allowable.

D. MEDICAL RECORD SPECIFICATION 

There are three submeasures for the ASC measure:

1) Percentage of clients aged 18 years and older who were screened for unhealthy alcohol use 

using a Systematic Screening Method at least once within the last 12 months

AND

2) Percentage of clients aged 18 years and older who were identified as unhealthy alcohol users 

(in submeasure #1) who received Brief Counseling 

AND

3) Percentage of clients aged 18 years and older who were screened for unhealthy alcohol use 

using a Systematic Screening Method at least once within the last 12 months AND who 

received Brief Counseling if identified as unhealthy alcohol users, or were not identified as 

an unhealthy alcohol user (Providers should use only submeasures 1 and 2 unless they were 

reporting this measure as part of MIPS before 2017).
55

Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief 

Counseling (ASC)

SUBMEASURE 1: ALL CLIENTS WHO WERE SCREENED FOR UNHEALTHY 

ALCOHOL USE 

DENOMINATOR (SUBMEASURE 1): 

All clients aged 18 years and older seen for at least two visits or at least one preventive visit 

during the Measurement Year (see MIPS source measure for 2023, or more current in later years, 

for visual example).

Denominator Criteria: 

All clients in the Eligible Population (section C)

AND NOT

Denominator Exclusions: 

Clients with dementia at any time during the patient’s history through the end of the 

Measurement Year (M1164 or equivalent information source)

OR

Clients who use hospice services any time during the Measurement Year (M1165 or 

equivalent information source)

NOTE: If documented, an individual already diagnosed with an alcohol use disorder 

prior to the Measurement Year also may be excluded from the denominator. This is 

determined on the date of the most recent denominator eligible encounter for all 

submeasures.

NUMERATOR (SUBMEASURE 1): 

All clients in the denominator who were screened for unhealthy alcohol use using a Systematic 

Screening Method at least once within the last 12 months 

NUMERATOR NOTE: To satisfy the intent of this measure, a client must have at least 

one screening for unhealthy alcohol use during the 12-month period. If a client has 

multiple screenings for unhealthy alcohol use during the 12-month period, only the most 

recent denominator eligible screening, which has a documented status of unhealthy 

alcohol user or unhealthy alcohol non-user, will be used to satisfy the measure 

requirements. 

Numerator Options: 

Performance Met: 

• Client identified as an unhealthy alcohol user when screened for unhealthy 

alcohol use using a Systematic Screening Method (G2196 or equivalent 

information source), 

OR 
56

Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief 

Counseling (ASC)

• Client screened for unhealthy alcohol use using a Systematic Screening Method 

and not identified as an unhealthy alcohol user (G2197 or equivalent 

information source)

OR 

Performance Not Met: Client not screened for unhealthy alcohol use using a Systematic 

Screening Method (G2199 or equivalent information source)

SUBMEASURE 2: ALL CLIENTS WHO WERE IDENTIFIED AS UNHEALTHY 

ALCOHOL USERS AND WHO RECEIVED BRIEF COUNSELING 

DENOMINATOR (SUBMEASURE 2): 

All clients aged 18 years and older seen for at least two visits or at least one preventive visit 

during the Measurement Year who were screened for unhealthy alcohol use and identified as an 

unhealthy alcohol user (see MIPS source measure for 2023, or more current in later years, for 

visual example).

Denominator Criteria: 

All clients in the Eligible Population (section C)

AND 

All eligible instances when G2196 (or equivalent information source) is submitted for 

Performance Met (client identified as an unhealthy alcohol user when screened for 

unhealthy alcohol use using a Systematic Screening Method) in the numerator of 

Submeasure 1 

AND NOT 

Denominator Exclusions: 

Clients with dementia at any time during the patient’s history through the end of the 

Measurement Year (M1164 or equivalent information source)

OR

Clients who use hospice services any time during the Measurement Year (M1165 or 

equivalent information source)

NUMERATOR (SUBMEASURE 2): 

All clients in the denominator who received Brief Counseling 

Numerator Options: 

Performance Met: Client identified as an unhealthy alcohol user received Brief 

Counseling (G2200 or equivalent information source) 

OR 

Performance Not Met: Client did not receive Brief Counseling if identified as an 

unhealthy alcohol user, reason not given (G2202 or equivalent information source)
57

Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief 

Counseling (ASC)

SUBMEASURE 3: ALL CLIENTS WHO WERE SCREENED FOR UNHEALTHY 

ALCOHOL USE AND, IF IDENTIFIED AS AN UNHEALTHY ALCOHOL USER, 

RECEIVED BRIEF COUNSELING, OR WERE NOT IDENTIFIED AS AN 

UNHEALTHY ALCOHOL USER (Providers should not use submeasure 3 unless they were 

reporting TSC as part of MIPS before 2017.)

DENOMINATOR (SUBMEASURE 3): 

All clients aged 18 years and older seen for at least two visits or at least one preventive visit 

during the Measurement Year (see MIPS source measure for 2023, or more current in later years, 

for visual example).

Denominator Criteria: 

All clients in the Eligible Population (section C)

AND NOT 

Denominator Exclusions: 

Clients with dementia at any time during the patient’s history through the end of the 

Measurement Year (M1164 or equivalent information source)

OR

Clients who use hospice services any time during the Measurement Year (M1165 or 

equivalent information source)

NOTE: If documented, an individual already diagnosed with an alcohol use disorder 

prior to the Measurement Year also may be excluded from the denominator. This is 

determined on the date of the most recent denominator eligible encounter for all 

submeasures.

NUMERATOR (SUBMEASURE 3): 

All clients in the denominator who were screened for unhealthy alcohol use using a Systematic 

Screening Method at least once within 12 months AND who received Brief Counseling if 

identified as an unhealthy alcohol user 

NUMERATOR NOTE: To satisfy the intent of this measure, a client must have at least 

one unhealthy alcohol use screening during the 12-month period. If a client has multiple 

unhealthy alcohol use screenings during the 12-month period, only the most recent 

denominator eligible screening, which has a documented status of unhealthy alcohol user 

or unhealthy alcohol non-user, will be used to satisfy the measure requirements. 

Numerator Options: 

Performance Met: Client identified as an unhealthy alcohol user when screened for 

unhealthy alcohol use using a Systematic Screening Method and received Brief 

Counseling (G9621 or equivalent information source) 

OR 
58

Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief 

Counseling (ASC)

Performance Met: Client not identified as an unhealthy alcohol user when screened for 

unhealthy alcohol use using a Systematic Screening Method (G9622 or equivalent 

information source) 

OR 

Performance Not Met: Client not screened for unhealthy alcohol use using a Systematic 

Screening Method or client did not receive Brief Counseling if identified as an unhealthy 

alcohol user, reason not given (G9624 or equivalent information source)

E. ADDITIONAL NOTES

Both this and the source measure were specified at the provider level. Neither is risk adjusted. 

This measure is modified from the source measure to provide a specification consistent in format 

to other measures in this set of BHC measures. The substance of the measure is unchanged. 

Interpretation of scores: Better quality = Higher Percentage

F. FREQUENTLY ASKED QUESTIONS

Questions Related to Screening Tools:

Q: Do all BHCs in a state have to use the same screening tool? 

A: No, all BHCs do not have to use the same screening tool. They should, however, all use an 

approach that is “systematic” as that is defined in the Technical Specification for the measure 

(i.e., AUDIT, AUDIT-C, single question screening).

Q: Is it the case that the AUDIT and AUDIT-C are the only tools to use for unhealthy alcohol 

use?

A: No. There is one other option: the brief screening tool that is included in the Technical 

Specification definitions and which contains a single-question screen about number of drinks, 

which differs for men, women, and older adults. Information also is available about what cut-off 

score a client needs to obtain on any of the 3 allowable screens to be considered as having

unhealthy alcohol use. 

Q: For the measure of screening and intervention for unhealthy alcohol use, if we have other 

screens already embedded in our EHR, can we use those instead of the AUDIT? 

A: Only the AUDIT, AUDIT-C, and the single-question screen specified in the ASC measure are 

permissible. Those are the only screens you can use to satisfy the numerator. 

Q: For the measure of screening and intervention for unhealthy alcohol use, is the AUDIT tool in 

the public domain? 

A: The AUDIT is freely available from a variety of sources, including the World Health 

Organization (WHO) that developed the AUDIT. You can access it on the WHO website at: 

WHO AUDIT Guidelines. However, it may not be sold or used for commercial purposes. The 

AUDIT has been validated across sex, age, and cultures and is available in more than 50 

languages.
59

Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief 

Counseling (ASC)

Q: For the measure of screening and intervention for unhealthy alcohol use, is the CAGE 

appropriate given that we have that in our EHR? 

A: The CAGE is not one of the three allowed screening tools. It is important to note that the 

CAGE is only validated for adults, so it is not appropriate for use with adolescents. It also is less 

valid than alternative screening tools with some other client groups such as pregnant women. 

The CAGE is often included as a default screen in EHRs, but that does not mean it is always 

appropriate for all ages or segments of the population. You should determine how to include 

other screens in the EHR to make sure you have what you need to satisfy the measure and what 

you need for a particular population segment. 

Questions Related to Screening Clients with a Diagnosed Alcohol Use Disorder:

Q: Is screening required for individuals with a diagnosed alcohol use disorder? 

A: No, those with an existing active diagnosis of an alcohol use disorder prior to the 

Measurement Year would be omitted from the denominator.

Questions Related to Frequency of Screening:

Q: Can BHCs screen more frequently than once a year?

A: Yes, BHCs can screen more frequently. The measure, however, only looks at the last screen 

in the Measurement Year. Note: The earlier version of this measure only looked at screening at 

least every 24 months. This revision changes that and makes the BHC measure consistent with 

the current MIPS measure.

Questions Related to Screening Provider:

Q: Which staff is required to screen? 

A: The measure does not specify which staff should do the screening other than by inclusion of 

specific codes designating an eligible encounter. The BHC should follow any state or other 

requirements for licensure and training that would otherwise apply.

Questions Related to Timing of Screening and Brief Intervention:

Q: Do the screening and brief intervention need to happen in the same session/encounter? 

A: If you are screening someone for alcohol use, however, the time for a brief intervention is 

when they are screened. It should happen at the same encounter. 

Questions Related to Client Age:

Q: Can the measure be reported for clients younger than age 18 years?

A: It is only required in the measure for those ages 18 year or older but BHCs may also report 

this submeasure for individuals younger than age 18 years of age if they wish but that 

information should be included in the additional notes in the bottom of the ASC data reporting 

template. If you are screening adolescents, however, you will need to use standardized tools that 
60

Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief 

Counseling (ASC)

have been validated for that age group. Both the AUDIT and AUDIT-C are validated for 

adolescents, but cut-offs may need to be lower. See Liskola et al. (2018).

Questions Related to Coding:

Q: Our system does not support the G or M codes needed to calculate the denominator 

exclusions or numerators. What should we do?

A: Although we recommend using the G or M codes, a provider that does not use the G or M 

codes noted in the specifications may rely on an equally reliable source of information 

(designated as “equivalent information source” in the specifications).
61

Screening for Social Drivers of Health (SDOH)

Screening for Social Drivers of Health (SDOH)

Based on MIPS CQMS #487 (2023), stewarded by CMS 

A. DESCRIPTION 

The SDOH measure calculates the Percentage of clients 18 years and older screened for food 

insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety. 

Data Source: Medical Records 

Important Reporting Guidance: 

This section of the specification includes important guidance for reporting the SDOH measure. 

Also refer to section F for Frequently Asked Questions.

• This measure is to be reported once per Measurement Year for clients seen during the 

Measurement Year. 

• Providers will rely on medical records to compile this information. There are several 

potential sources of information that may be used individually or together: 

o Electronic health records (including billing records) 

o Paper health records 

o A registry 

• A Provider that does not use the M codes noted in the numerator specifications below 

may rely on an equally reliable source of information (designated as “equivalent 

information source” in the numerator specifications).

• SDOH is stratified separately based on whether the client is:

o Medicaid only or Other (including those dually eligible for Medicare and 

Medicaid)

AND

o a member of which of the following ethnic groups: Not Hispanic or Latino, 

Hispanic or Latino, or Unknown

AND

o a member of which of the following racial groups: White or Caucasian, Black 

or African American, American Indian or Alaska Native, Asian, Native 

Hawaiian or Pacific Islander, More than one race, or Unknown

• Refer to the specific data-reporting template for the reporting requirements applicable to 

each measure.
62

Screening for Social Drivers of Health (SDOH)

Measurement Period: The Measurement Period is the period for which data are required for 

reporting purposes. The Measurement Period for both the denominator and the numerator is 

the Measurement Year. 

B. DEFINITIONS

TERM DEFINITION 

Measurement Period

The specific time period for which data are needed for the 

numerator and denominator of a given measure. The Measurement 

Period may differ for the numerator and denominator and for each 

measure and is specified in section A above.

Measurement Year The standard 12-month reporting period common to all measures 

being reported by the Provider.

Percentage A Percentage is calculated as follows: numerator divided by 

denominator (n/d).

Provider The Provider entity that is being measured (i.e., BHC) 

Social Drivers of Health 

(SDOH)

Also referred to as Social Determinants of Health, SDOH “are the 

nonmedical factors that influence health outcomes. They are the 

conditions in which people are born, grow, work, live, and age, 

and the wider set of forces and systems shaping the conditions of 

daily life.” (CDC, 2022).

Standardized HealthRelated Social Needs 

(HRSN) Screening

HRSN is the term used by HHS to refer to an individual's unmet, 

adverse social conditions that contribute to poor health as a result 

of the community’s underlying SDOH. Examples of standardized 

HRSN screening tools include but are not limited to: 

• Accountable Health Communities HealthRelated Social Needs Screening Tool

(2017)

• Accountable Health Communities HealthRelated Social Needs Screening Tool

(2022)

• The Protocol for Responding to and Assessing Patients’

Risks and Experiences (PRAPARE) Tool (2016)

• WellRx Questionnaire (2014)

• American Academy of Family Physicians (AAFP) Screening

Tool (2018)

C. ELIGIBLE POPULATION

CRITERIA REQUIREMENTS 

Event/Age Follow the steps below to identify the eligible population:

Step 1
63

Screening for Social Drivers of Health (SDOH)

CRITERIA REQUIREMENTS 

Identify clients seen at the Provider during the Measurement Year.

Step 2

Identify clients from step 1 who were aged 18 years and older on 

the date of service during the Measurement Year.

Step 3

Identify clients from step 2 who had at least one of the following 

encounters at the Provider during the Measurement Year (CPT): 

59400, 59510, 59610, 59618, 78012, 78070, 78075, 78102, 78140, 

78185, 78195, 78202, 78215, 78261, 78290, 78300, 78305, 78315, 

78414, 78428, 78456, 78458, 78579, 78580, 78582, 78597, 78601, 

78630, 78699, 78708, 78725, 78740, 78801, 78803, 78999, 90791, 

90792, 90832, 90834, 90837, 90839, 90845, 90945, 90947, 90951, 

90952, 90953, 90954, 90955, 90956, 90957, 90958, 90959, 90960, 

90961, 90962, 90963, 90964, 90965, 90966, 90967, 90968, 90969, 

90970, 92002, 92004, 92012, 92014, 92507, 92508, 92521, 92522, 

92523, 92524, 92526, 92537, 92538, 92540, 92541, 92542, 92544, 

92545, 92548, 92549, 92550, 92557, 92567, 92568, 92570, 92588, 

92625, 92626, 92650*, 92651, 92652, 92653, 96116, 96156, 

96158, 97129, 97161, 97162, 97163, 97164, 97802, 97803, 97804, 

98960, 98961, 98962, 99203, 99204, 99205, 99211, 99212, 99213, 

99214, 99215, 99221, 99222, 99223, 99231, 99232, 99233, 99236, 

99242*, 99243*, 99244*, 99245*, 99281, 99282, 99283, 99284, 

99285, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 

99381*, 99382*, 99383*, 99384*, 99385*, 99386*, 99387*, 

99391*, 99392*, 99393*, 99394*, 99395*, 99396*, 99397*, 

99401*, 99402*, 99403*, 99404*, 99411*, 99412*, 99429*, 

99495, 99496, 99512*, D0120*, D0140*, D0145*, D0150, 

D0160*, D0170*, D0180*, D7111, D7140, D7210, D7220, 

D7230, D7240, D7241, D7250, D7251, G0101, G0108, G0270, 

G0271, G0402, G0438, G0439, G0447, G0473, G9054

D. MEDICAL RECORD SPECIFICATION 

DENOMINATOR: 

All clients in the Eligible Population (section C) (see MIPS source measure for 2023, or more 

current in later years, for visual example).

DENOMINATOR NOTE: *Signifies that this CPT Category I code is a non-covered 

service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered 

services should be counted in the denominator population. 
64

Screening for Social Drivers of Health (SDOH)

NOTE: Client encounters for this measure conducted via telehealth (e.g., encounters 

coded with GQ, GT, 95, or POS 02 modifiers) are allowable.

NUMERATOR: 

Number of patients 18 years and older screened for food insecurity, housing instability, 

transportation needs, utility difficulties, and interpersonal safety.

NUMERATOR NOTE: The patient is required to have a standardized health-related 

social needs (HRSN) screening done once per performance period. Documentation that

a review of a previous performed standardized HRSN screening during the 

performance period is acceptable for meeting the numerator criteria. See definitions for 

examples of standardized HRSN screening tools.

Numerator Options: 

Performance Met: 

Number of patients screened for food insecurity, housing instability, transportation needs, utility 

difficulties, and interpersonal safety (M1207 or equivalent information source)

OR 

Performance Not Met:

Number of patients not screened for food insecurity, housing instability, transportation 

needs, utility difficulties, and interpersonal safety. (M1208 or equivalent information 

source)

E. ADDITIONAL NOTES

Both this and the source measure were specified at the provider level. Neither is risk adjusted. 

This measure is modified from the source measure to provide a specification consistent in format 

to other measures in this set of BHC measures. The substance of the measure is unchanged. 

Interpretation of scores: Better quality = Higher Percentage

F. FREQUENTLY ASKED QUESTIONS

Questions Related to Screening Tools:

Q: Do all BHCs in a state have to use the same screening tool? 

A: No, unless the state says otherwise, all BHCs do not have to use the same screening tool. 

They should, however, all use a tool that is “standardized,” preferably one of those included in 

the Definition of Standardized Health-Related Social Needs (HRSN) Screening in section B of 

the Technical Specification for the measure. A standardized instrument is one that has been 

determined to be valid and reliable when administered and scored in a manner consistent with its

validation in a given population. 
65

Screening for Social Drivers of Health (SDOH)

Questions Related to Frequency of Screening:

Q: Can BHCs screen more frequently than once a year?

A: Yes, BHCs can screen more frequently. The measure, however, only requires one screening 

per Measurement Year. 

Questions Related to Screening Provider:

Q: Which staff is required to screen? 

A: The measure does not specify which staff should do the screening other than by inclusion of 

specific codes designating an eligible encounter. The BHC should follow any state or other 

requirements for licensure and training that would otherwise apply.

Questions Related to Client Age:

Q: Can the measure be reported for clients younger than age 18 years?

A: It is only required in the measure for those ages 18 year or older but BHCs may also report 

this submeasure for individuals younger than age 18 years of age if they wish but that 

information should be included in the additional notes in the bottom of the SDOH data reporting 

template. 

Questions Related to Coding for the Numerator(s):

Q: Our system does not support the M codes needed to calculate the numerators. What should 

we do?

A: Although we recommend using the M codes for the numerators, a provider that does not use 

the M codes noted in the numerator specifications may rely on an equally reliable source of 

information (designated as “equivalent information source” in the numerator specifications).
66

Supplemental Materials for Screening for Depression and Follow-Up Plan (CDF-AD and 

CDF-CH)

Important Supplemental Materials for Clinic-Collected Required

BHC Measures derived from CMS Medicaid Adult and/or Child 

Core Set Measures (CDF-AD and CDF-CH)

These supplemental materials are necessary for implementation of the Clinic-Collected Required 

BHC Measures that are derived from the CMS Medicaid Adult and/or Child Core Set Measures. 

This volume includes the exact specifications that are on the CMS website for the 2023 Medicaid 

Core Set, with simple modifications noted in the text. Limited additional needed modifications 

are included below, as well as supplemental useful materials.

1. Measure CDF-AD: Screening for Depression and Follow-Up Plan: Age 18 and 

Older

2. Measure CDF-CH: Screening for Depression and Follow-Up Plan: Ages 12 to 17

Changes within the specification: For both CDF measures, the changes within the CMS 

Medicaid Adult and Child Core Sets specifications reflect: (1) substitution of the word “client” 

for “beneficiary” or “patient”, unless the latter is part of a copyrighted code description; (2) 

removal of age stratification in the adult measure (i.e., applicable here to adults ages 18 years 

and older); and (3) removal of references to the Core Set.

Additional information: For both CDF measures, the following material is provided to assist 

clinics in using the specifications and follows the numbering system used in the non-Medicaid 

Core Set-derived BHC specifications:

A. DESCRIPTION

Important Reporting Guidance:

• Both the CDF-AD and CDF-CH measures are to be used by BHCs to measure 

performance related to clients seen at the Provider during the Measurement Year.

• A Provider that does not use the G codes noted in the specifications may rely on an 

equally reliable source of information.

• Both CDF-AD and CDF-CH are to be stratified separately based on whether the 

client is:

o Medicaid only or Other (including those dually eligible for Medicare and 

Medicaid)

AND

o A member of which of the following ethnic groups: Not Hispanic or Latino, 

Hispanic or Latino, or Unknown

AND

o A member of which of the following racial groups: White or Caucasian, Black or 

African American, American Indian or Alaska Native, Asian, Native Hawaiian or 

Other Pacific Islander, More than one race, or Unknown
67

Supplemental Materials for Screening for Depression and Follow-Up Plan (CDF-AD and 

CDF-CH)

• Refer to the specific data-reporting template for the reporting requirements applicable 

to each measure.

Measurement Period: The Measurement Period is the period for which data are required for 

reporting purposes. The Measurement Period for the CDF denominator is the Measurement 

Year and, for the CDF numerator, is the Measurement Year. See Figure 1 for visual 

depiction of Measurement Year and Measurement Periods.

Figure 1. Visual of Measurement Year and Measurement Periods

Measurement Year

Measurement Year (MY): 12 month reporting period

Denominator Measurement Period (MP): 12 month MY

Numerator Measurement Period (MP): 12 month MY

Key: MY: Measurement Year; MP: Measurement Period.

B. DEFINITIONS

TERM DEFINITION 

Measurement Period

The specific time period for which data are needed for the 

numerator and denominator of a given measure. The Measurement 

Period may differ for the numerator and denominator and for each 

measure and is specified in section A above.

Measurement Year The standard 12-month reporting period common to all measures 

being reported by the Provider.

Percentage A Percentage is calculated as follows: numerator divided by 

denominator (n/d).

Provider The Provider entity that is being measured (i.e., BHC) 

E. ADDITIONAL NOTES

Interpretation of scores: Better quality = Higher Percentage

F. FREQUENTLY ASKED QUESTIONS

Questions related to eligible encounters: 

Q: For the CDF measures, how do you define an encounter? Is it a visit with any provider (e.g., 

therapist, MD, nurse practitioner, physician assistant)?

A: The codes that indicate whether an encounter makes an individual eligible for inclusion in the 

denominator are provided in the measure specification. These codes include ones for services 

that may be utilized by a psychiatrist, a Master’s-level clinician, a psychologist, PCPs, or other 

providers. You should review the precise codes and who, within the licensure and other 

applicable requirements in your state, can provide the “eligible encounter.” Note that 42 CFR 

§440.50(a)(2)) allows those working under the supervision of a physician to perform services a 

physician would perform if it is within the licensure scope of services. For purposes of the 

CCBHC demonstration, if other codes are available, the state should consider developing a list of 

all such codes and the codes should be used uniformly across all CCBHCs.
68

Supplemental Materials for Screening for Depression and Follow-Up Plan (CDF-AD and 

CDF-CH) 

Questions regarding screening tools: 

Q: What screening tools should we use for the CDF measures? 

A: The technical specifications for the CDF-AD and CDF-CH measures require that BHCs use 

standardized instruments and the specifications identify multiple examples of such instruments, 

including ones specifically for adults, children, prenatal, and perinatal screening. The lists are not 

exhaustive and you may use another, as long as it is a normalized and validated depression 

screening tool developed for the population in which it is being utilized. 

Questions regarding exclusion criteria for existing diagnosis of depression or bipolar disorder: 

Q: The CDF measure specifications exclude individuals with a diagnosis of depression or 

bipolar disorder. What if you do not know when the diagnosis was made or what depression 

screening tool was used? 

A: The denominator exclusion in the CDF-AD and CDF-CH measures for those with an existing 

diagnosis of depression or bipolar disorder means that the person already has a diagnosis. In 

other words, that person presumably still satisfies the criteria for the diagnosis, and therefore you 

do not count them in either the numerator or the denominator because they are already 

diagnosed. It does not matter what tool was used to diagnose them in the past, and you do not 

need to screen them again for purposes of the measure. It is simply a way to only identify people 

who have not yet been diagnosed for depression or bipolar disorder. 

Questions regarding need to screen all clients: 

Q: Do the CDF measures require us to screen every client that is either new or currently open, 

who does not have a diagnosis of depression or bipolar disorder? 

A: If clients are 12 years of age or older and have an encounter identified in the specification that 

qualifies them to be included in the denominator, such clients do need to be screened unless they: 

(1) meet an exclusion (i.e., have an existing diagnosis of depression or bipolar disorder) or

satisfy one of the exceptions to being screened (i.e., exclusions include (a) refusal, (b) an urgent

or emergent situation that precludes it, or (c) their cognitive or functional capacity, or

motivation, may affect the accuracy of results).

Questions regarding need to screen on every visit: 

Q: The CDF measures seem to indicate that screening should be done at all visits if there is not 

an existing diagnosis of depression or bipolar disorder. In some cases, individuals may be seen 

multiple times in a week (e.g., once for an injection, once to see a therapist, and once to see the 

doctor). Would we therefore have to screen for depression three times in one week? Is it the 

intent that these screenings be conducted at that frequency? 

REVISED A: For CDF-AD and CDF-CH measures, the numerator specification requires 

screening for everyone who is eligible and does not meet one of the exclusions or exceptions. 

Even if a client of a BHC is not diagnosed with depression or bipolar disorder but is being seen 

frequently for one or more other mental health and/or substance use disorder diagnoses, it 

remains possible that the person has undiagnosed co-occurring depression. That is why the 
69

Supplemental Materials for Screening for Depression and Follow-Up Plan (CDF-AD and 

CDF-CH)

measure previously was interpreted as requiring administration of a standardized instrument at 

each encounter if a diagnosis does not already exist. The electronic version of this measure, 

however, has been modified to indicate that “[t]his eCQM is a patient-based measure. 

Depression screening is required once per measurement period, not at all encounters." This 

reflects an upcoming change to the Core Set measure for 2024 which will parallel the electronic 

measure. For that reason, we will treat this as a once a Measurement Year requirement for those 

in the Eligible Population.

Standardized screening instruments for depression can be brief and can be administered at any 

point within 14 days prior to the encounter. However, this 14 day period prior to any given 

encounter means that administration of a standardized depression screening instrument within 

the past 14 days, that has been addressed by the provider, satisfies the screening requirement. If 

positive, it also triggers the requirement for a follow-up plan. 

Questions regarding alternative measurement approaches:

Q: In calculating the CDF measures, BHCs will gather information on (a) whether a screening 

occurred, (b) whether the screen was positive, and (c) whether there was a follow-up plan if the 

screen was positive. By including only one numerator (was screened and, if positive, had followup plan), it will be difficult to tell if low rates on the quality measure are because patients are not 

being screened or because of provider failure to follow-up on positive screens. Could this 

measure be modified to include the following breakout?

1. Screening

o Denominator: All eligible

o Numerator: Encounters where screening occurred

2. Follow-up

o Denominator: Positive screenings

o Numerator: Follow-up plan was made

A: This information would be useful, and BHCs can elect to modify how they calculate this 

measure in that way for their own use. We, however, cannot modify it from the existing 

structure that parallels the source measure and request that BHCs report it on the data reporting 

template as it is written in the specification. BHCs also have the option of reporting the 

suggested alternative approach in the Additional Notes section at the bottom of the data reporting 

template. 
70

Screening for Depression and Follow-Up Plan (CDF-AD)

Measure CDF-AD: Screening for Depression and Follow-Up Plan: Age 18 and 

Older11

Based on a CMS Medicaid Adult Core Set Measure (2023), stewarded by CMS

A. DESCRIPTION

Percentage of beneficiaries [clients] age 18 and older screened for depression on the date of the

encounter or 14 days prior to the date of the encounter using an age-appropriate standardized

depression screening tool, and if positive, a follow-up plan is documented on the date of the eligible

encounter.

Data Collection Method: Administrative or EHR

Guidance for Reporting:

The Screening for Depression and Follow-Up Plan measure includes beneficiaries [clients] ages 

12 and older. The Child Core Set [CDF-CH] measure applies to beneficiaries [clients] ages 12 

to 17 and the Adult Core Set [this] measure applies to beneficiaries [clients] age 18 and older. 

For the purpose of Adult Core Set reporting, states should calculate and report this measure for 

two age groups (as applicable): ages 18 to 64 and age 65 and older.

The intent of the measure is to screen for depression in beneficiaries [clients] who have never had 

a diagnosis of depression or bipolar disorder prior to the eligible encounter used to evaluate the 

numerator. Beneficiaries [Clients] who have ever been diagnosed with depression or bipolar 

disorder will be excluded from the measure. 

The denominator for this measure includes beneficiaries [clients] age 18 and older with an 

outpatient visit during the measurement year. The numerator for this measure includes the 

following two groups:

Those beneficiaries [clients] with a positive screen for depression on the date of an outpatient 

visit or up to 14 days prior to the encounter using a standardized tool with a follow-up plan 

documented.

Those beneficiaries [clients] with a negative screen for depression on the date of an outpatient 

visit or up to 14 days prior to the encounter using a standardized tool.

The QPP claims/CQM specifications for this measure include six G codes intended to capture 

whether individual providers reported on this measure. For the purpose of Adult Core Set 

reporting, t[T]here are two G codes included in the numerator to capture whether depression 

screening using an age-appropriate standardized tool was done on the date of the eligible 

encounter or up to 14 days prior to the date of the encounter and if the screen was positive, 

whether a follow-up plan was documented on the date of the eligible encounter.

11Aside from the minor modifications noted in this specification, this specification is taken directly from the 2023 

CMS Medicaid Adult Core Set Measures. Use the most current version for the year being reported. See also 

Important Supplemental Materials for Clinic-Collected Required BHC Measures derived from CMS Medicaid Adult 

and/or Child Core Set Measures (in this manual immediately before the CDF measures).
71

Screening for Depression and Follow-Up Plan (CDF-AD)

An age-appropriate, standardized, and validated depression screening tool must be used and 

results documented as positive or negative for numerator compliance. The name of the ageappropriate standardized depression screening tool utilized must be documented in the medical 

record. This measure does not require documentation of a specific score, just whether results of 

the normalized and validated depression screening tool used are considered positive or 

negative. Each standardized screening tool provides guidance on whether a particular score is 

considered positive for depression. The screening should occur on the date of a qualifying 

encounter or up to 14 days prior to the date of the qualifying encounter. The depression 

screening must be reviewed and addressed by the provider on the date of the encounter. 

Positive pre-screening results indicating a beneficiary [client] is at high risk for self-harm 

should receive more urgent intervention as determined by the provider practice.

The measure assesses the most recent depression screening completed either during the eligible 

encounter or within the 14 days prior to that encounter. Therefore, a clinician would not be 

able to complete another screening at the time of the encounter to count toward a follow-up, 

because that would serve as the most recent screening. In order to satisfy the follow-up 

requirement for a beneficiary [client] screening positively, the eligible clinician would need to 

provide one of the specified follow-up actions, which includes one or more of the following:

Referral to a provider for additional evaluation. 

Pharmacological interventions.

Other interventions for the treatment of depression.

A follow-up plan must be documented on the date of the qualifying encounter for a positive 

depression screen.

Should a beneficiary [client] screen positive for depression:

A clinician should only order pharmacological intervention when appropriate and after 

sufficient diagnostic evaluation. However, for the purposes of this measure, additional 

screening and assessment during the qualifying encounter will not qualify as a follow-up 

plan.

A clinician could opt to complete a suicide risk assessment when appropriate and based on 

individual beneficiary [client] characteristics. However, for the purposes of this measure, a 

suicide risk assessment will not qualify as a follow-up plan.

The screening tools listed in the measure specifications are examples of standardized tools. 

However, states may use any assessment tool that has been appropriately normalized and 

validated for the population in which it is being utilized. The name of the age-appropriate 

standardized depression screening tool utilized must be documented in the medical record.

This measure contains both exclusions and exceptions:

Denominator exclusion criteria are evaluated before checking if a beneficiary [client] meets 

the numerator criteria; a beneficiary [client] who qualifies for the denominator exclusion 

should be removed from the denominator.

Denominator exception criteria are only evaluated if the beneficiary [client] does not meet the 

numerator criteria; beneficiaries [clients] who do not meet numerator criteria and also 

meet denominator exception criteria (e.g., medical reason for not performing a screening) 

should be removed from the denominator. 
72

Screening for Depression and Follow-Up Plan (CDF-AD)

This measure can be calculated using administrative data only. Medical record review may be 

used to validate the state's administrative data (for example, documentation of the name of the 

standardized depression screening tool utilized). However, validation is not required to 

calculate and report this measure.

Include all paid, suspended, pending, and denied claims. 

The electronic specification for FFY 2023 is located on the eCQI resource center at 

https://ecqi.healthit.gov/sites/default/files/ecqm/measures/CMS2v11.html. [Use version current 

for year reporting.] States [Clinics] that use electronic specifications should indicate this by 

selecting “Electronic Health Records” in the Data Source section of the online reporting system

[template].

This measure includes the following coding systems: CPT and HCPCS. Refer to the 

Acknowledgments section at the beginning of the manual for copyright information. 

B. DEFINITIONS

Screening Completion of a clinical or diagnostic tool used to identify people at risk of 

developing or having a certain disease or condition, even in the absence of 

symptoms.

Standardized 

Depression 

Screening Tool

A normalized and validated depression screening tool developed for the 

population in which it is being utilized. Examples of depression screening tools 

include but are not limited to: 

Adult Screening Tools (age 18 and older)

Patient Health Questionnaire (PHQ-9), Beck Depression Inventory (BDI or 

BDI-II), Center for Epidemiologic Studies Depression Scale (CES-D), 

Depression Scale (DEPS), Duke Anxiety- Depression Scale (DADS), 

Geriatric Depression Scale (GDS), Cornell Scale for Depression in Dementia 

(CSDD), PRIME MD-PHQ2, Hamilton Rating Scale for Depression (HAMD), Quick Inventory of Depressive Symptomatology Self-Report (QID-SR), 

Computerized Adaptive Testing Depression Inventory (CAT-DI), and 

Computerized Adaptive Diagnostic Screener (CAD-MDD).

Perinatal Screening Tools

Edinburgh Postnatal Depression Scale, Postpartum Depression Screening Scale, 

Patient Health Questionnaire 9 (PHQ-9), Beck Depression Inventory, Beck 

Depression Inventory–II, Center for Epidemiologic Studies Depression 

Scale, and Zung Self-rating Depression Scale.
73

Screening for Depression and Follow-Up Plan (CDF-AD)

Follow-up plan Documented follow-up for a positive depression screening must include one or 

more of the following:

Referral to a provider for additional evaluation and assessment to formulate a 

follow-up plan for a positive depression screen.

Pharmacological interventions.

Other interventions or follow-up for the diagnosis or treatment of depression. 

Examples of a follow-up plan include but are not limited to:

Referral to a provider or program for further evaluation for depression, for 

example, referral to a psychiatrist, psychologist, social worker, mental health 

counselor, or other mental health service such as family or group therapy, 

support group, depression management program, or other service for 

treatment of depression.

Other interventions designed to treat depression such as behavioral health 

evaluation, psychotherapy, pharmacological interventions, or additional 

treatment options.

The documented follow-up plan must be related to positive depression 

screening, for example: “Patient [Client] referred for psychiatric evaluation due 

to positive depression screening.”

C. ELIGIBLE POPULATION

Age Age 18 or older on date of encounter. 

Event/diagnosis Outpatient visit (Table CDF-A) during the measurement year.

Continuous 

enrollment

None.

D. ADMINISTRATIVE SPECIFICATION

Denominator

The eligible population with an outpatient visit during the measurement year (Table CDF-A).

Table CDF-A. Codes to Identify Outpatient Visits

CPT HCPCS

59400, 59510, 59610, 59618, 90791, 90792, 90832, 

90834, 90837, 92625, 96105, 96110, 96112, 96116, 

96125, 96136, 96138, 96156, 96158, 97161, 97162, 

97163, 97165, 97166, 97167, 99078, 99202, 99203, 

99204, 99205, 99212, 99213, 99214, 99215, 99304, 

99305, 99306, 99307, 99308, 99309, 99310, 99315, 

99316, 99318, 99324, 99325, 99326, 99327, 99328, 

99334, 99335, 99336, 99337, 99339, 99340, 99401, 

99402, 99403, 99483, 99484, 99492, 99493, 99384, 

99385, 99386, 99387, 99394, 99395, 99396, 99397

G0101, G0402, G0438, G0439, 

G0444
74

Screening for Depression and Follow-Up Plan (CDF-AD)

Numerator

Beneficiaries [Clients] screened for depression on the date of the encounter or 14 days prior to the 

date of the encounter using an age-appropriate standardized depression screening tool AND, if 

positive, a follow-up plan is documented on the date of the eligible encounter using one of the codes 

in Table CDF-B.

Table CDF-B. Codes to Document Depression Screen

Code Description

G8431 Screening for depression is documented as being positive and a follow-up plan is 

documented

G8510 Screening for depression is documented as negative, a follow-up plan is not required

Exclusions

A beneficiary [client] is not eligible if one or more of the following conditions are documented in the 

beneficiary [client] medical record:

Beneficiaries [Clients] who have been diagnosed with depression or bipolar disorder

Use the codes in Table CDF-C, CDF-D, and CDF-E to identify exclusions. 

Table CDF-C. HCPCS Code to Identify Exclusions

Code Description

G9717 Documentation stating the patient has had a diagnosis of depression or has had a 

diagnosis of bipolar disorder

Table CDF-D. ICD-10 Codes to Identify Diagnosis of Depression (Exclusions)

ICD-10 Code Description

F01.51 Vascular dementia with behavioral disturbance

F32.A Depression, unspecified

F32.0 Major depressive disorder, single episode, mild

F32.1 Major depressive disorder, single episode, moderate

F32.2 Major depressive disorder, single episode, severe without psychotic features

F32.3 Major depressive disorder, single episode, severe with psychotic features

F32.4 Major depressive disorder, single episode, in partial remission

F32.5 Major depressive disorder, single episode, in full remission

F32.89 Other specified depressive episodes

F32.9 Major depressive disorder, single episode, unspecified

F33.0 Major depressive disorder, recurrent, mild

F33.1 Major depressive disorder, recurrent, moderate

F33.2 Major depressive disorder, recurrent severe without psychotic features
75

Screening for Depression and Follow-Up Plan (CDF-AD)

ICD-10 Code Description

F33.3 Major depressive disorder, recurrent, severe with psychotic symptoms

F33.40 Major depressive disorder, recurrent, in remission, unspecified

F33.41 Major depressive disorder, recurrent, in partial remission

F33.42 Major depressive disorder, recurrent, in full remission

F33.8 Other recurrent depressive disorders

F33.9 Major depressive disorder, recurrent, unspecified

F34.1 Dysthymic disorder

F34.81 Disruptive mood dysregulation disorder

F34.89 Other specified persistent mood disorders

F43.21 Adjustment disorder with depressed mood

F43.23 Adjustment disorder with mixed anxiety and depressed mood

F53.0 Postpartum depression

F53.1 Puerperal psychosis

O90.6 Postpartum mood disturbance

O99.340 Other mental disorders complicating pregnancy, unspecified trimester

O99.341 Other mental disorders complicating pregnancy, first trimester

O99.342 Other mental disorders complicating pregnancy, second trimester

O99.343 Other mental disorders complicating pregnancy, third trimester

O99.345 Other mental disorders complicating the puerperium

Table CDF-E. ICD-10 Codes to Identify Diagnosed Bipolar Disorder (Exclusions)

ICD-10 Code Description

F31.10 Bipolar disorder, current episode manic without psychotic features, unspecified

F31.11 Bipolar disorder, current episode manic without psychotic features, mild

F31.12 Bipolar disorder, current episode manic without psychotic features, moderate

F31.13 Bipolar disorder, current episode manic without psychotic features, severe

F31.2 Bipolar disorder, current episode manic severe with psychotic features

F31.30 Bipolar disorder, current episode depressed, mild or moderate severity, 

unspecified

F31.31 Bipolar disorder, current episode depressed, mild

F31.32 Bipolar disorder, current episode depressed, moderate

F31.4 Bipolar disorder, current episode depressed, severe, without psychotic features

F31.5 Bipolar disorder, current episode depressed, severe, with psychotic features

F31.60 Bipolar disorder, current episode mixed, unspecified
76

Screening for Depression and Follow-Up Plan (CDF-AD)

ICD-10 Code Description

F31.61 Bipolar disorder, current episode mixed, mild

F31.62 Bipolar disorder, current episode mixed, moderate

F31.63 Bipolar disorder, current episode mixed, severe, without psychotic features

F31.64 Bipolar disorder, current episode mixed, severe, with psychotic features

F31.70 Bipolar disorder, currently in remission, most recent episode unspecified

F31.71 Bipolar disorder, in partial remission, most recent episode hypomanic

F31.72 Bipolar disorder, in full remission, most recent episode hypomanic

F31.73 Bipolar disorder, in partial remission, most recent episode manic

F31.74 Bipolar disorder, in full remission, most recent episode manic

F31.75 Bipolar disorder, in partial remission, most recent episode depressed

F31.76 Bipolar disorder, in full remission, most recent episode depressed

F31.77 Bipolar disorder, in partial remission, most recent episode mixed

F31.78 Bipolar disorder, in full remission, most recent episode mixed

F31.81 Bipolar II disorder

F31.89 Other bipolar disorder

F31.9 Bipolar disorder, unspecified

Exceptions

A beneficiary [client] that does not meet the numerator criteria and meets the following exception 

criteria should be removed from the measure denominator. However, if the beneficiary [client] meets 

the numerator criteria, the beneficiary [client] would be included in the measure denominator.

Beneficiary [Client] reason:

Beneficiary [Client] refuses to participate.

Medical reason:

Beneficiary [Client] is in an urgent or emergent situation where time is of the essence and to 

delay treatment would jeopardize the beneficiary [client]’s health status. 

Situations where the beneficiary [client]’s cognitive, functional, or motivational limitations may 

impact the accuracy of results. 

Use the code in Table CDF-F to identify exceptions.

Table CDF-F. HCPCS Code to Identify Exceptions

Code Description

G8433 Screening for depression not completed, documented patient or medical reason
77

Screening for Depression and Follow-Up Plan (CDF-CH)

Measure CDF-CH: Screening for Depression and Follow-Up Plan: Ages 12 to 1712

Based on a CMS Medicaid Child Core Set Measure (2023), stewarded by CMS

A. DESCRIPTION

Percentage of beneficiaries [clients] ages 12 to 17 screened for depression on the date of the 

encounter or 14 days prior to the date of the encounter using an age-appropriate standardized 

depression screening tool, and if positive, a follow-up plan is documented on the date of the eligible 

encounter.

Data Collection Method: Administrative or EHR

Guidance for Reporting:

The Screening for Depression and Follow-Up Plan measure includes beneficiaries [clients] age 12 

and older. The Child Core Set measure [This measure] applies to beneficiaries [clients] ages 12 

to 17 and the Adult Core Set measure [CDF-AD measure] applies to beneficiaries [clients] age 

18 and older. 

The intent of the measure is to screen for depression in beneficiaries [clients] who have never had 

a diagnosis of depression or bipolar disorder prior to the eligible encounter used to evaluate the 

numerator. Beneficiaries [Clients] who have ever been diagnosed with depression or bipolar 

disorder will be excluded from the measure. 

The denominator for this measure includes beneficiaries [clients] ages 12 to 17 with an outpatient 

visit during the measurement year. The numerator for this measure includes the following two 

groups:

Those beneficiaries [clients] with a positive screen for depression on the date of an outpatient 

visit or up to 14 days prior to the encounter using a standardized tool with a follow-up plan 

documented.

Those beneficiaries [clients] with a negative screen for depression on the date of an outpatient 

visit or up to 14 days prior to the encounter using a standardized tool.

The QPP claims/CQM specifications for this measure included six G codes intended to capture 

whether individual providers reported on this measure. For the purpose of Child Core Set 

reporting, t[T]here are two G codes included in the numerator to capture whether depression 

screening using an age-appropriate standardized tool was done on the date of the eligible 

encounter or up to 14 days prior to the date of the encounter and if the screen was positive, 

whether a follow-up plan was documented on the date of the eligible encounter.

An age-appropriate, standardized, and validated depression screening tool must be used and results 

documented as positive or negative for numerator compliance. The name of the age-appropriate 

standardized depression screening tool utilized must be documented in the medical record. This 

measure does not require documentation of a specific score, just whether results of the 

normalized and validated depression screening tool used are considered positive or negative. 

The screening should occur on the date of a qualifying encounter or up to 14 days prior to the 

date of the qualifying encounter. The depression screening must be reviewed and addressed by 

the provider on the date of the encounter. Positive pre-screening results indicating a beneficiary

[client] is at high risk for self-harm should receive more urgent intervention as determined by 

the provider practice.

12Aside from the minor modifications noted in this specification, this specification is taken directly from the 2023 

CMS Medicaid Child Core Set Measures. Use the most current version for the year being reported. See also 

Important Supplemental Materials for Clinic-Collected Required BHC Measures derived from CMS Medicaid Adult 

and/or Child Core Set Measures (in this manual immediately before the CDF measures).
78

Screening for Depression and Follow-Up Plan (CDF-CH)

The measure assesses the most recent depression screening completed either during the eligible 

encounter or within the 14 days prior to that encounter. Therefore, a clinician would not be able 

to complete another screening at the time of the encounter to count toward a follow-up, 

because that would serve as the most recent screening. In order to satisfy the follow-up 

requirement for a beneficiary [client] screening positively, the eligible clinician would need to 

provide one of the specified follow-up actions, which includes one or more of the following:

Referral to a provider for additional evaluation.

Pharmacological interventions.

Other interventions for the treatment of depression.

A follow-up plan must be documented on the date of the qualifying encounter for a positive 

depression screen.

Should a beneficiary [client] screen positive for depression: 

A clinician should only order pharmacological intervention when appropriate and after 

sufficient diagnostic evaluation. However, for the purposes of this measure, additional 

screening and assessment during the qualifying encounter will not qualify as a follow-up 

plan.

A clinician could opt to complete a suicide risk assessment when appropriate and based on 

individual beneficiary [client] characteristics. However, for the purposes of this measure, a 

suicide risk assessment will not qualify as a follow-up plan.

The screening tools listed in the measure specifications are examples of standardized tools. 

However, states may use any assessment tool that has been appropriately normalized and 

validated for the population in which it is being utilized. The name of the age-appropriate 

standardized depression screening tool utilized must be documented in the medical record.

This measure contains both exclusions and exceptions:

Denominator exclusion criteria are evaluated before checking if a beneficiary [client] meets 

the numerator criteria; a beneficiary [client] who qualifies for the denominator exclusion 

should be removed from the denominator.

Denominator exception criteria are only evaluated if the beneficiary [client] does not meet the 

numerator criteria; beneficiaries [clients] who do not meet numerator criteria and also meet 

denominator exception criteria (e.g., medical reason for not performing a screening) should 

be removed from the denominator. 

This measure can be calculated using administrative data only. Medical record review may be 

used to validate the state's administrative data (for example, documentation of the name of the 

standardized depression screening tool utilized). However, validation is not required to 

calculate and report this measure. 

Include all paid, suspended, pending, and denied claims.

The electronic specification for FFY 2023 is located on the eCQI resource center at 

https://ecqi.healthit.gov/sites/default/files/ecqm/measures/CMS2v11.html. [Use version current 

for year reporting.] States [Clinics] that use electronic specifications should indicate this by 

selecting “Electronic Health Records” in the Data Source section of the online reporting system

[template].

This measure includes the following coding systems: CPT and HCPCS. Refer to the 

Acknowledgments section at the beginning of the manual for copyright information. 
79

Screening for Depression and Follow-Up Plan (CDF-CH)

B. DEFINITIONS

Screening Completion of a clinical or diagnostic tool used to identify people at risk of 

developing or having a certain disease or condition, even in the absence of 

symptoms.

Standardized 

Depression 

Screening Tool

A normalized and validated depression screening tool developed for the 

population in which it is being utilized. Examples of depression screening 

tools include but are not limited to: 

Adolescent Screening Tools (12–17 years)

Patient Health Questionnaire for Adolescents (PHQ-A), Beck 

Depression Inventory-Primary Care Version (BDI-PC), Mood Feeling 

Questionnaire (MFQ), Center for Epidemiologic Studies Depression 

Scale (CES-D), Patient Health Questionnaire (PHQ-9), Pediatric 

Symptom Checklist (PSC-17), and PRIME MD-PHQ2

Perinatal Screening Tools

Edinburgh Postnatal Depression Scale, Postpartum Depression Screening 

Scale, Patient Health Questionnaire 9 (PHQ-9), Beck Depression 

Inventory, Beck Depression Inventory–II, Center for Epidemiologic 

Studies Depression Scale, and Zung Self-rating Depression Scale 

Follow-up plan Documented follow-up for a positive depression screening must include 

one or more of the following:

Referral to a provider for additional evaluation and assessment to formulate 

a follow-up plan for a positive depression screen.

Pharmacological interventions.

Other interventions or follow-up for the diagnosis or treatment of 

depression.

Examples of a follow-up plan include but are not limited to:

Referral to a provider or program for further evaluation for depression, for 

example, referral to a psychiatrist, psychologist, social worker, mental 

health counselor, or other mental health service such as family or group 

therapy, support group, depression management program, or other 

service for treatment of depression.

Other interventions designed to treat depression such as behavioral health 

evaluation, psychotherapy, pharmacological interventions, or additional 

treatment options.

The documented follow-up plan must be related to positive depression 

screening, for example: “Patient [Client] referred for psychiatric evaluation 

due to positive depression screening.”

C. ELIGIBLE POPULATION

Age Ages 12 to 17 on date of encounter. 

Event/diagnosis Outpatient visit (Table CDF-A) during the measurement year.

Continuous 

enrollment

None.
80

Screening for Depression and Follow-Up Plan (CDF-CH)

D. ADMINISTRATIVE SPECIFICATION

Denominator

The eligible population with an outpatient visit during the measurement year (Table CDF-A).

Table CDF-A. Codes to Identify Outpatient Visits

CPT HCPCS

59400, 59510, 59610, 59618, 90791, 90792, 90832, 90834, 

90837, 92625, 96105, 96110, 96112, 96116, 96125, 96136, 

96138, 96156, 96158, 97161, 97162, 97163, 97165, 97166, 

97167, 99078, 99202, 99203, 99204, 99205, 99212, 99213, 

99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 

99310, 99315, 99316, 99318, 99324, 99325, 99326, 99327, 

99328, 99334, 99335, 99336, 99337, 99339, 99340, 99401, 

99402, 99403, 99483, 99484, 99492, 99493, 99384, 99385, 

99386, 99387, 99394, 99395, 99396, 99397

G0101, G0402, G0438, 

G0439, G0444

Numerator

Beneficiaries [Clients] screened for depression on the date of the encounter or 14 days prior to the 

date of the encounter using an age-appropriate standardized depression screening tool AND, if 

positive, a follow-up plan is documented on the date of the eligible encounter using one of the codes 

in Table CDF-B.

Table CDF-B. Codes to Document Depression Screen

Code Description

G8431 Screening for depression is documented as being positive and a follow-up plan 

is documented

G8510 Screening for depression is documented as negative, a follow-up plan is not 

required

Exclusions 

A beneficiary [client] is not eligible if one or more of the following conditions are documented in the 

beneficiary [client] medical record:

Beneficiaries [Clients] who have been diagnosed with depression or bipolar disorder

Use the codes in Table CDF-C, CDF-D, and CDF-E to identify exclusions.

Table CDF-C. HCPCS Code to Identify Exclusions

Code Description

G9717 Documentation stating the patient has had a diagnosis of depression or has had 

a diagnosis of bipolar disorder
81

Screening for Depression and Follow-Up Plan (CDF-CH)

Table CDF-D. ICD-10 Codes to Identify Diagnosis of Depression (Exclusions)

ICD-10 Code Description

F01.51 Vascular dementia with behavioral disturbance

F32.A Depression, unspecified

F32.0 Major depressive disorder, single episode, mild

F32.1 Major depressive disorder, single episode, moderate

F32.2 Major depressive disorder, single episode, severe without psychotic features

F32.3 Major depressive disorder, single episode, severe with psychotic features

F32.4 Major depressive disorder, single episode, in partial remission

F32.5 Major depressive disorder, single episode, in full remission

F32.89 Other specified depressive episodes

F32.9 Major depressive disorder, single episode, unspecified

F33.0 Major depressive disorder, recurrent, mild

F33.1 Major depressive disorder, recurrent, moderate

F33.2 Major depressive disorder, recurrent severe without psychotic features

F33.3 Major depressive disorder, recurrent, severe with psychotic symptoms

F33.40 Major depressive disorder, recurrent, in remission, unspecified

F33.41 Major depressive disorder, recurrent, in partial remission

F33.42 Major depressive disorder, recurrent, in full remission

F33.8 Other recurrent depressive disorders

F33.9 Major depressive disorder, recurrent, unspecified

F34.1 Dysthymic disorder

F34.81 Disruptive mood dysregulation disorder

F34.89 Other specified persistent mood disorders

F43.21 Adjustment disorder with depressed mood

F43.23 Adjustment disorder with mixed anxiety and depressed mood

F53.0 Postpartum depression

F53.1 Puerperal psychosis

O90.6 Postpartum mood disturbance

O99.340 Other mental disorders complicating pregnancy, unspecified trimester

O99.341 Other mental disorders complicating pregnancy, first trimester

O99.342 Other mental disorders complicating pregnancy, second trimester

O99.343 Other mental disorders complicating pregnancy, third trimester

O99.345 Other mental disorders complicating the puerperium
82

Screening for Depression and Follow-Up Plan (CDF-CH)

Table CDF-E. ICD-10 Codes to Identify Diagnosed Bipolar Disorder (Exclusions)

ICD-10 Code Description

F31.10 Bipolar disorder, current episode manic without psychotic features, unspecified

F31.11 Bipolar disorder, current episode manic without psychotic features, mild

F31.12 Bipolar disorder, current episode manic without psychotic features, moderate

F31.13 Bipolar disorder, current episode manic without psychotic features, severe

F31.2 Bipolar disorder, current episode manic severe with psychotic features

F31.30 Bipolar disorder, current episode depressed, mild or moderate severity, 

unspecified

F31.31 Bipolar disorder, current episode depressed, mild

F31.32 Bipolar disorder, current episode depressed, moderate

F31.4 Bipolar disorder, current episode depressed, severe, without psychotic features

F31.5 Bipolar disorder, current episode depressed, severe, with psychotic features

F31.60 Bipolar disorder, current episode mixed, unspecified

F31.61 Bipolar disorder, current episode mixed, mild

F31.62 Bipolar disorder, current episode mixed, moderate

F31.63 Bipolar disorder, current episode mixed, severe, without psychotic features

F31.64 Bipolar disorder, current episode mixed, severe, with psychotic features

F31.70 Bipolar disorder, currently in remission, most recent episode unspecified

F31.71 Bipolar disorder, in partial remission, most recent episode hypomanic

F31.72 Bipolar disorder, in full remission, most recent episode hypomanic

F31.73 Bipolar disorder, in partial remission, most recent episode manic

F31.74 Bipolar disorder, in full remission, most recent episode manic

F31.75 Bipolar disorder, in partial remission, most recent episode depressed

F31.76 Bipolar disorder, in full remission, most recent episode depressed

F31.77 Bipolar disorder, in partial remission, most recent episode mixed

F31.78 Bipolar disorder, in full remission, most recent episode mixed

F31.81 Bipolar II disorder

F31.89 Other bipolar disorder

F31.9 Bipolar disorder, unspecified

Exceptions

A beneficiary [client] that does not meet the numerator criteria and meets the following exception 

criteria should be removed from the measure denominator. However, if the beneficiary [client] meets 

the numerator criteria, the beneficiary [client] would be included in the measure denominator.

Beneficiary [Client] reason: 
83

Screening for Depression and Follow-Up Plan (CDF-CH)

Beneficiary [Client] refuses to participate.

Medical reason:

Beneficiary [Client] is in an urgent or emergent situation where time is of the essence and to 

delay treatment would jeopardize the beneficiary [client]’s health status.

Situations where the beneficiary [client]’s cognitive, functional, or motivational limitations may 

impact the accuracy of results.

Use the code in Table CDF-F to identify exceptions. 

Table CDF-F. HCPCS Code to Identify Exceptions

Code Description

G8433 Screening for depression not completed, documented patient [client] or 

medical reason
84

Clinic-Reported Measures Optional for Submission as Part of CCBHC Demonstration

Clinic-Reported Measures Optional for Submission as Part of CCBHC 

Demonstration

This section of Chapter IV includes the following Clinic-Collected optional measures:

1. Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention (TSC)

2. Major Depressive Disorder: Suicide Risk Assessment (SRA-A)

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

(SRA-C)

4. Weight Assessment and Counseling for Nutrition and Physical Activity for 

Children/Adolescents (WCC-CH) — including supplemental materials

5. Controlling High Blood Pressure (CBP-AD) — including supplemental materials
85

Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention 

(TSC)

Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention 

(TSC)13

Based on CMS MIPS CQMS #226 (2023), which is derived from a measure stewarded by the 

National Committee for Quality Assurance (NCQA)8

A. DESCRIPTION 

The TSC measure calculates the Percentage of clients aged 18 years and older who were 

screened for Tobacco Use one or more times within the Measurement Year AND who received a 

Tobacco Cessation Intervention during the Measurement Year or in the six months prior to the 

Measurement Year if identified as a tobacco user.

Data Collection Method: Medical Records 

Important Guidance for Reporting: 

This section of the specification includes important guidance for reporting the measure. At the 

end of the specification, we include a section (F) on Frequently Asked Questions that also are 

important for the user to review.

• The MIPS CQMS measure 226 on which this measure is based contains three 

submeasures or submission criteria, with the third designed to allow comparison of 

performance to published versions of the measure prior to the MIPS 2018 performance 

year, when the measure had a single performance rate. We include all three but, for 

newer reporters who are not also reporting MIPS measures, submeasure 3 is optional.

• This measure is to be reported once per Measurement Year for clients seen during the 

Measurement Year. 

• Providers will rely on medical records to compile this information. There are several 

potential sources of information that may be used individually or together: 

o Electronic health records (including billing records) 

o Paper health records 

o A registry 

• A Provider that does not use the G or M codes noted in the specifications below may rely 

on an equally reliable source of information (designated as “equivalent information 

source” in the specifications).

8The NCQA HEDIS® measure specification has been adjusted pursuant to NCQA’s Rules for Allowable 

Adjustments of HEDIS.

13Note: The National Quality Forum (NQF) endorsed version or TSC (#0028) contains different requirements, 

including screening only every 24 months. The 2016 version of this Behavioral Health Clinic (BHC) measure relied 

on the NQF version of the measure. This 2023 version aligns, instead, with the MIPS version which requires 

screening every 12 months and Tobacco Cessation Intervention services during the Measurement Year or during the 

six months prior to the Measurement Year.
86 

Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention 

(TSC)

• For the purposes of the measure, the most recent denominator eligible encounter should

be used to determine if the numerator action for the submeasure was performed within

the 6-month look back period.

• TSC is stratified separately based on whether the client is:

o Medicaid only or Other (including those dually eligible for Medicare and

Medicaid)

AND

o A member of which of the following ethnic groups: Not Hispanic or Latino,

Hispanic or Latino, or Unknown

AND

o A member of which of the following racial groups: White or Caucasian, Black or

African American, American Indian or Alaska Native, Asian, Native Hawaiian or

Pacific Islander, More than one race, or Unknown

• Refer to the specific data-reporting template for the reporting requirements applicable to

each measure.

Measurement Period: The Measurement Period is the period for which data are required for 

reporting purposes. The Measurement Period for the denominator for all TSC submeasures is the 

Measurement Year. The Measurement Period for the numerator, for submeasure 1, is the 

Measurement Year and, for submeasures 2 and 3, is the Measurement Year and the prior six 

months. See Figure 1 for visual depiction of Measurement Year and Measurement Periods.

Figure 1. Visual of Measurement Year and Measurement Periods

Six Months before Measurement Year Measurement Year

Measurement Year (MY): 12 month reporting period

Denominator Measurement Period (MP): 12 month MY

Numerator Measurement Period Submeasure 1: 12 month MY

Numerator Measurement Period Submeasures 2 and 3: MY and previous six months

Key: MY: Measurement Year; MP: Measurement Period.

B. DEFINITIONS

TERM DEFINITION 

Measurement Period

The specific period of time for which data are needed for the 

numerator and denominator of a given submeasure or quality 

measure. The Measurement Period may differ for the numerator and 

denominator and for each submeasure or measure and is described 

in section A above.

Measurement Year The standard 12-month reporting period common to all measures 

being reported by the Provider.

Percentage A Percentage is calculated as follows: numerator divided by 

denominator (n/d).

Provider The Provider entity that is being measured (i.e., BHC) 

Tobacco Cessation 

Intervention 

Tobacco Cessation Intervention includes brief counseling (3 minutes 

or less), and/or pharmacotherapy. 
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Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention 

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TERM DEFINITION 

Note: Concepts aligned with brief counseling (e.g., minimal and 

intensive advice/counseling interventions conducted both in person 

and over the phone) are included in the numerator. Other concepts 

such as written self-help materials (e.g., brochures, pamphlets) and 

complementary/alternative therapies do not qualify for the 

numerator. Counseling also may be of longer duration or be 

performed more frequently, as evidence shows that higher-intensity 

interventions are associated with higher tobacco cessation rates 

(U.S. Preventive Services Task Force, 2021).

Tobacco Use Tobacco Use includes use of any tobacco product.

The 2021 USPSTF recommendation references the US Food and 

Drug Administration definition of tobacco which includes “any 

product made or derived from tobacco intended for human 

consumption (except products that meet the definition of drugs), 

including, but not limited to, cigarettes, cigars (including cigarillos 

and little cigars), dissolvables, hookah tobacco, nicotine gels, pipe 

tobacco, roll-your-own tobacco, smokeless tobacco products 

(including dip, snuff, snus, and chewing tobacco), vapes, electronic 

cigarettes (e-cigarettes), hookah pens, and other electronic nicotine 

delivery systems.”

• The 2021 USPSTF recommendation describes smoking as 

generally referring to “the inhaling and exhaling of smoke 

produced by combustible tobacco products such as cigarettes, 

cigars, and pipes.”

• The 2021 USPSTF recommendation describes vaping as “the 

inhaling and exhaling of aerosols produced by e-cigarettes.” In 

addition, it states, “vaping products (i.e. , e-cigarettes) usually 

contain nicotine, which is the addictive ingredient in tobacco. 

Substances other than tobacco can also be used to smoke or 

vape. While the 2015 USPSTF recommendation statement used 

the term ‘electronic nicotine delivery systems’ or ‘ENDS,’ the 

USPSTF recognizes that the field has shifted to using the term 

‘e-cigarettes’ (or ‘e-cigs’) and uses the term e-cigarettes in the 

current recommendation statement. e-Cigarettes can come in 

many shapes and sizes, but generally they heat a liquid that 

contains nicotine (the addictive drug in tobacco) to produce an 

aerosol (or ‘vapor’) that is inhaled (‘vaped’) by users.” 
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Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention 

(TSC)

C. ELIGIBLE POPULATION 

CRITERIA REQUIREMENTS 

Event/Age Follow the steps below to identify the eligible population:

Step 1

Identify clients seen at the Provider during the Measurement 

Year.

Step 2

Identify clients from step 1 who were aged 18 years and older on 

the date of service during the Measurement Year.

Step 3

Identify clients from step 2 who met either of the following 

criteria during the Measurement Year:

3. Had at least two encounters at the Provider during the 

Measurement Year. Relevant codes (Current Procedural 

Terminology [CPT®] or Healthcare Common Procedure 

Coding System [HCPCS]) include: 90791, 90792, 90832, 

90834, 90837, 90845, 92002, 92004, 92012, 92014, 92521, 

92522, 92523, 92524, 92540, 92557, 92625, 96156, 96158, 

97161, 97162, 97163, 97165, 97166, 97167, 97168, 97802, 

97803, 97804, 99024, 99202, 99203, 99204, 99205, 99212, 

99213, 99214, 99215, 99341, 99342, 99344, 99345, 99347, 

99348, 99349, 99350, G0270, G0271

 OR

4. Had one preventive care visit. Relevant codes (Current 

Procedural Terminology [CPT®] or Healthcare Common 

Procedure Coding System [HCPCS]) include: 99385*, 

99386*, 99387*, 99395*, 99396*, 99397*, 99401*, 99402*, 

99403*, 99404*, 99411*, 99412*, 99429*, G0438, G0439

NOTE #1: *Signifies that this CPT Category I code is a noncovered service under the Medicare Part B Physician Fee 

Schedule (PFS). These non-covered services should be counted 

in the eligible population. 

NOTE #2: Client encounters for this measure conducted via 

telehealth (e.g., encounters coded with GQ, GT, 95, or POS 02 

modifiers) are allowable.
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Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention 

(TSC)

D. MEDICAL RECORD SPECIFICATION

There are three submeasures for the TSC measure:

1) Percentage of clients aged 18 years and older who were screened for Tobacco Use one or

more times within the Measurement Year

AND

2) Percentage of clients aged 18 years and older who were identified as a tobacco user

during the Measurement Year in submeasure 1 and who received a Tobacco Cessation

Intervention during the Measurement Year or in the six months prior to the Measurement

Year

AND

3) Percentage of clients aged 18 years and older who were screened for Tobacco Use one or

more times within the Measurement Year and, if identified as a tobacco user, received a

Tobacco Cessation Intervention during the Measurement Year or in the six months prior

to the Measurement Year, or identified as a tobacco non-user (Providers should use only

submeasures 1 and 2 unless they were reporting TSC as part of MIPS before 2018).

SUBMEASURE 1: ALL CLIENTS WHO WERE SCREENED FOR TOBACCO USE 

DENOMINATOR (SUBMEASURE 1): 

All clients aged 18 years and older seen for at least two visits or at least one preventive visit 

during the Measurement Year (see MIPS source measure for 2023, or more current in later years, 

for visual example).

Denominator Criteria: 

All clients in the Eligible Population (section C)

AND NOT

Denominator Exclusion: 

Clients who received hospice services at any time during the Measurement Year (M1159 

or equivalent information source)

NUMERATOR (SUBMEASURE 1): 

All clients in the denominator who were screened for Tobacco Use at least once within the 

Measurement Year

NUMERATOR NOTE: To satisfy the intent of this measure, a client must have at least 

one Tobacco Use screening during the Measurement Year. If a client has multiple 

Tobacco Use screenings during the Measurement Year, only the most recent screening, 

which has a documented status of tobacco user or tobacco non-user, will be used to 

satisfy the measure requirements.
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Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention 

(TSC)

Numerator Options: 

Performance Met: 

• Client screened for Tobacco Use AND identified as a tobacco user (G9902 or 

equivalent information source), 

OR 

• Client screened for Tobacco Use AND identified as a tobacco non-user (G9903

or equivalent information source)

OR 

Performance Not Met: Client not screened for Tobacco Use (G9905 or equivalent 

information source)

SUBMEASURE 2: ALL CLIENTS WHO WERE IDENTIFIED AS A TOBACCO USER 

AND WHO RECEIVED TOBACCO CESSATION INTERVENTION

DENOMINATOR (SUBMEASURE 2): 

All clients aged 18 years and older seen for at least two visits or at least one preventive visit who 

were screened for Tobacco Use during the Measurement Year and identified as a tobacco user 

(see MIPS source measure for 2023, or more current in later years, for visual example).

Denominator Criteria: 

All clients in the Eligible Population (section C)

AND 

All eligible instances when G9902 (or equivalent information source) is submitted for 

Performance Met (client screened for Tobacco Use and identified as a tobacco user) in 

the numerator of submeasure 1 

AND NOT

Denominator Exclusion: 

Clients who received hospice services at any time during the Measurement Year (M1159 

or equivalent information source)

NUMERATOR (SUBMEASURE 2): 

All clients in the denominator of submeasure 2 who received Tobacco Cessation Intervention 

during the Measurement Year or in the six months prior to the Measurement Year
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Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention 

(TSC)

Numerator Options: 

Performance Met: Client identified as a tobacco user received Tobacco Cessation 

Intervention during the Measurement Year or in the six months prior to the Measurement 

Year (G9906 or equivalent information source) 

OR 

Performance Not Met: Client identified as a tobacco user did not receive Tobacco 

Cessation Intervention during the Measurement Year or in the six months prior to the 

Measurement Year (G9908 or equivalent information source)

SUBMEASURE 3: ALL CLIENTS WHO WERE SCREENED FOR TOBACCO USE 

AND, IF IDENTIFIED AS A TOBACCO USER, RECEIVED TOBACCO CESSATION 

INTERVENTION, OR IDENTIFIED AS A TOBACCO NON-USER (Providers should not 

use submeasure 3 unless they were reporting TSC as part of MIPS before 2018.)

DENOMINATOR (SUBMEASURE 3): 

All clients aged 18 years and older seen for at least two visits or at least one preventive visit 

during the Measurement Year (see MIPS source measure for 2023, or more current in later years, 

for visual example).

Denominator Criteria: 

All clients in the Eligible Population (section C)

AND NOT

Denominator Exclusion: 

Clients who received hospice services at any time during the Measurement Year (M1159 

or equivalent information source)

NUMERATOR (SUBMEASURE 3): 

All clients in the denominator who were screened for Tobacco Use at least once within the 

Measurement Year AND who received Tobacco Cessation Intervention during the Measurement 

Year or in the six months prior to the Measurement Year, if identified as a tobacco user, or 

identified as a tobacco non-user.

NUMERATOR NOTE: To satisfy the intent of this measure, a client must have at least 

one Tobacco Use screening during the Measurement Year. If a client has multiple 

Tobacco Use screenings during the Measurement Year, only the most recent screening, 

which has a documented status of tobacco user or tobacco non-user, will be used to 

satisfy the measure requirements.

Numerator Options: 

Performance Met: Client screened for Tobacco Use AND identified as a tobacco user 

AND received Tobacco Cessation Intervention (counseling and/or pharmacotherapy) 
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Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention 

(TSC)

during the Measurement Year or in the six months prior to the Measurement Year 

(G0030 or equivalent information source) 

OR 

Performance Met: Current tobacco non-user (1036F or equivalent information 

source) 

OR 

Performance Not Met: Tobacco screening not performed OR Tobacco Cessation 

Intervention not provided during the Measurement Period or in the six months prior to the 

Measurement Period (G0029 or equivalent information source)

E. ADDITIONAL NOTES

Both this and the source measure were specified at the provider level. Neither is risk adjusted. 

This measure is modified from the source measure to provide a specification consistent in format 

to other measures in this set of BHC measures. The substance of the measure is unchanged. 

Interpretation of scores: Better quality = Higher Percentage

F. FREQUENTLY ASKED QUESTIONS

Questions Related to Definition of Tobacco:

Q: Should we include people who use smokeless tobacco in this measure?

A: Tobacco Use includes any type of tobacco, whether smokeless or smoked, including e-cigs.

Questions Related to Definition of Tobacco Cessation Intervention:

Q: Does a Tobacco Cessation Intervention include having a phone call with the state quit line? 

A: No, the eligible encounters must be provided by the BHC. This does not preclude use of a 

quit line, but there should be an eligible brief intervention by the BHC as well. 

Questions Related to Frequency of Screening:

Q: Can BHCs screen more frequently than once a year?

A: Yes, BHCs can screen more frequently. The measure, however, only looks at the last screen 

in the Measurement Year. 

Questions Related to Duration or Frequency of Cessation Intervention:

Q: Can we include encounters where the intervention is longer than three minutes?

A: Yes, the intervention may be of longer duration or be performed more frequently, as evidence 

shows there is a dose-response relationship between the intensity of counseling provided (either 

length or frequency) and tobacco cessation rates (U.S. Preventive Services Task Force, 2015).
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Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention 

(TSC)

Questions Related to Screening and/or Intervention Provider:

Q: For the measure of screening and cessation intervention for Tobacco Use, is use of the 

physician office codes required? Can nonphysicians report the CPT-II codes? Our state trains our 

Peer Recovery Support Specialists and our Wellness Coaches on the 5 A’s, so they would more 

likely be working with the clients on this subject. 

A: The measure does not specify which staff should do the screening or intervention other than 

by inclusion of specific codes designating an eligible encounter. BHCs may use staff who can 

provide these services within their state licensure. If operating under supervision of a physician, 

staff can use the physician codes. If you are a BHC participating in the CCBHC demonstration 

program, you also may compile a list of comparable codes; but the list should be clear and be 

provided to all CCBHCs in the state, and the deviation should be indicated on the reporting 

template.

Questions Related to Timing of Screening and Intervention:

Q: Do the screening and cessation intervention need to happen in the same session/encounter? 

A: The screening and intervention should be performed during the same encounter although the 

measure is silent on this point. 

Questions Related to Client Age:

Q: Can the measure be reported for clients younger than age 18 years?

A: It is only required for those ages 18 year or older but BHCs may also report this submeasure 

for individuals younger than age 18 years of age if they wish but that information should be 

included in the additional notes in the bottom of the TSC data reporting template.

Questions Related to Coding for the Numerator(s):

Q: Our system does not support the G or M codes needed to calculate the measure. What should 

we do?

A: Although we recommend using the specified G or M codes, a Provider that does not use the G 

or M codes noted in the specification, may rely on an equally reliable source of information 

(designated as “equivalent information source” in the numerator specifications).
94

Adult Major Depressive Disorder (MDD): Suicide Risk Assessment (SRA-A)

Adult Major Depressive Disorder (MDD): Suicide Risk Assessment (SRA-A)

Guidance for BHCs calculating MIPS eCQM ID CMS161v11 (2023), stewarded by Mathematica 

Policy Research

BHCs using this measure should access and use the electronic technical specifications that are 

current for the year being measured. At the time of publication of this manual, the 2023 eCQM 

ID CMS161v11 is the current version.

This document is intended as supplemental guidance for the use of those electronic 

specifications. This guidance uses the term “client” in lieu of “patient” and adds stratifications 

for purposes of CCBHC reporting.

A. DESCRIPTION 

According to the 2023 electronic specification, this is the “Percentage of all patient [client] visits 

for those patients [clients] that turn 18 or older during the measurement period in which a new or 

recurrent diagnosis of major depressive disorder (MDD) was identified and a suicide risk 

assessment (SRA) was completed during the visit”

Data Source: Electronic Medical Records 

Important Reporting Guidance: 

This section of the specification includes important guidance for reporting the SRA-A measure. 

Also refer to section F for Frequently Asked Questions.

• According to the 2023 electronic specification, “This eCQM is an episode-based measure 

and should be reported for each instance of a new or recurrent episode of major 

depressive disorder (MDD) during the measurement period. This measure should be 

reported for each eligible encounter during which a new or recurrent episode of MDD is 

identified in adults that turn 18 or older during the measurement period.”

• Providers will rely on electronic medical records to compile this information. 

• Both the SRA-A and SRA-C measures are to be used by BHCs to measure performance 

related to clients seen at the Provider during the Measurement Year.

• In contrast to the electronic specification, CCBHCs reporting SRA-A are required to 

stratify separately based on whether the client is:

o Medicaid only or Other (including those dually eligible for Medicare and 

Medicaid)

AND

o a member of which of the following ethnic groups: Not Hispanic or Latino, 

Hispanic or Latino, or Unknown

AND
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Adult Major Depressive Disorder (MDD): Suicide Risk Assessment (SRA-A)

o a member of which of the following racial groups: White or Caucasian, Black 

or African American, American Indian or Alaska Native, Asian, Native 

Hawaiian or Pacific Islander, More than one race, or Unknown

• Refer to the specific data-reporting template for the reporting requirements applicable to 

each measure.

Measurement Period: The Measurement Period is the period for which data are required for 

reporting purposes. The Measurement Period for the denominator is the Measurement Year and, 

for the numerator, is the Measurement Year and the 105 days before.

B. DEFINITIONS 

TERM DEFINITION 

Measurement Period

The specific time period for which data are needed for the 

numerator and denominator of a given measure. The Measurement 

Period may differ for the numerator and denominator and for each 

measure and is specified in section A above.

Measurement Year The standard 12-month reporting period common to all measures 

being reported by the Provider.

Percentage A Percentage is calculated as follows: numerator divided by 

denominator (n/d).

Provider The Provider entity that is being measured (i.e., BHC) 

Suicide Risk 

Assessment

According to the 2023 electronic specification, “The specific type 

and magnitude of the suicide risk assessment is intended to be at 

the discretion of the individual clinician and should be specific to 

the needs of the patient [client]. At a minimum, suicide risk 

assessment should evaluate:

1) Suicidal ideation

2) Patient’s [Client's] intent of initiating a suicide attempt

AND, if either is present,

3) Patient [Client] plans for a suicide attempt

4) Whether the patient [client] has means for completing suicide

Low burden tools to track suicidal ideation and behavior such as 

the Columbia-Suicide Severity Rating Scale (C-SSRS) and the 

Suicide Assessment Five-Step Evaluation and Triage (SAFE-T) 

can also be used. Because no validated assessment tool or 

instrument fully meets the aforementioned requirements for the 

suicide risk assessment, individual tools or instruments have not 

been explicitly included in coding.”

C. ELIGIBLE POPULATION 

CRITERIA REQUIREMENTS 

Event/Age Follow the steps below to identify the eligible population:
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Adult Major Depressive Disorder (MDD): Suicide Risk Assessment (SRA-A)

CRITERIA REQUIREMENTS 

Step 1

Identify clients seen at the Provider during the Measurement Year.

Step 2

After step 1, use the “Initial Population” described in the current 

electronic specification. For 2023, this is “Patient [Client] visits 

for patients [clients] that turn 18 or older during the measurement 

period during which a new diagnosis of MDD, single or recurrent 

episode, was identified.”

D. ELECTRONIC MEDICAL RECORD SPECIFICATION 

DENOMINATOR: 

The eligible population as listed in Section C is the denominator. Use the detailed electronic 

specifications in the current version of the measure.

NUMERATOR: 

Use the detailed electronic specifications in the current version of the measure. For 2023, the 

numerator is described as “Patient [Client] visits during which a new diagnosis of MDD, single 

or recurrent episode, was identified and a suicide risk assessment was completed during the 

visit.” 

NUMERATOR NOTE #1: According to the 2023 electronic specification, “It is 

expected that a suicide risk assessment will be completed at the visit during which a 

new diagnosis is made or at the visit during which a recurrent episode is first identified 

(i.e., at the initial evaluation). For the purposes of this measure, an episode of major 

depressive disorder (MDD) would be considered to be recurrent if a patient has not had 

an MDD-related encounter in the past 105 days. If there is a gap of 105 or more days 

between visits for major depressive disorder (MDD), that would imply a recurrent 

episode. The 105-day look-back period is an operational provision and not a clinical 

recommendation, or definition of relapse, remission, or recurrence.”

NUMERATOR NOTE #2: According to the 2023 electronic specification, “In 

recognition of the growing use of integrated and team-based care, the diagnosis of 

depression and the assessment for suicide risk need not be performed by the same 

provider or clinician.”

NUMERATOR NOTE #3: According to the 2023 electronic specification, “Suicide 

risk assessments completed via telehealth services can also meet numerator 

performance.”
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Adult Major Depressive Disorder (MDD): Suicide Risk Assessment (SRA-A) 

E. ADDITIONAL NOTES

The source measure is specified at the provider level. It is not risk adjusted.

Interpretation of scores: Better quality = Higher Percentage

F. FREQUENTLY ASKED QUESTIONS

Questions Related to Age:

Q: How do we assess for suicide risk for younger clients who are not included in the eligible 

population for this measure?

A: According to the 2023 electronic specification, “The logic statement for the age requirement, 

as written, captures patients [clients] who turn 18 years old during the measurement period so 

that these patients [clients] are included in the measure, as long as the minimum criteria noted 

above is evaluated. To ensure all patients [clients] with major depressive disorder (MDD) are 

assessed for suicide risk, there are two clinical quality measures addressing suicide risk 

assessment; CMS177- Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk 

Assessment covers children and adolescents aged 6 through 17, and CMS161 covers the adult 

population aged 18 years and older, as no individual suicide risk assessment tool or instrument 

would satisfy the requirements alone.”

Questions Regarding the Definition of “Recurrent Episode”

Q: In the “Adult Major Depressive Disorder (MDD): Suicide Risk Assessment (SRA-A)”

measure, how is “recurrent episode” defined?

A: According to the 2023 electronic specification, “It is expected that a suicide risk assessment 

will be completed at the visit during which a new diagnosis is made or at the visit during which 

a recurrent episode is first identified (i.e., at the initial evaluation). For the purposes of this 

measure, an episode of major depressive disorder (MDD) would be considered to be recurrent if 

a patient has not had an MDD-related encounter in the past 105 days. If there is a gap of 105 or 

more days between visits for major depressive disorder (MDD), that would imply a recurrent 

episode. The 105-day look-back period is an operational provision and not a clinical 

recommendation, or definition of relapse, remission, or recurrence.”

Questions Regarding Suicide Risk Assessment Resources: 

Q: Can you provide us with additional information on evidence-based practices to inform our 

suicide-risk assessment protocols? 

A: Yes, please see https://www.nimh.nih.gov/research/research-conducted-at-nimh/asqtoolkit-materials.
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Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment (SRAC)

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

(SRA-C)

Guidance for BHCs calculating MIPS eCQM ID CMS177v11 (2023), stewarded by Mathematica 

Policy Research

BHCs using this measure should access and use the electronic technical specifications that are 

current for the year being measured. At the time of publication of this manual, the 2023 eCQM 

ID CMS177v11 is the current version.

This document is intended as supplemental guidance for the use of those electronic 

specifications. This guidance uses the term “client” in lieu of “patient” and adds stratifications 

for purposes of CCBHC reporting.

A. DESCRIPTION

According to the 2023 electronic specification, this is the “Percentage of patient [client] visits for 

those patients [clients] aged 6 through 17 years with a diagnosis of major depressive disorder 

(MDD) with an assessment for suicide risk”

Data Source: Electronic Medical Records 

Important Reporting Guidance: 

This section of the specification includes important guidance for reporting the SRA-C measure. 

Also refer to section F for Frequently Asked Questions.

• According to the 2023 electronic specification, “This eCQM is an episode-based

measure. An episode is defined as each eligible encounter for major depressive disorder

(MDD) during the measurement period.”

• Providers will rely on electronic medical records to compile this information.

• Both the SRA-A and SRA-C measures are to be used by BHCs to measure performance

related to clients seen at the Provider during the Measurement Year.

• In contrast to the electronic specification, CCBHCs reporting SRA-C are required to

stratify separately based on whether the client is:

o Medicaid only or Other (including those dually eligible for Medicare and

Medicaid)

AND

o a member of which of the following ethnic groups: Not Hispanic or Latino,

Hispanic or Latino, or Unknown

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

o a member of which of the following racial groups: White or Caucasian, Black 

or African American, American Indian or Alaska Native, Asian, Native 

Hawaiian or Pacific Islander, More than one race, or Unknown

• Refer to the specific data-reporting template for the reporting requirements applicable to 

each measure.

Measurement Period: The Measurement Period is the period for which data are required for 

reporting purposes. The Measurement Period for both the denominator and the numerator is 

the Measurement Year. 

B. DEFINITIONS 

TERM DEFINITION 

Measurement Period

The specific time period for which data are needed for the 

numerator and denominator of a given measure. The Measurement 

Period may differ for the numerator and denominator and for each 

measure and is specified in section A above.

Measurement Year The standard 12-month reporting period common to all measures 

being reported by the Provider.

Percentage A Percentage is calculated as follows: numerator divided by 

denominator (n/d).

Provider The Provider entity that is being measured (i.e., BHC) 

Suicide Risk 

Assessment

According to the 2023 electronic specification, “The specific type 

and magnitude of the suicide risk assessment is intended to be at 

the discretion of the individual clinician and should be specific to 

the needs of the patient [client]. At a minimum, suicide risk 

assessment should evaluate:

1. Risk (e.g., age, sex, stressors, comorbid conditions, 

hopelessness, impulsivity) and protective factors (e.g., religious 

belief, concern not to hurt family) that may influence the desire to 

attempt suicide.

2. Current severity of suicidality.

3. Most severe point of suicidality in episode and lifetime.

Low burden tools to track suicidal ideation and behavior such as 

the Columbia-Suicidal Severity Rating Scale can also be used. 

Because no validated assessment tool or instrument fully meets the 

aforementioned requirements for the suicide risk assessment, 

individual tools or instruments have not been explicitly included in 

coding.”

According to the 2023 electronic specification, “Use of a 

standardized tool(s) or instrument(s) to assess suicide risk will 

meet numerator performance, so long as the minimum criteria 

noted above is evaluated. Standardized tools can be mapped to the 
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Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment (SRAC)

TERM DEFINITION 

concept "Intervention, Performed": "Suicide risk assessment 

(procedure)" included in the numerator logic below [in the current 

electronic specification], as no individual suicide risk assessment 

tool or instrument would satisfy the requirements alone.”

C. ELIGIBLE POPULATION

CRITERIA REQUIREMENTS 

Event/Age Follow the steps below to identify the eligible population:

Step 1

Identify clients seen at the Provider during the Measurement Year.

Step 2

After step 1, use the “Initial Population” described in the current 

electronic specification. For 2023, this is “All patient [client] 

visits for those patients [clients] aged 6 through 17 years with a 

diagnosis of major depressive disorder.”

D. ELECTRONIC MEDICAL RECORD SPECIFICATION

DENOMINATOR: 

The eligible population as listed in Section C is the denominator. Use the detailed electronic 

specifications in the current version of the measure.

NUMERATOR: 

Use the detailed electronic specifications in the current version of the measure. For 2023, the 

numerator is described as “Patient [Client] visits with an assessment for suicide risk.” 

NUMERATOR NOTE #1: According to the 2023 electronic specification, “A suicide 

risk assessment should be performed at every visit for MDD during the measurement 

period.”

NUMERATOR NOTE #2: According to the 2023 electronic specification, “In 

recognition of the growing use of integrated and team-based care, the diagnosis of 

depression and the assessment for suicide risk need not be performed by the same 

provider or clinician.”

NUMERATOR NOTE #3: According to the 2023 electronic specification, “Suicide 

risk assessments completed via telehealth services can also meet numerator 

performance.”
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Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment (SRAC)

E. ADDITIONAL NOTES

The source measure is specified at the provider level. It is not risk adjusted.

Interpretation of scores: Better quality = Higher Percentage 

F. FREQUENTLY ASKED QUESTIONS

Questions requesting appropriate assessment instruments or tools: 

Q: For the SRA-C measure, the technical specification says we need to use a standardized 

assessment tool, but it does not define which one to use. What do you recommend? 

A: The SRA-C measure does not identify specific standardized assessment tools that it requires, 

but it does include types of information or inquiries that should be included in the assessment. 

BHCs should follow that definition. 

Questions related to when clients should be assessed: 

Q: Regarding the measure of child suicide risk assessment, a risk assessment is required to be 

completed at each visit where there is a MDD diagnosis. Some clinicians are concerned that this 

is too much to ask of the clients and that if they keep asking youth these questions, they may 

eventually decide that suicidality is expected of them. Is it necessary to assess youth with MDD 

for suicide risk each time they are seen? 

A: For youth, the measure does expect that the SRA will be conducted at each visit within an 

episode of MDD to assess for suicide risk. The type and magnitude of the assessment is left to 

the discretion of the clinician, but it should be standardized and the Technical Specification notes 

that low burden tools can be used. There are no exclusions. Clinical judgment also should be 

exercised in determining what is best for the client. 

Q: Regarding the children’s measure, sessions are often performed with the parents without the 

child present. Can such clients be included in the eligible population and what is the reporting 

expectation in such cases? 

A: We suggest that the BHC indicate in the Additional Notes on the data reporting template 

that it does not and cannot conduct an SRA for a child when only parents are in the session and 

that the BHC is excluding those visits from the denominator and numerator. 

Questions Regarding Suicide Risk Assessment Resources:

Q: Can you provide us with additional information on evidence-based practices to inform our 

suicide-risk assessment protocols?

A: Yes, please see https://www.nimh.nih.gov/research/research-conducted-at-nimh/asq-toolkitmaterials.
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Supplemental Materials for Weight Assessment and Counseling for Nutrition and 

Physical Activity for Children/Adolescents (WCC-CH) 

Important Supplemental Materials for Clinic-Collected Optional

BHC Measures derived from CMS Medicaid Adult and/or Child 

Core Set Measures (WCC-CH)

Measure WCC-CH: Weight Assessment and Counseling for Nutrition and Physical 

Activity for Children/Adolescents

These supplemental materials are necessary for implementation of the BHC Clinic-Collected 

Optional BHC Measures that are derived from the CMS Medicaid Adult and/or Child Core Set 

Measures. This volume includes the exact specifications that are on the CMS website for the 

2023 Medicaid Core Set, with simple modifications noted in the text. Limited additional needed 

modifications are included below, as well as supplemental useful materials.

Changes within the specification: For the WCC-CH measure, the changes in the specification 

from the CMS Medicaid Child Core Set reflects: (1) substitution of the word “client” for 

“beneficiary” or “patient”, unless the latter is part of a copyrighted code description; (2) removal 

of age stratification within the child client population; and (3) removal of references to the Core 

Set.

Additional information: For the WCC-CH measure, the following material is provided to assist 

clinics using the specifications and follows the numbering system used in the non-Medicaid Core 

Set-derived BHC specifications:

A. DESCRIPTION

Important Reporting Guidance:

• The WCC-CH measure is to be used by BHCs to measure performance related to

clients seen at the Provider during the Measurement Year.

• Value set references are underlined in the specifications (e.g., Physical Activity

Counseling Value Set). Current value sets are available on the CMS Medicaid Child

Core Set Reporting Resource website. Use the version current for the year being

reported.

• The WCC-CH measure is to be stratified separately based on whether the client is:

o Medicaid only or Other (including those dually eligible for Medicare and

Medicaid)

AND

o A member of which of the following ethnic groups: Not Hispanic or Latino,

Hispanic or Latino, or Unknown

AND

o A member of which of the following racial groups: White or Caucasian, Black or

African American, American Indian or Alaska Native, Asian, Native Hawaiian or

Other Pacific Islander, More than one race, or Unknown
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Physical Activity for Children/Adolescents (WCC-CH)

• Refer to the specific data-reporting template for the reporting requirements applicable 

to each measure.

Measurement Period: The Measurement Period is the period for which data are required for 

reporting purposes. The Measurement Period for the WCC denominator is the Measurement 

Year and, for the WCC numerator, is the Measurement Year. See Figure 1 for visual 

depiction of Measurement Year and Measurement Periods.

Figure 1. Visual of Measurement Year and Measurement Periods

Measurement Year

Measurement Year (MY): 12 month reporting period

Denominator Measurement Period (MP): 12 month MY

Numerator Measurement Period (MP): 12 month MY

Key: MY: Measurement Year; MP: Measurement Period.

B. DEFINITIONS

TERM DEFINITION 

Measurement Period

The specific time period for which data are needed for the 

numerator and denominator of a given measure. The Measurement 

Period may differ for the numerator and denominator and for each 

measure and is specified in section A above.

Measurement Year The standard 12-month reporting period common to all measures 

being reported by the Provider.

Percentage A Percentage is calculated as follows: numerator divided by 

denominator (n/d).

Provider The Provider entity that is being measured (i.e., BHC) 

E. ADDITIONAL NOTES

Interpretation of scores: Better quality = Higher Percentage

F. FREQUENTLY ASKED QUESTIONS

Question on relation of height and weight to BMI:

Q: For Weight Assessment and Counseling for Nutrition and Physical Activity for

Children/Adolescents (WCC-CH),” if BMI percentile is present, why are height and weight 

required?

A: These are requirements from the source measure, most likely to ensure that whoever

calculated the percentile captured the height and weight and did the calculation accurately based 

on those measurements.

Question on sampling for the WCC-CH measure:

Q: Are BHCs required to use sampling for the WCC-CH measure? If the BHCs have systems in
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Physical Activity for Children/Adolescents (WCC-CH)

place to report on all consumers in the measure, can they report on all consumers or must they 

pick a subset?

A: Sampling is not required. Reporting on all consumers is completely acceptable. Sampling

would likely be harder for you if you already have the required information in your EHR.

Questions regarding providers who may assess and provide services for clients under the 

WCC-CH measure:

Q: Should a primary care practitioner (PCP) or obstetrician/gynecologist (OB/GYN) complete 

the assessments and services included in the WCC-CH measure?

A: The Medicaid Core Set measure from which this measure derives requires that the services 

be provided “at an outpatient visit with a primary care practitioner (PCP) or 

obstetrician/gynecologist (OB/GYN)” and, further, that “[Client]-reported services and 

biometric values (height, weight, BMI percentile) are acceptable only if the information is 

collected by a primary care practitioner (refer to Appendix D of this manual for the definition of 

“PCP”) or specialist, if the specialist is providing a primary care service related to the condition 

being assessed, while taking a patient's history.” Although Appendix D defines PCP more 

broadly than one might literally, we realize that this still will make it difficult in many cases for 

BHCs to obtain data and assure that the BMI screening and other assessments or counseling 

occur. For this reason and in the context of the CCBHC demonstration, medical personnel 

beyond PCPs or OB/GYNs can conduct services contemplated within the specification, if they 

operate within the scope of their licensure. Because this is a deviation from the measure 

Technical Specification, the deviation should be indicated in the section of the data reporting 

template where adherence or non-adherence to the Technical Specification is reported.

Q: For the CCBHC demonstration project, the requirement for the OB/GYN and PCP to screen 

clients has been relaxed for the WCC-BH measure. Is the list of codes for the outpatient value 

set still going to be the same? If so, could this potentially be limiting to clinics that did not use a 

PCP or OB/GYN?

A: This is a BHC-reported measure. The BHCs will be able to have any “medical personnel” 

(within the licensure or certification requirements of the state) undertake the BMI screening to 

satisfy the measure. This might include nurses, medical assistants, and others. If a BHC or

state does not believe that that the codes will allow this for all such staff at the BHCs, include 

the codes that are pertinent for eligible services with those other personnel and indicate this in 

the data reporting template as a deviation from the Technical Specifications. In circumstances 

such as this, the state should develop a list of such codes that is transparent and consistent 

across providers, especially across CCBHCs. Please note that federal regulations allow only 

properly licensed medical personnel, who are working under the supervision of a physician, to 

use billing codes designed for physicians.

Questions on reporting physical health services:

Q: Concerning the WCC-CH measure, if the CCBHC demonstration does not provide primary

care services, why are CCBHCs required to report on the BMI for children served by a PCP?

A: One focus of the CCBHC initiative is to foster better coordination of physical and behavioral 

health care, and part of the scope of services to be provided by CCBHCs is physical health 
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Physical Activity for Children/Adolescents (WCC-CH)

screening and monitoring. The screenings such as BMI that are part of the quality measures are 

designed to promote this scope of services. If there is a PCP and you know that the screening 

already has been conducted and documented, then you can obtain and use that information.
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Measure WCC-CH: Weight Assessment and Counseling for Nutrition and Physical 

Activity for Children/Adolescents

Measure WCC-CH: Weight Assessment and Counseling for Nutrition and Physical 

Activity for Children/Adolescents8,14

Based on a CMS Medicaid Child Core Set Measure (2023), which is derived from a measure 

stewarded by the National Committee for Quality Assurance (NCQA)

A. DESCRIPTION

Percentage of children ages 3 to 17 who had an outpatient visit with a primary care practitioner

(PCP) or obstetrician/gynecologist (OB/GYN) and who had evidence of the following during the

measurement year:

Body mass index (BMI) percentile documentation*

Counseling for nutrition

Counseling for physical activity

* Because BMI norms for youth vary with age and gender, this measure evaluates whether BMI

percentile is assessed, rather than an absolute BMI value.

Data Collection Method: Administrative, Hybrid, or EHR

Guidance for Reporting: 

This measure applies to beneficiaries [clients] ages 3 to 17. For the purpose of [Medicaid] Child 

Core Set reporting, states should calculate and report this measure for two age groups and a 

total rate for each of the three indicators: ages 3 to 11, ages 12 to 17, and total (ages 1 to 17). 

[For purposes of Behavioral Health Clinic reporting, states [clinics] report only the total.]

The eligible population (denominator) for this measure includes children ages 3 to 17 who have an 

outpatient visit and meet the continuous enrollment criteria.

A BMI percentile is included in the numerator count if the specified documentation is present, 

regardless of the primary intent of the visit. A BMI without a percentile is not acceptable for 

inclusion in the numerator count.

The height, weight, and BMI must be from the same data source.

The height and weight measurement should be taken during the measurement year.

If using hybrid specifications, documentation in the medical record should indicate the weight and 

BMI value, dated during the measurement year.

Include all paid, suspended, pending, and denied claims.

This measure includes an optional exclusion for beneficiaries [clients] who die during the 

measurement year. For additional information, refer to the deceased beneficiary [client] 

exclusion guidance in Section II. Data Collection and Reporting of the Child Core Set [Section 

III. Technical Specification Components].

The electronic specification for FFY 2023 is located on the eCQI resource center at 

https://ecqi.healthit.gov/ecqm/ec/2022/cms155v10. [Use version current for year reporting.] 

8The NCQA HEDIS® measure specification has been adjusted pursuant to NCQA’s Rules for Allowable 

Adjustments of HEDIS.

14Aside from the minor modifications noted in this specification, this specification is taken directly from the 2023 

CMS Medicaid Child Core Set Measures. Use the most current version for the year being reported.

See also Important Supplemental Materials for Clinic-Collected Optional BHC Measures derived from CMS 

Medicaid Adult and/or Child Core Set Measures (in this manual immediately before this specification).
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Activity for Children/Adolescents

States that use electronic specifications should indicate this by selecting “Electronic Health 

Records” in the Data Source section of the online reporting system [template].

Refer to [Appendix D of this manual] for definitions of a PCP and OB/GYN and other prenatal 

care practitioner.

This measure’s Value Set Directory includes the following coding systems for services, procedures, 

and diagnoses: CPT, HCPCS, ICD-10-CM, LOINC, SNOMED, and UB. Refer to the 

Acknowledgments section at the beginning of the manual for copyright information. 

B. DEFINITION

BMI percentile The percentile ranking based on the CDC’s BMI-for-age growth charts, 

which indicates the relative position of the patient’s BMI number among 

others of the same gender and age.

C. ELIGIBLE POPULATION

Ages Ages 3 to 17 as of December 31 of the measurement year. 

Continuous 

enrollment

The measurement year.

Allowable gap No more than one gap in enrollment of up to 45 days during the 

measurement year. To determine continuous enrollment for a beneficiary

[client] for whom enrollment is verified monthly, the beneficiary [client]

may not have more than a 1-month gap in coverage (e.g., a beneficiary

[client] whose coverage lapses for 2 months [60 days] is not considered 

continuously enrolled).

Anchor date December 31 of the measurement year.

Benefit Medical.

Event/diagnosis An outpatient visit (Outpatient Value Set) with a PCP or an OB/GYN 

during the measurement year.

Required exclusion Beneficiaries [Clients] in hospice or using hospice services anytime during 

the measurement year. If a state reports this measure using the Hybrid 

method, and a beneficiary [client] is found to be in hospice or using hospice 

services during medical record review, the beneficiary [client] is removed 

from the sample and replaced by a beneficiary [client] from the oversample. 

For additional information, refer to the hospice exclusion guidance in 

Section II. Data Collection and Reporting of the Child Core Set [Section 

III. Technical Specification Components].

D. ADMINISTRATIVE SPECIFICATION

Denominator

The eligible population as defined above.

Numerators

BMI Percentile
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Measure WCC-CH: Weight Assessment and Counseling for Nutrition and Physical 

Activity for Children/Adolescents

BMI percentile (BMI Percentile Value Set) during the measurement year.

Counseling for Nutrition

Counseling for nutrition (Nutrition Counseling Value Set) during the measurement year.

Counseling for Physical Activity

Counseling for physical activity (Physical Activity Counseling Value Set) during the measurement 

year.

Exclusions (optional)

Female beneficiaries [clients] who have a diagnosis of pregnancy (Pregnancy Value Set) during the 

measurement year. The denominator for all rates must be the same. A state that excludes these 

beneficiaries [clients] must do so for all rates.

E. HYBRID SPECIFICATION

Denominator

A systematic sample drawn from the eligible population for the Total age band (ages 3 to 17). The 

Total sample is stratified by age to report rates for the ages 3 to 11 and ages 12 to 17 age 

stratifications. Refer to the sampling guidance under Section II. Data Collection and Reporting of the 

Child Core Set [Behavioral Health Clinic Quality Measures] for additional information. 

Numerators

BMI Percentile

BMI percentile during the measurement year as identified by administrative data or medical record 

review. 

Administrative Data

Refer to Administrative Specification to identify positive numerator hits from the administrative 

data.

Medical Record Review

Documentation must include height, weight, and BMI percentile during the measurement year. The 

height, weight, and BMI percentile must be from the same data source. 

Either of the following meets criteria for BMI percentile:

BMI percentile documented as a value (e.g., 85th percentile)

BMI percentile plotted on age-growth chart

Only evidence of the BMI percentile or BMI percentile plotted on an age-growth chart meets criteria. 

Beneficiary [Client]-reported services and biometric values (height, weight, BMI percentile) are 

acceptable only if the information is collected by a primary care practitioner (refer to [Appendix D of 

this manual] for the definition of “PCP”) or specialist, if the specialist is providing a primary care 

service related to the condition being assessed, while taking a patient's history. The information must 

be recorded, dated, and maintained in the beneficiary [client]'s legal health record. 

Ranges and thresholds do not meet criteria for this indicator. A distinct BMI percentile is required 

for numerator compliance. Documentation of >99 percent or <1 percent meet criteria because a 

distinct BMI percentile is evident (e.g., 100 percent or 0 percent).
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Activity for Children/Adolescents

Counseling for Nutrition 

Documentation of counseling for nutrition or referral for nutrition education during the measurement 

year as identified by administrative data or medical record review.

Administrative Data

Refer to Administrative Specification to identify positive numerator hits from the administrative 

data.

Medical Record Review

Documentation must include a note indicating the date and at least one of the following:

Discussion of current nutrition behaviors (e.g., eating habits, dieting behaviors)

Checklist indicating nutrition was addressed

Counseling or referral for nutrition education

Beneficiary [Client] received education materials on nutrition during a face-to-face visit

Anticipatory guidance for nutrition

Weight or obesity counseling

Counseling for Physical Activity

Documentation of counseling for physical activity or referral for physical activity during the 

measurement year as identified by administrative data or medical record review.

Administrative Data

Refer to Administrative Specification to identify positive numerator hits from the administrative 

data.

Medical Record Review

Documentation must include a note indicating the date and at least one of the following:

Discussion of current physical activity behaviors (e.g., exercise routine, participation in sports 

activities, exam for sports participation)

Checklist indicating physical activity was addressed

Counseling or referral for physical activity

Beneficiary [Client] received educational materials on physical activity during a face-to-face visit

Anticipatory guidance specific to the child’s physical activity

Weight or obesity counseling 

Exclusions (optional)

Refer to Administrative Specification for exclusion criteria. Exclusionary evidence in the medical 

record must include a note indicating a diagnosis of pregnancy. The diagnosis must have occurred 

during the measurement year.

F. ADDITIONAL NOTES

The following notations or examples of documentation do not count as numerator compliant:

BMI Percentile

No BMI percentile documented in medical record or plotted on age-growth chart

Notation of BMI value only
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Measure WCC-CH: Weight Assessment and Counseling for Nutrition and Physical 

Activity for Children/Adolescents

Notation of height and weight only

Nutrition 

No counseling/education on nutrition and diet

Counseling/education before or after the measurement year

Notation of “health education” or “anticipatory guidance” without specific mention of 

nutrition

A physical exam finding or observation alone (e.g., well-nourished) is not compliant because 

it does not indicate counseling for nutrition 

Documentation related to a beneficiary [client]’s “appetite” does not meet criteria

Physical Activity

No counseling/education on physical activity

Notation of “cleared for gym class” alone without documentation of a discussion

Counseling/education before or after the measurement year 

Notation of “health education” or “anticipatory guidance” without specific mention of 

physical activity

Notation of anticipatory guidance related solely to safety (e.g., wears helmet or water safety) 

without specific mention of physical activity recommendations

Notation solely related to screen time (computer or television) without specific mention of 

physical activity

Services may be rendered during a visit other than a well-child visit. These services count if the 

specified documentation is present, regardless of the primary intent of the visit; however, 

services specific to the assessment or treatment of an acute or chronic condition do not count 

toward the Counseling for Nutrition and Counseling for Physical Activity indicators.

For example, the following documentation is specific to the assessment or treatment of an acute 

or chronic condition and does not meet criteria:

Notation that a beneficiary [client] with chronic knee pain is able to run without limping 

Notation that a beneficiary [client] has exercise-induced asthma

Notation that a beneficiary [client] with diarrhea is following the BRAT diet

Notation that a beneficiary [client] has decreased appetite as a result of an acute or chronic 

condition

Services rendered for obesity or eating disorders may be used to meet criteria for the Counseling for 

Nutrition and Counseling for Physical Activity indicators if the specified documentation is 

present.

Referral to the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) 

may be used to meet criteria for the Counseling for Nutrition indicator.

The BMI Percentile, Counseling for Nutrition, and Counseling for Physical Activity indicators do 

not require a specific setting. Therefore, services rendered during a telephone visit, e-visit, or 

virtual check-in meet criteria.
111

Supplemental Materials for Controlling High Blood Pressure (CBP-AD)

Important Supplemental Materials for Clinic-Collected Optional

BHC Measures derived from CMS Medicaid Adult and/or Child 

Core Set Measures (CBP-AD)

Measure CBP-AD: Controlling High Blood Pressure

These supplemental materials are necessary for implementation of the BHC Clinic-Collected 

Optional BHC Measures that are derived from the CMS Medicaid Adult and/or Child Core Set 

Measures. This volume includes the exact specifications that are on the CMS website for the 

2023 Medicaid Core Set, with simple modifications noted in the text. Limited additional needed 

modifications are included below, as well as supplemental useful materials.

Changes within the specification: For the CBP-AD measure, the changes in the specification 

from the CMS Medicaid Adult Core Set reflects: (1) substitution of the word “client” for 

“beneficiary” or “patient”, unless the latter is part of a copyrighted code description; (2) removal 

of age stratification in the adult measure (i.e., applicable here to adults ages 18 years and older); 

and (3) removal of references to the Core Set.

Additional information: For the CBP-AD measure, the following material is provided to assist 

clinics using the specifications and follows the numbering system used in the non-Medicaid Core 

Set-derived BHC specifications:

A. DESCRIPTION

Important Reporting Guidance:

• The CBP-AD measure is to be used by BHCs to measure performance related to 

clients seen at the Provider during the Measurement Year.

• Value set references are underlined in the specifications (e.g., Essential Hypertension 

Value Set). Current value sets are available on the CMS Medicaid Adult Core Set 

Reporting Resource website. Use the version current for the year being reported.

• The CBP-AD measure is to be stratified separately based on whether the client is:

o Medicaid only or Other (including those dually eligible for Medicare and 

Medicaid)

AND

o A member of which of the following ethnic groups: Not Hispanic or Latino, 

Hispanic or Latino, or Unknown

AND

o A member of which of the following racial groups: White or Caucasian, Black or 

African American, American Indian or Alaska Native, Asian, Native Hawaiian or 

Other Pacific Islander, More than one race, or Unknown

• Refer to the specific data-reporting template for the reporting requirements applicable 

to each measure.

Measurement Period: The Measurement Period is the period for which data are required for 

reporting purposes. The Measurement Period for the CBP-AD denominator is the 
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Supplemental Materials for Controlling High Blood Pressure (CBP-AD)

Measurement Year and the prior year and, for the WCC numerator, is the Measurement 

Year. See Figure 1 for visual depiction of Measurement Year and Measurement Periods.

Figure 1. Visual of Measurement Year and Measurement Periods

Measurement Year

Measurement Year (MY): 12 month reporting period

Denominator Measurement Period (MP): 12 month MY and prior year

Numerator Measurement Period (MP): 12 month MY

Key: MY: Measurement Year; MP: Measurement Period.

B. DEFINITIONS

TERM DEFINITION 

Measurement Period

The specific time period for which data are needed for the 

numerator and denominator of a given measure. The Measurement 

Period may differ for the numerator and denominator and for each 

measure and is specified in section A above.

Measurement Year The standard 12-month reporting period common to all measures 

being reported by the Provider.

Percentage A Percentage is calculated as follows: numerator divided by 

denominator (n/d).

Provider The Provider entity that is being measured (i.e., BHC) 

E. ADDITIONAL NOTES

Interpretation of scores: Better quality = Higher Percentage

F. FREQUENTLY ASKED QUESTIONS

None 
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Measure CBP-AD: Controlling High Blood Pressure

Measure CBP-AD: Controlling High Blood Pressure18,15

Based on a CMS Medicaid Adult Core Set Measure (2023), which is derived from a measure 

stewarded by the National Committee for Quality Assurance (NCQA) 

A. DESCRIPTION

Percentage of beneficiaries [clients] ages 18 to 85 who had a diagnosis of hypertension and whose

blood pressure (BP) was adequately controlled (<140/90 mm Hg) during the measurement year.

Data Collection Method: Administrative, Hybrid, or EHR

Guidance for Reporting:

For HEDIS, his measure applies to beneficiaries [clients] ages 18 to 85. For the purpose of 

[Medicaid] Adult Core Set reporting, states should calculate and report this measure for two 

age groups (as applicable): ages 18 to 64 and ages 65 to 85. [For purposes of Behavioral 

Health Clinic reporting, states [clinics] should only report the total.]

Include all paid, suspended, pending, and denied claims.

This measure includes an optional exclusion for beneficiaries [clients] who die during the 

measurement year. For additional information, refer to the deceased beneficiary [client] 

exclusion guidance in Section II. Data Collection and Reporting of the Adult Core Set [Section 

III. Technical Specification Components].

NCQA’s Medication List Directory (MLD) for Dementia Medications is available to order free of 

charge in the NCQA Store (https://store.ncqa.org/hedis-my-2022-medication-listdirectory.html). [Use version current for year reporting.] Once ordered, the Medication List 

Directory can be accessed through the NCQA Download Center

(https://my.ncqa.org/Downloads).

The electronic specification for FFY 2023 is located on the eCQI resource center at 

https://ecqi.healthit.gov/ecqm/ec/2022/cms165v10. [Use version current for year reporting.] 

States that use electronic specifications should indicate this by selecting “Electronic Health 

Records” in the Data Source section of the online reporting [template] system.

This measure’s Value Set Directory includes the following coding systems for services, procedures, 

and diagnoses: CPT, HCPCS, ICD-9-CM, ICD-9-PCS, ICD-10-CM, ICD-10-PCS, LOINC, POS, 

SNOMED, and UB. The Medication List Directory include the following coding systems for 

medications: NDC and RxNorm. Refer to the Acknowledgments section at the beginning of the 

manual for copyright information.

B. DEFINITIONS

Adequate control Both a representative systolic BP <140 mm Hg and a representative 

diastolic BP of <90 mm Hg.

15Aside from the minor modifications noted in this specification, this specification is taken directly from the 2023 

CMS Medicaid Adult Core Set Measures. Use the most current version for the year being reported. See also 

Important Supplemental Materials for Clinic-Collected Optional BHC Measures derived from CMS Medicaid Adult 

and/or Child Core Set Measures (in this manual immediately before this specification).

8The NCQA HEDIS® measure specification has been adjusted pursuant to NCQA’s Rules for Allowable 

Adjustments of HEDIS. 
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Representative BP The most recent BP reading during the measurement year on or after the 

second diagnosis of hypertension. If multiple BP measurements occur on 

the same date, or are noted in the chart on the same date, use the lowest 

systolic and lowest diastolic BP reading. If no BP is recorded during the 

measurement year, assume that the beneficiary [client] is “not controlled.”

C. ELIGIBLE POPULATION

Age Ages 18 to 85 as of December 31 of the measurement year.

Continuous 

enrollment

The measurement year.

Allowable gap No more than one gap in enrollment of up to 45 days during the measurement 

year. To determine continuous enrollment for a beneficiary [client] for whom 

enrollment is verified monthly, the beneficiary [client] may not have more 

than a 1-month gap in coverage (e.g., a beneficiary [client] whose coverage 

lapses for 2 months [60 days] is not considered continuously enrolled).

Anchor date December 31 of the measurement year.

Benefit Medical.

Event/diagnosis Beneficiaries [Clients] who had at least two visits on different dates of service 

with a diagnosis of hypertension on or between January 1 of the year prior to 

the measurement year and June 30 of the measurement year. Visit type need 

not be the same for the two visits. Any of the following code combinations 

meet criteria:

Outpatient visit (Outpatient Without UBREV Value Set) with any diagnosis of 

hypertension (Essential Hypertension Value Set)

A telephone visit (Telephone Visits Value Set) with any diagnosis of 

hypertension (Essential Hypertension Value Set) 

An e-visit or virtual check-in (Online Assessments Value Set) with any 

diagnosis of hypertension (Essential Hypertension Value Set)

Required 

exclusions

Exclude beneficiaries [clients] who meet either of the following criteria:

• Beneficiaries [Clients] in hospice or using hospice services anytime during 

the measurement year. If a state reports this measure using the Hybrid 

method, and a beneficiary [client] is found to be in hospice or using 

hospice services during medical record review, the beneficiary [client] is 

removed from the sample and replaced by a beneficiary [client] from the 

oversample. For additional information, refer to the hospice exclusion 

guidance in Section II. Data Collection and Reporting of the Adult Core 

Set [Section III. Technical Specification Components].

• Beneficiaries [Clients] receiving palliative care (Palliative Care 

Assessment Value Set; Palliative Care Encounter Value Set; Palliative

Care Intervention Value Set) during the measurement year.
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Optional 

exclusions

Note: Supplemental and medical record data may not be used for these 

exclusions.

Exclude beneficiaries [clients] who meet either of the following criteria: 

Beneficiaries [Clients] ages 66 to 80 as of December 31 of the measurement 

year with frailty and advanced illness. Beneficiaries [Clients] must meet 

both of the following frailty and advanced illness criteria to be excluded: 

At least one claim/encounter for frailty (Frailty Device Value Set; Frailty 

Diagnosis Value Set; Frailty Encounter Value Set; Frailty Symptom 

Value Set) during the measurement year

Any of the following during the measurement year or the year prior to the 

measurement year (count services that occur over both years):

At least two outpatient visits (Outpatient Value Set), observation visits 

(Observation Value Set), ED visits (ED Value Set), telephone visits 

(Telephone Visits Value Set), e-visits or virtual check-ins (Online 

Assessments Value Set), nonacute inpatient encounters (Nonacute 

Inpatient Value Set), or nonacute inpatient discharges (instructions 

below; the diagnosis must be on the discharge claim) on different 

dates of service, with an advanced illness diagnosis (Advanced 

Illness Value Set). Visit type need not be the same for the two visits. 

To identify a nonacute inpatient discharge:

1. Identify all acute and nonacute inpatient stays (Inpatient Stay 

Value Set)

Confirm the stay was for nonacute care based on the presence of a 

nonacute code (Nonacute Inpatient Stay Value Set) on the claim

Identify the discharge date for the stay

At least one acute inpatient encounter (Acute Inpatient Value Set) with 

an advanced illness diagnosis (Advanced Illness Value Set) 

At least one acute inpatient discharge with an advanced illness 

diagnosis (Advanced Illness Value Set) on the discharge claim. To 

identify an acute inpatient discharge:

1. Identify all acute and nonacute inpatient stays (Inpatient Stay 

Value Set)

Exclude nonacute inpatient stays (Nonacute Inpatient Stay Value 

Set)

Identify the discharge date for the stay

A dispensed dementia medication (Dementia Medications List, see link 

to the Medication List Directory in Guidance for Reporting above)

Beneficiaries [Clients] age 81 and older as of December 31 of the 

measurement year with frailty (Frailty Device Value Set; Frailty Diagnosis 

Value Set; Frailty Encounter Value Set; Frailty Symptom Value Set) 

during the measurement year
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D. ADMINISTRATIVE SPECIFICATION

Denominator

The eligible population as defined above.

Numerator

Identify the most recent BP reading (Systolic Blood Pressure Value Set; Diastolic Blood Pressure 

Value Set) taken during the measurement year. Exclude BPs taken in an acute inpatient setting 

(Acute Inpatient Value Set; Acute Inpatient POS Value Set) or during an ED visit (ED Value Set; 

ED POS Value Set).

The BP reading must occur on or after the date of the second diagnosis of hypertension (identified 

using the event/diagnosis criteria).

The beneficiary [client] is numerator compliant if the BP is <140/90 mm Hg. The beneficiary [client]

is not compliant if the BP is ≥ 140/90 mm Hg, if there is no BP reading during the measurement 

year, or if the reading is incomplete (e.g., the systolic or diastolic level is missing). If there are 

multiple BPs on the same date of service, use the lowest systolic and lowest diastolic BP on that date 

as the representative BP.

States that use CPT Category II codes to identify numerator compliance for this indicator must 

search for all codes in the following value sets and use the most recent codes during the 

measurement year to determine numerator compliance for both systolic and diastolic levels.

Value Set Numerator Compliance

Systolic Less Than 140 Value Set Systolic compliant 

Systolic Greater Than or Equal To 140 Value Set Systolic not compliant

Diastolic Less Than 80 Value Set Diastolic compliant

Diastolic 80-89 Value Set Diastolic compliant

Diastolic Greater Than or Equal To 90 Value Set Diastolic not compliant

Exclusions (optional)

Exclude from the eligible population all beneficiaries [clients] with evidence of end-stage renal 

disease (ESRD) (ESRD Diagnosis Value Set), dialysis (Dialysis Procedure Value Set), 

nephrectomy (Total Nephrectomy Value Set; Partial Nephrectomy Value Set) or kidney 

transplant (Kidney Transplant Value Set; History of Kidney Transplant Value Set) on or prior to 

December 31 of the measurement year.

Exclude from the eligible population female beneficiaries [clients] with a diagnosis of pregnancy 

(Pregnancy Value Set) during the measurement year.

Exclude from the eligible population all beneficiaries [clients] who had a nonacute inpatient 

admission during the measurement year. To identify nonacute inpatient admissions:

1. Identify all acute and nonacute inpatient stays (Inpatient Stay Value Set).

Confirm the stay was for nonacute care based on the presence of a nonacute code (Nonacute 

Inpatient Stay Value Set) on the claim.

Identify the admission date for the stay.
117

Measure CBP-AD: Controlling High Blood Pressure

E. HYBRID SPECIFICATION

Denominator

A systematic sample drawn from the eligible population. Refer to the sampling guidance under 

Section II. Data Collection and Reporting of the Child Core Set [Behavioral Health Clinic Quality 

Measures].

Identifying the Medical Record 

All eligible BP measurements recorded in the record must be considered. If a beneficiary [client]’s 

medical record cannot be found, the beneficiary [client] remains in this measure denominator and is 

considered noncompliant for the numerator.

Use the following guidance to find the appropriate medical record to review.

Identify the beneficiary [client]’s PCP.

If the beneficiary [client] had more than one PCP for the time-period, identify the PCP who most 

recently provided care to the beneficiary [client].

If the beneficiary [client] did not visit a PCP for the time-period or does not have a PCP, identify the 

practitioner who most recently provided care to the beneficiary [client].

If a practitioner other than the beneficiary [client]’s PCP manages the hypertension, the medical 

record of that practitioner may be used. 

Numerator

The number of beneficiaries [clients] in the denominator whose most recent BP (both systolic and 

diastolic) is adequately controlled during the measurement year. For a beneficiary [client]’s BP to be 

controlled the systolic and diastolic BP must be <140/90 mm Hg (adequate control). To determine if 

a beneficiary [client]’s BP is adequately controlled, the representative BP must be identified.

Administrative Data

Refer to the Administrative Specification to identify positive numerator hits from administrative 

data.

Medical Record Review

Identify the most recent BP reading noted during the measurement year.

The BP reading must occur on or after the date when the second diagnosis of hypertension 

(identified using the event/diagnosis criteria) occurred.

Do not include BP readings:

Taken during an acute inpatient stay or ED visit

Taken on the same day as a diagnostic test or diagnostic or therapeutic procedure that requires a 

change in diet or change in medication on or one day before the day of the test or procedure, 

with the exception of fasting blood tests

Taken by the beneficiary [client] using a non-digital device such as with a manual blood pressure 

cuff and a stethoscope

Identify the lowest systolic and lowest diastolic BP reading from the most recent BP notation in the 

medical record. If multiple readings were recorded for a single date, use the lowest systolic and 

lowest diastolic BP on that date as the representative BP. The systolic and diastolic results do not 

need to be from the same reading.
118

Measure CBP-AD: Controlling High Blood Pressure

BP readings taken by the beneficiary [client] and documented in the beneficiary [client]’s medical 

record are eligible for use in reporting (provided the BP does not meet any exclusion criteria). There 

is no requirement that there be evidence the BP was collected by a PCP or specialist.

The beneficiary [client] is not numerator compliant if the BP reading is ≥ 140/90 mm Hg or is 

missing, if there is no BP reading during the measurement year, or if the reading is incomplete (e.g., 

the systolic or diastolic level is missing).

Ranges and thresholds do not meet criteria for this measure. A distinct numeric result for both the 

systolic and diastolic BP reading is required for numerator compliance. A BP documented as an 

“average BP” (e.g., “average BP: 139/70”) is eligible for use.

Exclusions (optional)

Refer to the Administrative Specification for exclusion criteria. Exclusionary evidence in the medical 

record must include a note indicating diagnosis of pregnancy or evidence of a nonacute inpatient 

admission during the measurement year, or evidence of ESRD, dialysis, nephrectomy, or kidney 

transplant any time during the beneficiary [client]’s history through December 31 of the 

measurement year.

F. ADDITIONAL NOTES

When identifying the most recent BP reading, all eligible BP readings in the appropriate medical 

record should be considered, regardless of practitioner type and setting (excluding acute 

inpatient and ED visit settings).

An electronic medical record (EMR) can be used to identify the most recent BP reading if it meets 

the criteria for appropriate medical record.

When excluding BP readings from the numerator, the intent is to identify diagnostic or therapeutic 

procedures that require a medication regimen, a change in diet, or a change in medication. 

Examples of such procedures include colonoscopies; dialysis, infusions, and chemotherapy; and 

nebulizer treatments with albuterol. A beneficiary [client] forgetting to take regular medications 

on the day of the procedure is not considered a required change in medication, and therefore the 

BP reading is eligible. 

BP readings taken on the same day that the patient receives a common low-intensity or preventive 

procedure are eligible for use. These include procedures such as vaccinations; injections (e.g., allergy, 

vitamin B-12, insulin, steroid, toradol, Depo-Provera, testosterone, lidocaine); tuberculosis tests; 

intrauterine device (IUD) insertions; eye exams; or wart or mole removal.
119

State-Collected Measure Technical Specifications

V. STATE-COLLECTED MEASURE TECHNICAL 

SPECIFICATIONS

Section V contains the technical specifications and other guidance for the State-Collected BHC 

measures, including twelve measures that are required as part of the Section 223 CCBHC 

Demonstration, and two measures that are optional. These are:

Required Measures: 

Patient Experience of Care Survey

Youth/Family Experience of Care Survey

Antidepressant Medication Management (AMM-AD)

Use of Pharmacotherapy for Opioid Use Disorder (OUD-AD) 

Adherence to Antipsychotic Medications for Individuals with Schizophrenia (SAA-AD)

Plan All-Cause Readmissions Rate (PCR-AD)

Follow-Up Care for Children Prescribed Attention-Deficit Hyperactivity Disorder (ADHD) 

Medication (ADD-CH)

Hemoglobin A1c Control for Patients with Diabetes (HBD-AD)

Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (IET-AD)

Follow-Up After Hospitalization for Mental Illness (FUH-CH and FUH-AD)

Follow-Up After Emergency Department Visit for Mental Illness (FUM-AD and FUM-CH)

Follow-Up After Emergency Department Visit for Alcohol and Other Drug Dependence (FUAAD and FUA-CH)

Optional Measures:

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

Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM-CH)
120

State-Collected Measures Required for Submission as Part of CCBHC Demonstration

State-Collected Measures Required for Submission as Part of CCBHC 

Demonstration

This section of Chapter V includes the following State-Collected required measures:

1. Patient Experience of Care Survey

2. Youth/Family Experience of Care Survey

3. Antidepressant Medication Management (AMM-AD) — including supplemental 

materials

4. Use of Pharmacotherapy for Opioid Use Disorder (OUD-AD) — including supplemental 

materials 

5. Adherence to Antipsychotic Medications for Individuals with Schizophrenia (SAA-AD) 

— including supplemental materials

6. Plan All-Cause Readmissions Rate (PCR-AD) — including supplemental materials

7. Follow-Up Care for Children Prescribed Attention-Deficit Hyperactivity Disorder 

(ADHD) Medication (ADD-CH) — including supplemental materials

8. Hemoglobin A1c Control for Patients with Diabetes (HBD-AD) — including 

supplemental materials

9. Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (IET-AD) 

— including supplemental materials

10. Follow-Up After Hospitalization for Mental Illness (FUH-CH and FUH-AD) —

including supplemental materials

11. Follow-Up After Emergency Department Visit for Mental Illness (FUM-AD and FUMCH) — including supplemental materials

12. Follow-Up After Emergency Department Visit for Alcohol and Other Drug Dependence 

(FUA-AD and FUA-CH) — including supplemental materials
121

Patient Experience of Care Survey (PEC)

Patient Experience of Care Survey (PEC)

SAMHSA-Developed Measure

A. DESCRIPTION 

The PEC measure uses states’ existing annual completion and submission of the Mental 

Health Statistics Improvement Program (MHSIP) Adult Consumer Experience of Care 

Survey, identifying results separately for BHCs and comparison clinics and oversampling 

those clinics.

Data Collection Method: MHSIP Survey

Important Guidance for Reporting: 

This section of the specification includes important guidance for reporting the PEC measure. 

Also refer to section E for Frequently Asked Questions.

• Results of the MHSIP generally are not reported unless the survey is statewide and 

the sample size is sufficient to be statistically meaningful, and, as a general rule, 

states are directed not to report results from only a few providers or one region. For 

purposes of the CCBHC Demonstration Program, however, states will have 

specific responsibilities. States are to continue sampling as they presently do, using 

the same version of the MHSIP as they do at present. States, however, are asked to 

make the following modifications:

o If not already doing so, modify procedures to allow reporting by CCBHC and 

comparison clinics specifically.

o Oversample CCBHCs and comparison clinics to generate sufficient sample 

size, specifically reaching out to 300 clients per CCBHC and comparison 

clinic.

o States will submit the results aggregated at the CCBHC and comparison clinic 

level as part of CCBHC data reporting using Tables 9, 11, and 11a of the URS 

reporting template that is current at the time of the survey and that may be 

found at SAMHSA|Uniform Reporting System (URS) Report Resources (Tables 

16, 17A, and 17B for the Mental Health Block Grant), including required 

information on sampling methodology and response rates. This report will be 

provided separately from that already compiled by the state to allow analysis 

of only those data pertinent to the Demonstration Program.

• Refer to the specific data-reporting template for the reporting requirements applicable 

to each measure.
122

Patient Experience of Care Survey (PEC)

Measurement Period: The Measurement Period for both the denominator and numerator

is the Measurement Year, with the survey to be performed as part of the state’s existing 

survey.

B. DEFINITIONS 

TERM DEFINITION 

Adult Consumer Experience of 

Care Survey 

The Mental Health Statistics Improvement Program (MHSIP) 

Adult Consumer Experience of Care Survey is used to collect 

data on adult behavioral health client experience of care. The 

official version and instructions are found at 

SAMHSA|Uniform Reporting System (URS) Report 

Resources. Some states have customized this survey, and 

instructions on the site address that circumstance. 

Measurement Period

The specific period of time for which data are needed for 

the numerator and denominator of a given measure. The 

Measurement Period is specified in section A above.

Measurement Year The standard 12-month reporting period common to all 

measures being reported by the Provider.

Mental Health Statistics 

Improvement Program (MHSIP) 

The MHSIP Consumer Surveys measure concerns that are 

important to clients of publicly funded mental health services 

in the areas of Access, Quality/Appropriateness, Outcomes, 

Overall Satisfaction, Participation in Treatment Planning, 

Social Connectedness and Functioning. 

Provider The Provider entity that is being measured (i.e., BHC) 

Uniform Reporting System 

(URS) 

The URS is used by SAMHSA to collect uniform reporting of 

state-level data to describe the public mental health system and 

the outcomes of that system’s programs .

C. ELIGIBLE POPULATION

CRITERIA REQUIREMENTS 

Age Clients aged 18 years or older at the time of survey 

D. SPECIFICATION 

For purposes of the CCBHC Demonstration Program, results for CCBHCs and comparison clinics 

should be submitted in a way that permits distinction between each CCBHC and each comparison 

clinic, with oversampling of those provider entities.
123

Patient Experience of Care Survey (PEC)

E. FREQUENTLY ASKED QUESTIONS

Questions Regarding Survey Sample: 

Q: Does the survey need to cover all populations served?

A: The goal of the survey is to be representative of the population served but the measure is 

written to allow the states to continue to collect as they do now, with the exception of 

oversampling (300) and requiring that the results be reported separately for the BHCs.

Q: Is the sample size of 300 the TOTAL of youth and adult, or 300 EACH: youth and adult?

A: The sample size of 300 is for youth and adult separately, unless there are fewer than those 

numbers of individuals in the population of the BHC.

Q: Do the sample sizes need to be representative of the relative size of the populations?

A: There is no requirement that the states change what they are doing now, other than 

oversampling (300) and reporting the results separately by BHCs. The goal is that it be as 

representative as possible, given that caveat.

Q: Our state currently selects a blind sample across the entire system with no provider- specific 

identifiers. The departmental IRB exercises oversight of the process. Surveying within the 

particular agency will be a significant departure from the current practice. How do we handle 

this?

A: Yes. It may be a departure for some states and should be raised with state departmental 

internal review boards.

Questions Regarding Stratification:

Q: Are there any stratification requirements?

A: There are no explicit stratification requirements in the two existing surveys referenced in the 

BHC measures. Some states do incorporate more stratification than do others, in part to get a 

more representative sample. These BHC measures incorporating the two (2) patient experience 

of care measures were very deliberately created to allow states to continue to conduct the surveys 

just as they are doing presently. For that reason, there is nothing specific here related to 

stratification. The only change for these surveys is that you must report at the BHC level and 

reach out to 300 clients per BHC per survey for reporting within the BHC quality measures.

Questions Regarding Application to Clients Receiving Substance Use Services:

Q: We do not use mixed surveys for substance use clients. Is there an appropriate survey to use 

on substance use clients?

A: The quality measures are intended to apply to everybody served by the BHC. The CCBHC 

demonstration program is designed to integrate care and to break down distinctions within 

behavioral health. The same surveys should, for the CCBHC demonstration program, be used for 

all CCBHC clients. For non-CCBHC states or BHCs that are not either CCBHCs or comparison 

sites, the state has the option of using another survey if they wish.
124

Youth and Family Experience of Care Survey (Y/FEC)

Youth and Family Experience of Care Survey (Y/FEC)

SAMHSA-Developed Measure

A. DESCRIPTION 

The Y/FEC measure uses states’ existing annual completion and submission of the 

Youth/Family Services Survey for Families (YSS-F) Experience of Care Survey, identifying 

results separately for BHCs and comparison clinics and oversampling those clinics.

Data Collection Method: YSS-F Survey

Important Guidance for Reporting: 

This section of the specification includes important guidance for reporting the Y/FEC 

measure. Also refer to section E for Frequently Asked Questions.

• Results of the YSS-F generally are not reported unless the survey is statewide and the 

sample size is sufficient to be statistically meaningful, and, as a general rule, states 

are directed not to report results from only a few providers or one region. For 

purposes of the CCBHC Demonstration Program, however, states will have 

specific responsibilities. States are to continue sampling as they presently do, using 

the same version of the YSS-F as they do at present. States, however, are asked to 

make the following modifications:

o If not already doing so, modify procedures to allow reporting by CCBHC and 

comparison clinics specifically.

o Oversample CCBHCs and comparison clinics to generate sufficient sample 

size, specifically reaching out to 300 clients per CCBHC and comparison 

clinic.

o States will submit the results aggregated at the CCBHC and comparison 

clinic level as part of CCBHC data reporting using Tables 9, 11, and 11a of 

the URS reporting template that is current at the time of the survey and that 

may be found at SAMHSA|Uniform Reporting System (URS) Report Resources

(Tables 16, 17A, and 17B for the Mental Health Block Grant), including 

required information on sampling methodology and response rates. This report 

will be provided separately from that already compiled by the state to allow 

analysis of only those data pertinent to the Demonstration Program.

• Refer to the specific data-reporting template for the reporting requirements applicable 

to each measure.
125

Youth and Family Experience of Care Survey (Y/FEC)

Measurement Period: The Measurement Period for both the denominator and numerator

is the Measurement Year, with the survey to be performed as part of the state’s existing 

survey.

B. DEFINITIONS 

TERM DEFINITION 

Measurement Period

The specific period of time for which data are needed for 

the numerator and denominator of a given measure. The 

Measurement Period is specified in section A above.

Measurement Year The standard 12-month reporting period common to all 

measures being reported by the Provider.

Provider The Provider entity that is being measured (i.e., BHC) 

Uniform Reporting System 

(URS) 

The URS is used by SAMHSA to collect uniform reporting 

of state-level data to describe the public mental health 

system and the outcomes of that system’s programs .

YSS-F Experience of Care 

Survey 

The YSS-F Experience of Care Survey is used to collect 

data on youth and family behavioral health client experience 

of care. The official version and instructions are found at 

SAMHSA|Uniform Reporting System (URS) Report 

Resources. Some states have customized this survey, and 

instructions on the site address that circumstance.

C. ELIGIBLE POPULATION

CRITERIA REQUIREMENTS 

Age Clients aged 17 years or younger at the time of survey 

D. SPECIFICATION 

For purposes of the CCBHC Demonstration Program, results for CCBHCs and comparison clinics 

should be submitted in a way that permits distinction between each CCBHC and each comparison 

clinic, with oversampling of those provider entities.

E. FREQUENTLY ASKED QUESTIONS

Questions Regarding Survey Sample: 

Q: Does the survey need to cover all populations served?

A: The goal of the survey is to be representative of the population served but the measure is 

written to allow the states to continue to collect as they do now, with the exception of 

oversampling (300) and requiring that the results be reported separately for the BHCs.
126

Youth and Family Experience of Care Survey (Y/FEC)

Q: Is the sample size of 300 the TOTAL of youth and adult, or 300 EACH: youth and adult?

A: The sample size of 300 is for youth and adult separately, unless there are fewer than those 

numbers of individuals in the population of the BHC.

Q: Do the sample sizes need to be representative of the relative size of the populations?

A: There is no requirement that the states change what they are doing now, other than 

oversampling (300) and reporting the results separately by BHCs. The goal is that it be as 

representative as possible, given that caveat.

Q: Our state currently selects a blind sample across the entire system with no provider- specific 

identifiers. The departmental IRB exercises oversight of the process. Surveying within the 

particular agency will be a significant departure from the current practice. How do we handle 

this?

A: Yes. It may be a departure for some states and should be raised with state departmental 

internal review boards.

Questions Regarding Stratification:

Q: Are there any stratification requirements?

A: There are no explicit stratification requirements in the two existing surveys referenced in the 

BHC measures. Some states do incorporate more stratification than do others, in part to get a 

more representative sample. These BHC measures incorporating the two (2) patient experience 

of care measures were very deliberately created to allow states to continue to conduct the surveys 

just as they are doing presently. For that reason, there is nothing specific here related to 

stratification. The only change for these surveys is that you must report at the BHC level and 

reach out to 300 clients per BHC per survey for reporting within the BHC quality measures.

Questions Regarding Application to Clients Receiving Substance Use Services:

Q: We do not use mixed surveys for substance use clients. Is there an appropriate survey to use 

on substance use clients?

A: The quality measures are intended to apply to everybody served by the BHC. The CCBHC 

demonstration program is designed to integrate care and to break down distinctions within 

behavioral health. The same surveys should, for the CCBHC demonstration program, be used for 

all CCBHC clients. For non-CCBHC states or BHCs that are not either CCBHCs or comparison 

sites, the state has the option of using another survey if they wish.
127

Supplemental Materials for Antidepressant Medication Management (AMM-AD)

Important Supplemental Materials for State-Collected Required

BHC Measures derived from CMS Medicaid Adult and/or Child 

Core Set Measures (AMM-AD)

These supplemental materials are necessary for implementation of the State-Collected Required 

BHC Measures that are derived from the CMS Medicaid Adult and/or Child Core Set Measures. 

This volume includes the exact specifications that are on the CMS website for the 2023 Medicaid 

Core Set, with simple modifications noted in the text. Limited additional needed modifications 

are included below, as well as supplemental useful materials.

Changes directly in the specifications: For all Core Set-derived measures, the changes in the 

specification from the CMS Medicaid Adult or Child Core Set reflect: (1) substitution of the 

word “client” for “beneficiary” or “patient”, unless the latter is part of a copyrighted code 

description; (2) removal of age stratification for adults (i.e., applicable to adults ages 18 years 

and older); and (3) removal of most references to the Core Set.

Additional needed modifications specific to each measure are included below, as well as 

supplemental useful materials.

Measure AMM-AD: Antidepressant Medication Management

Additional information: The following material is provided to assist clinics using the 

specifications and follows the numbering system used in the non-Core derived BHC 

specifications:

A. DESCRIPTION

Important Reporting Guidance:

• The AMM-AD measure is to be used to measure performance related to clients seen at 

the BHC Provider during the Measurement Year.

• Current value sets are available on the CMS Medicaid Adult Core Set Reporting 

Resource website. Use the version current for the year being reported.

• AMM-AD is stratified separately based on whether the client is:

o Medicaid only or Other (including those dually eligible for Medicare and 

Medicaid)

AND

o A member of which of the following ethnic groups: Not Hispanic or Latino, 

Hispanic or Latino, or Unknown

AND

o A member of which of the following racial groups: White or Caucasian, Black or 

African American, American Indian or Alaska Native, Asian, Native Hawaiian or 

Other Pacific Islander, More than one race, or Unknown
128

Supplemental Materials for Antidepressant Medication Management (AMM-AD)

• Refer to the specific data-reporting template for the reporting requirements applicable to 

each measure.

Measurement Period: The Measurement Period is the period for which data are required for 

reporting purposes. The AMM measure denominator includes two Measurement Periods, 

both of which are defined in the specification: (a) Index prescription start date (IPSD) and 

(b) Negative medication history review. The Measurement Periods for the AMM measure 

numerator include a different period for each of the two submeasures of Effective Acute 

Phase Treatment (IPSD through 114 days following IPSD) and Effective Continuation 

Phase Treatment (IPSD through 231 days following IPSD).

B. DEFINITIONS

TERM DEFINITION 

Measurement Period

The specific time period for which data are needed for the 

numerator and denominator of a given measure. The Measurement 

Period may differ for the numerator and denominator and for each 

measure and is specified in section A above.

Measurement Year The standard 12-month reporting period common to all measures 

being reported by the Provider.

Percentage A Percentage is calculated as follows: numerator divided by 

denominator (n/d).

Provider The Provider entity that is being measured (i.e., BHC) 

E. ADDITIONAL NOTES

Interpretation of scores: Better quality = Higher Percentage

F. FREQUENTLY ASKED QUESTIONS

None
Measure AMM-AD: Antidepressant Medication Management

Measure AMM-AD: Antidepressant Medication Management8,16

Based on a CMS Medicaid Adult Core Set Measure (2023), which is derived from a measure 

stewarded by the National Committee for Quality Assurance (NCQA)

A. DESCRIPTION

Percentage of beneficiaries [clients] age 18 and older who were treated with antidepressant

medication, had a diagnosis of major depression, and who remained on an antidepressant medication

treatment. Two rates are reported:

Effective Acute Phase Treatment. Percentage of beneficiaries [clients] who remained on an

antidepressant medication for at least 84 days (12 weeks)

Effective Continuation Phase Treatment. Percentage of beneficiaries [clients] who remained on an

antidepressant medication for at least 180 days (6 months)

Data Collection Method: Administrative or EHR

Guidance for Reporting:

For HEDIS, this measure applies to beneficiaries [clients] age 18 and older. For the purpose of

Adult Core Set reporting, states should calculate and report the two rates listed above for each 

of the two age groups (as applicable): ages 18 to 64 and age 65 and older. Include all paid, 

suspended, pending, and denied claims.

This measure includes an optional exclusion for beneficiaries [clients] who die during the 

measurement year. For additional information, refer to the deceased beneficiary [client] 

exclusion guidance in Section II. Data Collection and Reporting of the Adult Core Set [Section 

III. Technical Specification Components].

NCQA’s Medication List Directory (MLD) for Antidepressant Medications is available to order 

free of charge in the NCQA Store (https://store.ncqa.org/hedis-my-2022-medication-listdirectory.html). [Use version current for year reporting.] Once ordered, the Medication List 

Directory can be accessed through the NCQA Download Center 

(https://my.ncqa.org/Downloads).

The electronic specification for FFY 2023 is located on the eCQI resource center at

https://ecqi.healthit.gov/ecqm/ec/2022/cms128v10. [Use version current for year reporting.] 

States that use electronic specifications should indicate this by selecting “Electronic Health 

Records” in the Data Source section of the online reporting system [template].

This measure’s Value Set Directory includes the following coding systems for services, procedures, 

and diagnoses: CPT, HCPCS, ICD-10-CM, ICD-10-PCS, POS, SNOMED, and UB. The Medication 

List Directory includes the following coding systems for medications: NDC and RxNorm. Refer to 

the Acknowledgments section at the beginning of the manual for copyright information.

B. DEFINITIONS

Intake period The 12-month window starting on May 1 of the year prior to the measurement 

year and ending on April 30 of the measurement year.

8The NCQA HEDIS® measure specification has been adjusted pursuant to NCQA’s Rules for Allowable 

Adjustments of HEDIS. 

16Aside from the minor modifications noted in this specification, this specification is taken directly from the 2023 

CMS Medicaid Adult Core Set Measures. Use the most current version for the year being reported. See also 

Important Supplemental Materials for State-Collected Required BHC Measures derived from CMS Medicaid Adult

129 

and/or Child Core Set Measures (in this manual immediately before this specification).
130

Measure AMM-AD: Antidepressant Medication Management

IPSD Index Prescription Start Date (IPSD). The earliest prescription dispensing date 

for an antidepressant medication where the date is in the Intake Period and there 

is a Negative Medication History.

Negative medication 

history

A period of 105 days prior to the IPSD when the beneficiary [client] had no 

pharmacy claims for either new or refill prescriptions for an antidepressant 

medication.

Treatment days The actual number of calendar days covered with prescriptions within the 

specified measurement interval. For Effective Continuation Phase Treatment, a 

prescription of 90 days (3 months) supply dispensed on the 151st day will have 

82 days counted in the 232-day interval.

C. ELIGIBLE POPULATION

Age Age 18 and older as of April 30 of the measurement year.

Continuous 

enrollment

105 days prior to the IPSD through 231 days after the IPSD.

Allowable gap One gap in enrollment of up to 45 days. To determine continuous enrollment for a 

beneficiary [client] for whom enrollment is verified monthly, the beneficiary [client]

may not have more than a 1-month gap in coverage (e.g., a beneficiary [client] whose 

coverage lapses for 2 months [60 days] is not considered continuously enrolled).

Anchor date IPSD.

Benefits Medical and pharmacy.

Event/

diagnosis

Follow the steps below to identify the eligible population, which is used for both rates.

Step 1: Determine the IPSD

Identify the date of the earliest dispensing event for an antidepressant medication 

(Antidepressant Medications List, see link to the Medication List Directory in 

Guidance for Reporting above) during the Intake Period.

Step 2: Required exclusions 

Exclude beneficiaries [clients] who did not have an encounter with a diagnosis of 

major depression during the 121-day period from 60 days prior to the IPSD, through 

the IPSD and the 60 days after the IPSD. Beneficiaries [Clients] who meet any of the 

following criteria remain in the eligible population:

An acute or nonacute inpatient stay with any diagnosis of major depression (Major 

Depression Value Set) on the discharge claim. To identify acute and nonacute 

inpatient stays:

1. Identify all acute and nonacute inpatient stays (Inpatient Stay Value Set).

2. Identify the admission and discharge dates for the stay. Either an admission or 

discharge during the required time frame meets criteria.

An acute inpatient encounter with any diagnosis of major depression: Acute Inpatient 

Value Set with Major Depression Value Set

A nonacute inpatient encounter with any diagnosis of major depression: Nonacute 

Inpatient Value Set with Major Depression Value Set
131

Measure AMM-AD: Antidepressant Medication Management

Event/

diagnosis 

(continued)

An outpatient visit with any diagnosis of major depression: Visit Setting Unspecified 

Value Set with Outpatient POS Value Set with Major Depression Value Set

An outpatient visit with any diagnosis of major depression: BH Outpatient Value Set

with Major Depression Value Set

An intensive outpatient encounter or partial hospitalization with any diagnosis of major 

depression: Visit Setting Unspecified Value Set with Partial Hospitalization POS 

Value Set with Major Depression Value Set

An intensive outpatient encounter or partial hospitalization with any diagnosis of major 

depression: Partial Hospitalization or Intensive Outpatient Value Set with Major 

Depression Value Set

A community mental health center visit with any diagnosis of major depression: Visit 

Setting Unspecified Value Set with Community Mental Health Center POS Value 

Set with Major Depression Value Set

Electroconvulsive therapy with any diagnosis of major depression: Electroconvulsive 

Therapy Value Set with Major Depression Value Set

Transcranial magnetic stimulation visit with any diagnosis of major depression: 

Transcranial Magnetic Stimulation Value Set with Major Depression Value Set

A telehealth visit with any diagnosis of major depression: Visit Setting Unspecified 

Value Set with Telehealth POS Value Set with Major Depression Value Set

An observation visit (Observation Value Set) with any diagnosis of major depression 

(Major Depression Value Set)

An ED visit (ED Value Set) with any diagnosis of major depression (Major Depression 

Value Set)

An ED visit with any diagnosis of major depression: Visit Setting Unspecified Value 

Set with ED POS Value Set with Major Depression Value Set

A telephone visit (Telephone Visits Value Set) with any diagnosis of major depression 

(Major Depression Value Set)

An e-visit or virtual check-in (Online Assessments Value Set) with any diagnosis of 

major depression (Major Depression Value Set)

Beneficiaries [Clients] in hospice or using hospice services anytime during the 

measurement year. For additional information, refer to the hospice exclusion 

guidance in Section II. Data Collection and Reporting of the Adult Core Set

[Section III. Technical Specification Components].

Step 3: Test for Negative Medication History 

Exclude beneficiaries [clients] who filled a prescription for an antidepressant 

medication 105 days prior to the IPSD.

Step 4: Calculate continuous enrollment

Beneficiaries [Clients] must be continuously enrolled for 105 days prior to the IPSD to 

231 days after the IPSD.
132

Measure AMM-AD: Antidepressant Medication Management

D. ADMINISTRATIVE SPECIFICATION

Denominator

The eligible population as defined above. 

Numerators

Effective Acute Phase Treatment

At least 84 days (12 weeks) of treatment with antidepressant medication (Antidepressant 

Medications List, see link to the Medication List Directory in Guidance for Reporting above) 

beginning on the IPSD through 114 days after the 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.

Effective Continuation Phase Treatment

At least 180 days (6 months) of treatment with antidepressant medication (Antidepressant 

Medications List, see link to the Medication List Directory in Guidance for Reporting above), 

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.

E. ADDITIONAL NOTES

There may be different methods for billing intensive outpatient encounters and partial 

hospitalizations. Some methods may be comparable to outpatient billing, with separate claims for 

each date of service; others may be comparable to inpatient billing, with an admission date, a 

discharge date, and units of service. Where billing methods are comparable to inpatient billing, each 

unit of service may be counted as an individual visit. The unit of service must have occurred during 

the period specified.
133

Supplemental Materials for Use of Pharmacotherapy for Opioid Use Disorder

(OUD-AD)

Important Supplemental Materials for State-Collected Required

BHC Measures derived from CMS Medicaid Adult and/or Child 

Core Set Measures (OUD-AD)

These supplemental materials are necessary for implementation of the State-Collected Required 

BHC Measures that are derived from the CMS Medicaid Adult and/or Child Core Set Measures. 

This volume includes the exact specifications that are on the CMS website for the 2023 Medicaid 

Core Set, with simple modifications noted in the text. Limited additional needed modifications 

are included below, as well as supplemental useful materials.

Changes directly in the specifications: For all Core Set-derived measures, the changes in the 

specification from the CMS Medicaid Adult or Child Core Set reflect: (1) substitution of the 

word “client” for “beneficiary” or “patient”, unless the latter is part of a copyrighted code 

description; and (2) removal of most references to the Core Set.

Additional needed modifications specific to each measure are included below, as well as 

supplemental useful materials.

Measure OUD-AD: Use of Pharmacotherapy for Opioid Use Disorder 

Additional information: The following material is provided to assist clinics using the 

specifications and follows the numbering system used in the non-Core derived BHC 

specifications:

A. DESCRIPTION

Important Reporting Guidance:

• The OUD-AD measure is to be used to measure performance related to clients seen at the 

BHC Provider during the Measurement Year.

• Current value sets are available on the CMS Medicaid Adult Core Set Reporting 

Resource website. Use the version current for the year being reported.

• OUD-AD is stratified separately based on whether the client is:

o Medicaid only or Other (including those dually eligible for Medicare and 

Medicaid)

AND

o A member of which of the following ethnic groups: Not Hispanic or Latino, 

Hispanic or Latino, or Unknown

AND

o A member of which of the following racial groups: White or Caucasian, Black or 

African American, American Indian or Alaska Native, Asian, Native Hawaiian or 

Other Pacific Islander, More than one race, or Unknown
134

Supplemental Materials for Use of Pharmacotherapy for Opioid Use Disorder

(OUD-AD)

• Refer to the specific data-reporting template for the reporting requirements applicable 

to each measure.

Measurement Period: The Measurement Period is the period for which data are required for 

reporting purposes. For both the denominator and the numerator of OUD-AD, the

Measurement Period is the Measurement Year.

B. DEFINITIONS

TERM DEFINITION 

Measurement Period

The specific time period for which data are needed for the 

numerator and denominator of a given measure. The Measurement 

Period may differ for the numerator and denominator and for each 

measure and is specified in section A above.

Measurement Year The standard 12-month reporting period common to all measures 

being reported by the Provider.

Percentage A Percentage is calculated as follows: numerator divided by 

denominator (n/d).

Provider The Provider entity that is being measured (i.e., BHC) 

E. ADDITIONAL NOTES

Interpretation of scores: Better quality = Higher Percentage

F. FREQUENTLY ASKED QUESTIONS

None
135

Use of Pharmacotherapy for Opioid Use Disorder (OUD-AD)

Measure OUD-AD: Use of Pharmacotherapy for Opioid Use Disorder16

Based on a CMS Medicaid Adult Core Set Measure (2023)

A. DESCRIPTION

Percentage of Medicaid beneficiaries [clients] ages 18 to 64 with an opioid use disorder (OUD) who

filled a prescription for or were administered or dispensed an FDA-approved medication for the

disorder during the measurement year. Five rates are reported:

A total (overall) rate capturing any medications used in medication assisted treatment of opioid

dependence and addiction (Rate 1)

Four separate rates representing the following types of FDA-approved drug products: 

Buprenorphine (Rate 2)

Oral naltrexone (Rate 3)

Long-acting, injectable naltrexone (Rate 4)

Methadone (Rate 5)

Data Collection Method: Administrative

Guidance for Reporting:

The measure includes a total rate (Rate 1) and four separate rates for the following four types of 

FDA-approved drug products: 

Buprenorphine (Rate 2)

Oral naltrexone (Rate 3)

Long-acting, injectable naltrexone (Rate 4)

Methadone (Rate 5) 

Tables OUD-A and OUD-B are available at https://www.medicaid.gov/medicaid/quality-ofcare/downloads/2023-adult-non-hedis-value-set-directory.zip. [Use version current for year 

reporting.] Table OUD-B designates which medications are assigned to the separate rates. 

Filter on the ‘Numerator’ column to identify which NDC codes are assigned to each rate. 

The measure uses inpatient, outpatient, residential, long-term care, and pharmacy claims and 

encounters.

The numerator for the total rate is not a sum of the numerators for the four medication cohorts. 

Count beneficiaries [clients] in the numerator for the total rate if they had at least one of the 

four FDA-approved drug products for OUD during the measurement year. Report beneficiaries

[clients] with multiple drug products only once for the numerator for the total rate.

Only formulations with an OUD indication (not pain management) are included in value sets for 

measure calculation. 

This measure includes the following coding systems: HCPCS, NDC, ICD-10-CM, and ICD-10-PCS. 

Refer to the Acknowledgments section at the beginning of the manual for copyright information.

16Aside from the minor modifications noted in this specification, this specification is taken directly from the 2023 

CMS Medicaid Adult Core Set Measures. Use the most current version for the year being reported. See also 

Important Supplemental Materials for State-Collected Required BHC Measures derived from CMS Medicaid Adult 

and/or Child Core Set Measures (in this manual immediately before this specification).
136

Use of Pharmacotherapy for Opioid Use Disorder (OUD-AD)

B. DEFINITIONS

Measurement 

year

January 1 to December 31 of the measurement year.

C. ELIGIBLE POPULATION

Age Ages 18 to 64 years. Age is calculated as of January 1 of the measurement year.

Continuous 

enrollment

The measurement year.

Allowable gap No allowable gap during the continuous enrollment period. 

Anchor date None.

Benefit Medical and chemical dependency (inpatient, residential, and outpatient).

Event/

Diagnosis

Beneficiaries [Clients] who had at least one encounter with a diagnosis of 

opioid abuse, dependence, or remission (primary or other) at any time during 

the measurement year. ICD-10 codes for OUD are provided in Table OUD-A 

available at https://www.medicaid.gov/medicaid/quality-ofcare/downloads/2023-adult-non-hedis-value-set-directory.zip. [Use version 

current for year reporting.]

Care settings Inpatient/hospital, outpatient, emergency department.

D. ADMINISTRATIVE SPECIFICATION

Denominator 

The eligible population as defined above.

Numerators

For each beneficiary [client] in the denominator population, follow the steps below to identify 

beneficiaries [clients] for the total numerator and the numerator for each rate.

Numerator 1: Total 

Identify beneficiaries [clients] with evidence of at least one prescription filled, or who were 

administered or dispensed an FDA-approved medication for OUD during the measurement year 

through use of pharmacy claims (relevant NDC code) or through relevant HCPCS coding of medical 

service. See Table OUD-B, available at https://www.medicaid.gov/medicaid/quality-ofcare/downloads/2023-adult-non-hedis-value-set-directory.zip. [Use version current for year 

reporting.]

Note: The numerator for the total rate is not a sum of the numerators for the four medication cohorts. 

Count beneficiaries [clients] in the numerator for the total rate if they had at least one of the four 

FDA-approved drug products for OUD during the measurement year. Report beneficiaries [clients] 

with multiple drug products only once for the numerator for the total rate.

Numerator 2: Buprenorphine 

Identify beneficiaries [clients] with evidence of at least one prescription for buprenorphine at any 

point during the measurement year. See Table OUD-B, available at 

https://www.medicaid.gov/medicaid/quality-of-care/downloads/2023-adult-non-hedis-value-set-
137

Use of Pharmacotherapy for Opioid Use Disorder (OUD-AD)

directory.zip. [Use version current for year reporting.] Include NDC codes assigned to Numerator 2 

in the Numerator column in Table OUD-B.

Numerator 3: Oral Naltrexone

Identify beneficiaries [clients] with evidence of at least one prescription for oral naltrexone at any 

point during the measurement year. See Table OUD-B, available at 

https://www.medicaid.gov/medicaid/quality-of-care/downloads/2023-adult-non-hedis-value-setdirectory.zip. [Use version current for year reporting.] Include NDC codes assigned to Numerator 3 

in the Numerator column in Table OUD-B.

Numerator 4: Long-Acting, Injectable Naltrexone

Identify beneficiaries [clients] with evidence of at least one prescription for long-acting, injectable 

naltrexone at any point during the measurement year. See Table OUD-B, available at 

https://www.medicaid.gov/medicaid/quality-of-care/downloads/2023-adult-non-hedis-value-setdirectory.zip. [Use version current for year reporting.] Include NDC codes assigned to Numerator 4 

in the Numerator column in Table OUD-B.

Numerator 5: Methadone

Identify beneficiaries [clients] with evidence of at least one dose of methadone at any point during 

the measurement year. See Table OUD-B, available at https://www.medicaid.gov/medicaid/qualityof-care/downloads/2023-adult-non-hedis-value-set-directory.zip. [Use version current for year 

reporting.] This rate includes HCPCS codes only. There are no NDC codes assigned to this rate.

Rates

The total rate is calculated by dividing the number of beneficiaries [clients] with evidence of at least 

one prescription (Numerator 1) by the number of beneficiaries [clients] with at least one encounter 

associated with a diagnosis of opioid abuse, dependence, or remission (i.e., the Denominator).

To calculate the separate rates for each of the four FDA-approved medications for OUD, divide the 

Numerator for the medication by the Denominator. For example, to calculate the buprenorphine rate, 

divide the number of beneficiaries [clients] with evidence of at least one prescription for 

buprenorphine during the measurement year (Numerator 2) by the number of beneficiaries [clients] 

with at least one encounter associated with a diagnosis of opioid abuse, dependence, or remission 

(i.e., the Denominator).

E. ADDITIONAL NOTES

None.
138

Supplemental Materials for Measure SAA-AD: Adherence to Antipsychotic 

Medications for Individuals with Schizophrenia (SAA-AD)

Important Supplemental Materials for State-Collected Required BHC 

Measures derived from CMS Medicaid Adult and/or Child Core Set 

Measures (SAA-AD)

These supplemental materials are necessary for implementation of the State-Collected Required 

BHC Measures that are derived from the CMS Medicaid Adult and/or Child Core Set Measures. 

This volume includes the exact specifications that are on the CMS website for the 2023 Medicaid 

Core Set, with simple modifications noted in the text. Limited additional needed modifications 

are included below, as well as supplemental useful materials.

Changes directly in the specifications: For all Core Set-derived measures, the changes in the 

specification from the CMS Medicaid Adult or Child Core Set reflect: (1) substitution of the 

word “client” for “beneficiary” or “patient”, unless the latter is part of a copyrighted code 

description; and (2) removal of most references to the Core Set.

Additional needed modifications specific to each measure are included below, as well as 

supplemental useful materials.

Measure SAA-AD: Adherence to Antipsychotic Medications for Individuals with 

Schizophrenia

Additional information: The following material is provided to assist clinics using the 

specifications and follows the numbering system used in the non-Core derived BHC 

specifications:

A. DESCRIPTION

Important Reporting Guidance:

• The SAA-AD measure is to be used to measure performance related to clients seen at the 

BHC Provider during the Measurement Year.

• Current value sets are available on the CMS Medicaid Adult Core Set Reporting 

Resource website. Use the version current for the year being reported.

• SAA-AD is stratified separately based on whether the client is:

o Medicaid only or Other (including those dually eligible for Medicare and 

Medicaid)

AND

o A member of which of the following ethnic groups: Not Hispanic or Latino, 

Hispanic or Latino, or Unknown

AND
139

Supplemental Materials for Measure SAA-AD: Adherence to Antipsychotic 

Medications for Individuals with Schizophrenia (SAA-AD)

o A member of which of the following racial groups: White or Caucasian, Black or 

African American, American Indian or Alaska Native, Asian, Native Hawaiian or 

Other Pacific Islander, More than one race, or Unknown

• Refer to the specific data-reporting template for the reporting requirements applicable 

to each measure.

Measurement Period: The Measurement Period is the period for which data are required for 

reporting purposes. For both the denominator and the numerator of SAA-AD, the

Measurement Period is the Measurement Year.

B. DEFINITIONS

TERM DEFINITION 

Measurement Period

The specific time period for which data are needed for the 

numerator and denominator of a given measure. The Measurement 

Period may differ for the numerator and denominator and for each 

measure and is specified in section A above.

Measurement Year The standard 12-month reporting period common to all measures 

being reported by the Provider.

Percentage A Percentage is calculated as follows: numerator divided by 

denominator (n/d).

Provider The Provider entity that is being measured (i.e., BHC) 

E. ADDITIONAL NOTES

Interpretation of scores: Better quality = Higher Percentage

F. FREQUENTLY ASKED QUESTIONS

None
140

Adherence to Antipsychotic Medications for Individuals with Schizophrenia (SAAAD)

Measure SAA-AD: Adherence to Antipsychotic Medications for

Individuals With Schizophrenia8,16

Based on a CMS Medicaid Adult Core Set Measure (2023), which is derived from a measure 

stewarded by the National Committee for Quality Assurance (NCQA)17

A. DESCRIPTION

Percentage of beneficiaries [clients] ages 18 and older during the measurement year with

schizophrenia or schizoaffective disorder who were dispensed and remained on an antipsychotic

medication for at least 80 percent of their treatment period.

Data Collection Method: Administrative

Guidance for Reporting:

If an oral medication and a long-acting injection are dispensed on the same day, calculate number 

of days covered by an antipsychotic medication (for the numerator) using the prescription with 

the longest days supply.

If an oral medication and long-acting injection are dispensed on different days, with some 

overlapping days of supply, count each day within the treatment period only once toward the 

numerator.

Include all paid, suspended, pending, and denied claims.

This measure includes an optional exclusion for beneficiaries [clients] who die during the 

measurement year. For additional information, refer to the deceased beneficiary [client] 

exclusion guidance in Section II. Data Collection and Reporting of the Adult Core Set [Section 

III. Technical Specification Components].

NCQA’s Medication List Directory (MLD) for Dementia Medications, Oral Antipsychotic 

Medications, and Long-Acting Injections is available to order free of charge in the NCQA 

Store (https://store.ncqa.org/hedis-my-2022-medication-list-directory.html). [Use version 

current for year reporting.] Once ordered, the Medication List Directory can be accessed 

through the NCQA Download Center (https://my.ncqa.org/Downloads).

This measure’s Value Set Directory includes the following coding systems for services, procedures, 

and diagnoses: CPT, HCPCS, ICD-9-CM, ICD-10-CM, ICD-10-PCS, POS, SNOMED, and UB. The 

Medication List Directory includes the following coding systems for medications: NDC and 

RxNorm. Refer to the Acknowledgments section at the beginning of the manual for copyright 

information.

8The NCQA HEDIS® measure specification has been adjusted pursuant to NCQA’s Rules for Allowable 

Adjustments of HEDIS.

16Aside from the minor modifications noted in this specification, this specification is taken directly from the 2023 

CMS Medicaid Adult Core Set Measures. Use the most current version for the year being reported. See also 

Important Supplemental Materials for State-Collected Required BHC Measures derived from CMS Medicaid Adult 

and/or Child Core Set Measures (in this manual immediately before this specification).

17Adapted by NCQA with permission of the measure developer, CMS.
141 

Adherence to Antipsychotic Medications for Individuals with Schizophrenia (SAAAD)

B. DEFINITIONS

IPSD Index Prescription Start Date (IPSD). The earliest prescription dispensing date 

for any antipsychotic medication during the measurement year.

Treatment period The period of time beginning on the IPSD through the last day of the 

measurement year.

PDC Proportion of Days Covered. The number of days a beneficiary [client] is 

covered by at least one antipsychotic medication prescription, divided by the 

number of days in the treatment period.

Oral medication 

dispensing event

One prescription of an amount lasting 30 days or less. To calculate dispensing 

events for prescriptions longer than 30 days, divide the days supply by 30 and 

round down to convert. For example, a 100-day prescription is equal to three 

dispensing events.

Multiple prescriptions for different medications dispensed on the same day are 

counted as separate dispensing events. If multiple prescriptions for the same 

medication are dispensed on the same day, use the prescription with the longest 

days supply. Use the medication lists (see Medication List table below and link 

to the Medication List Directory in Guidance for Reporting above) to determine 

if the drugs are the same or different. Drugs in different lists are considered 

different drugs.

Long-acting 

injections 

dispensing event

Injections count as one dispensing event. Multiple codes (from the value sets 

and medication lists) for the same or different medication on the same day are 

counted as a single dispensing event.

Calculating 

number of days 

covered for oral 

medications

If multiple prescriptions for the same or different oral medications are 

dispensed on the same day, calculate number of days covered by an 

antipsychotic medication (for the numerator) using the prescription with the 

longest days supply. 

If multiple prescriptions for different oral medications are dispensed on 

different days, count each day within the treatment period only once toward the 

numerator.

If multiple prescriptions for the same oral medication are dispensed on different 

days, sum the days supply and use the total to calculate the number of days 

covered by an antipsychotic medication (for the numerator). For example, if 

three antipsychotic prescriptions for the same oral medication are dispensed on 

different days, each with a 30-day supply; sum the days supply for a total of 90 

days covered by an oral antipsychotic (even if there is overlap). 

Use the medication lists (see Medication List table below and link to the 

Medication List Directory in Guidance for Reporting above) to determine if the 

drugs are the same or different. Drugs in different lists are considered different 

drugs.

Calculating 

number of days 

covered for longacting injections

Calculate number of days covered (for the numerator) for long-acting injections 

using the days supply specified for the medication in the medication list or in 

the value set name. 

For multiple codes (from the value sets and medication lists) for the same or 

different medications on the same day, use the medication with the longest days 

supply. 

For multiple codes (from the value sets and medication lists) for the same or 

different medications on different days with overlapping days supply, count 

each day within the treatment period only once toward the numerator.
142

Adherence to Antipsychotic Medications for Individuals with Schizophrenia (SAAAD)

Note: If an oral medication and a long-acting injection are dispensed on the same day, calculate 

number of days covered by an antipsychotic medication (for the numerator) using the prescription 

with the longest days supply.

If an oral medication and long-acting injection are dispensed on different days, with some 

overlapping days of supply, count each day within the treatment period only once toward the 

numerator. 

C. ELIGIBLE POPULATION

Age Ages 18 and older as of January 1 of the measurement year.

Continuous 

enrollment

The measurement year.

Allowable gap No more than one gap in enrollment of up to 45 days during the measurement year. To 

determine continuous enrollment for a beneficiary [client] for whom enrollment is 

verified monthly, the beneficiary [client] may not have more than a 1-month gap in 

coverage (e.g., a beneficiary [client] whose coverage lapses for 2 months [60 days] is 

not considered continuously enrolled).

Anchor date December 31 of the measurement year.

Benefits Medical and pharmacy.

Event/

diagnosis

Follow the steps below to identify the eligible population.

Step 1

Identify beneficiaries [clients] 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 encounter with any diagnosis of schizophrenia or 

schizoaffective disorder. Either of the following code combinations meets criteria:

BH Stand Alone Acute Inpatient Value Set with Schizophrenia Value Set

- Visit Setting Unspecified Value Set with Acute Inpatient POS Value Set with 

Schizophrenia Value Set

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 meets criteria: 

- An outpatient visit with any diagnosis of schizophrenia or schizoaffective 

disorder (Visit Setting Unspecified Value Set with Outpatient POS Value Set 

with Schizophrenia Value Set)

- An outpatient visit with any diagnosis of schizophrenia or schizoaffective 

disorder (BH Outpatient Value Set with Schizophrenia Value Set)

- An intensive outpatient encounter or partial hospitalization with any diagnosis of 

schizophrenia or schizoaffective disorder (Visit Setting Unspecified Value Set

with Partial Hospitalization POS Value Set with Schizophrenia Value Set)
143

Adherence to Antipsychotic Medications for Individuals with Schizophrenia (SAAAD)

Event/

diagnosis 

(continued)

- An intensive outpatient encounter or partial hospitalization with any diagnosis of

schizophrenia or schizoaffective disorder (Partial Hospitalization or Intensive

Outpatient Value Set with Schizophrenia Value Set)

- A community mental health center visit with any diagnosis of schizophrenia or

schizoaffective disorder (Visit Setting Unspecified Value Set with Community

Mental Health Center POS Value Set with Schizophrenia Value Set)

- Electroconvulsive therapy (Electroconvulsive Therapy Value Set) with any

diagnosis of schizophrenia or schizoaffective disorder (Schizophrenia Value Set)

- An observation visit (Observation Value Set) with any diagnosis of schizophrenia

or schizoaffective disorder (Schizophrenia Value Set)

- An ED visit (ED Value Set) with any diagnosis of schizophrenia or

schizoaffective disorder (Schizophrenia Value Set)

- An ED visit with any diagnosis of schizophrenia or schizoaffective disorder

(Visit Setting Unspecified Value Set with ED POS Value Set with Schizophrenia

Value Set)

- A nonacute inpatient encounter (BH Stand Alone Nonacute Inpatient Value Set)

with any diagnosis of schizophrenia or schizoaffective disorder (Schizophrenia

Value Set)

- A nonacute inpatient encounter with any diagnosis of schizophrenia or

schizoaffective disorder (Visit Setting Unspecified Value Set with Nonacute

Inpatient POS Value Set with Schizophrenia Value Set)

- A telehealth visit with any diagnosis of schizophrenia or schizoaffective disorder

(Visit Setting Unspecified Value Set with Telehealth POS Value Set with

Schizophrenia Value Set)

- A telephone visit (Telephone Visits Value Set) with any diagnosis of

schizophrenia or schizoaffective disorder (Schizophrenia Value Set)

- An e-visit or virtual check-in (Online Assessments Value Set) with any diagnosis

of schizophrenia or schizoaffective disorder (Schizophrenia Value Set)

Step 2: Required Exclusions Exclude beneficiaries [clients] who met any of the 

following during the measurement year:

A diagnosis of dementia (Dementia Value Set) 

Did not have at least two antipsychotic medication dispensing events. There are two 

ways to identify dispensing events: by claim/encounter data and by pharmacy data. 

The state must use both methods to identify dispensing events, but an event need 

only be identified by one method to be counted.

Event/

diagnosis 

(continued)

- Claims/encounter data. An antipsychotic medication (Long-Acting Injections 14

Days Supply Value Set; Long-Acting Injections 28 Days Supply Value Set;

Long Acting Injections 30 Days Supply Value Set)

Pharmacy data. Dispensed an antipsychotic medication. Use all the medication lists 

in the Oral Antipsychotic Medications and Long-Acting Injections (see 

Medication List table below and link to the Medication List Directory in 

Guidance for Reporting above) to identify antipsychotic medication dispensing 

events

Beneficiaries [Clients] in hospice or using hospice services anytime during the 

measurement year. For additional information, refer to the hospice exclusion 

guidance in Section II. Data Collection and Reporting of the Adult Core Set [Section 

III. Technical Specification Components].
144

Adherence to Antipsychotic Medications for Individuals with Schizophrenia (SAAAD)

Optional 

exclusions

Note: Supplemental and medical record data may not be used for the following 

exclusions.

Exclude beneficiaries [clients] who meet any of the following criteria:

Beneficiaries [Clients] ages 66 to 80 as of December 31 of the measurement year with 

frailty and advanced illness. Beneficiaries [Clients] must meet both of the following 

frailty and advanced illness criteria to be excluded: 

1. At least one claim/encounter for frailty (Frailty Device Value Set; Frailty

Diagnosis Value Set; Frailty Encounter Value Set; Frailty Symptom Value Set)

during the measurement year

2. Any of the following during the measurement year or the year prior to the measurement

year (count services that occur over both years):

At least two outpatient visits (Outpatient Value Set), observation visits

(Observation Value Set), ED visits (ED Value Set), telephone visits 

(Telephone Visits Value Set), e-visits or virtual check-ins (Online 

Assessments Value Set), nonacute inpatient encounters (Nonacute Inpatient 

Value Set), or nonacute inpatient discharges (instructions below; the diagnosis 

must be on the discharge claim) on different dates of service, with an 

advanced illness diagnosis (Advanced Illness Value Set). Visit type need not 

be the same for the two visits. To identify a nonacute inpatient discharge:

1. Identify all acute and nonacute inpatient stays (Inpatient Stay Value Set).

Confirm the stay was for nonacute care based on the presence of a nonacute

code (Nonacute Inpatient Stay Value Set) on the claim.

Identify the discharge date for the stay.

At least one acute inpatient encounter (Acute Inpatient Value Set) with an 

advanced illness diagnosis (Advanced Illness Value Set)

Optional 

exclusions 

(continued) 

At least one acute inpatient discharge with an advanced illness diagnosis 

(Advanced Illness Value Set) on the discharge claim. To identify an acute 

inpatient discharge:

1. Identify all acute and nonacute inpatient stays (Inpatient Stay Value Set).

2. Exclude nonacute inpatient stays (Nonacute Inpatient Stay Value Set).

3. Identify the discharge date for the stay.

A dispensed dementia medication (Dementia Medications List, see link to the 

Medication List Directory in Guidance for Reporting above)

Beneficiaries [Clients] age 81 and older as of December 31 of the measurement year 

with frailty (Frailty Device Value Set; Frailty Diagnosis Value Set; Frailty Encounter 

Value Set; Frailty Symptom Value Set) during the measurement year.

Oral Antipsychotic Medications 

Description Prescription Medication Lists

Miscellaneous 

antipsychotic agents 

(oral)

Aripiprazole Aripiprazole Oral Medications List

Asenapine Asenapine Oral Medications List

Brexpiprazole Brexpiprazole Oral Medications List

Cariprazine Cariprazine Oral Medications List

Clozapine Clozapine Oral Medications List
145 

Adherence to Antipsychotic Medications for Individuals with Schizophrenia (SAAAD)

Description Prescription Medication Lists

Haloperidol Haloperidol Oral Medications List

Iloperidone Iloperidone Oral Medications List

Loxapine Loxapine Oral Medications List

Lumateperone Lumateperone Oral Medications List 

Lurasidone Lurasidone Oral Medications List

Molindone Molindone Oral Medications List

Olanzapine Olanzapine Oral Medications List

Paliperidone Paliperidone Oral Medications List

Quetiapine Quetiapine Oral Medications List

Risperidone Risperidone Oral Medications List

Ziprasidone Ziprasidone Oral Medications List

Phenothiazine 

antipsychotics (oral)

Chlorpromazine Chlorpromazine Oral Medications List

Fluphenazine Fluphenazine Oral Medications List

Perphenazine Perphenazine Oral Medications List

Prochlorperazine Prochlorperazine Oral Medications List

Thioridazine Thioridazine Oral Medications List

Trifluoperazine Trifluoperazine Oral Medications List

Psychotherapeutic 

combinations (oral)

AmitriptylineperphenazineAmitriptyline Perphenazine Oral Medications List

Thioxanthenes 

(oral)

Thiothixene Thiothixene Oral Medications List

Long-Acting Injections 

Description Prescription Medication Lists

Long-acting 

injections

14 days supply

Risperidone (excluding Perseris®) Long Acting Injections 14 Days 

Supply Medications List

Long-acting 

injections

28 days supply

Aripiprazole

Aripiprazole lauroxil

Fluphenazine decanoate

Haloperidol decanoate

Olanzapine

Paliperidone palmitate

Long Acting Injections 28 Days

Supply Medications List

Long-acting 

injections

30 days supply

Risperidone (Perseris®) Long Acting Injections 30 Days 

Supply Medications List
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Adherence to Antipsychotic Medications for Individuals with Schizophrenia (SAAAD)

D. ADMINISTRATIVE SPECIFICATION

Denominator

The eligible population as defined above.

Numerator

The number of beneficiaries [clients] who achieved a PDC of at least 80 percent for their 

antipsychotic medications during the measurement year.

Follow the steps below to identify numerator compliance. Use the Long Acting Injections 14 Days 

Supply Value Set; Long Acting Injections 28 Days Supply Value Set; Long Acting Injections 30 

Days Supply Value Set and all the medication lists in the Oral Antipsychotic Medications and LongActing Injections (see Medication List table above and link to the Medication List Directory in 

Guidance for Reporting above) to identify antipsychotic medication dispensing events.

Step 1

Identify the IPSD. The IPSD is the earliest dispensing event for any antipsychotic medication during 

the measurement year. 

Step 2

To determine the treatment period, calculate the number of days beginning on the IPSD through the 

end of the measurement year.

Step 3

Count the days covered by at least one antipsychotic medication during the treatment period. To 

ensure that days supply that extend beyond the measurement year are not counted, subtract any days 

supply that extends beyond December 31 of the measurement year.

Step 4

Calculate the beneficiary [client]’s PDC using the following equation. Multiply the equation by 100 

and round (using the .5 rule) to the nearest whole number. For example, if a beneficiary [client] has 

291 total days covered by a medication during a 365-day treatment period, this calculates to 0.7972. 

Multiply this number by 100, convert it to 79.72% and round it to 80%, the nearest whole number. 

Step 5

Sum the number of beneficiaries [clients] whose PDC is ≥ 80 percent for their treatment period.
147

Supplemental Materials for Plan All-Cause Readmissions (PCR-AD)

Important Supplemental Materials for State-Collected Required BHC 

Measures derived from CMS Medicaid Adult and/or Child Core Set 

Measures (PCR-AD)

These supplemental materials are necessary for implementation of the State-Collected Required 

BHC Measures that are derived from the CMS Medicaid Adult and/or Child Core Set Measures. 

This volume includes the exact specifications that are on the CMS website for the 2023 Medicaid 

Core Set, with simple modifications noted in the text. Limited additional needed modifications 

are included below, as well as supplemental useful materials.

Changes directly in the specifications: For all Core Set-derived measures, the changes in the 

specification from the CMS Medicaid Adult or Child Core Set reflect: (1) substitution of the 

word “client” for “beneficiary” or “patient”, unless the latter is part of a copyrighted code 

description; and (2) removal of most references to the Core Set.

Additional needed modifications specific to each measure are included below, as well as 

supplemental useful materials.

Measure PCR-AD: Plan All-Cause Readmissions

Additional information: The following material is provided to assist clinics using the 

specifications and follows the numbering system used in the non-Core derived BHC 

specifications:

A. DESCRIPTION

Important Reporting Guidance:

• The PCR-AD measure is to be used to measure performance related to clients seen at the 

BHC Provider during the Measurement Year.

• Current value sets are available on the CMS Medicaid Adult Core Set Reporting 

Resource website. Use the version current for the year being reported.

• PCR-AD is stratified separately based on whether the client is:

o Medicaid only or Other (including those dually eligible for Medicare and 

Medicaid)

• Refer to the specific data-reporting template for the reporting requirements applicable to 

each measure.

Measurement Period: The Measurement Period is the period for which data are required for 

reporting purposes. The Measurement Period for the PCR-AD denominator covers the 

allowable period for Index Hospital Stays to be included and is January 1 – December 1 when 

the Measurement Year is the Calendar Year. The Measurement Period for the PCR-AD

numerator (or the allowable period for readmissions to be included) is the Measurement 

Year, excluding the first two days of that Measurement Year (January 3 – December 31).
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Supplemental Materials for Plan All-Cause Readmissions (PCR-AD)

B. DEFINITIONS

TERM DEFINITION 

Measurement Period

The specific time period for which data are needed for the 

numerator and denominator of a given measure. The Measurement 

Period may differ for the numerator and denominator and for each 

measure and is specified in section A above.

Measurement Year The standard 12-month reporting period common to all measures 

being reported by the Provider.

Percentage A Percentage is calculated as follows: numerator divided by 

denominator (n/d).

Provider The Provider entity that is being measured (i.e., BHC) 

E. ADDITIONAL NOTES

Interpretation of scores: Better quality = Lower Percentage

F. FREQUENTLY ASKED QUESTIONS

None
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Plan All-Cause Readmissions (PCR-AD)

Measure PCR-AD: Plan All-Cause Readmissions8,16

Based on a CMS Medicaid Adult Core Set Measure (2023), which is derived from a measure stewarded 

by the National Committee for Quality Assurance (NCQA)

A. DESCRIPTION

For beneficiaries [clients] ages 18 to 64, the number of acute inpatient and observation stays during

the measurement year that were followed by an unplanned acute readmission for any diagnosis

within 30 days and the predicted probability of an acute readmission. Data are reported in the

following categories:

Count of Index Hospital Stays (IHS)

Count of Observed 30-Day Readmissions

Count of Expected 30-Day Readmissions

Data Collection Method: Administrative

Guidance for Reporting:

For HEDIS, this measure applies to beneficiaries [clients] ages 18 to 64. Although the HEDIS 

measure includes stratified reporting by age, [as] for the Adult Core Set, states should calculate 

and report only the Total rate [rather than stratifying by age]. 

This measure requires risk adjustment. Risk adjustment guidelines are provided in the 

administrative specification. Please note that in the risk adjustment tables, clinical conditions 

(CCs) and hierarchical clinical conditions (HCCs) not listed receive a weight of ZERO (e.g., 

0.0000).

Report the Count of Expected 30-Day Readmissions for this measure to four decimal places.

As shown in Table PCR-A, the data elements in columns 1, 2, 4, 7, and 8 are reported by the state. 

The data elements in columns 3, 5, 6, and 9 will be derived from the reported data.

Supplemental data may not be used for this measure [with the exception of supplemental data 

needed to determine the hospice exclusion].

When applying risk adjustment, include all services, whether or not the state paid for them or 

expects to pay for them (e.g., include denied claims). When identifying all other events, do not 

include denied services (e.g., only include paid services and services expected to be paid). 

If this measure has a Count of Index Hospital Stays less than 150 and the state chooses not to 

report this measure due to small numbers, please note this in the “Reason for Not 

Reporting[Adherence to Measure Specifications]” fields and specify the denominator size.

For observation stays (Observation Stay Value Set) that do not have a recorded admission or 

discharge date, set the admission date to the earliest date of service on the claim and set the 

discharge date to the last date of service on the claim.

8The NCQA HEDIS® measure specification has been adjusted pursuant to NCQA’s Rules for Allowable 

Adjustments of HEDIS. 

16Aside from the minor modifications noted in this specification, this specification is taken directly from the 2023 

CMS Medicaid Adult Core Set Measures. Use the most current version for the year being reported. See also 

Important Supplemental Materials for State-Collected Required BHC Measures derived from CMS Medicaid Adult 

and/or Child Core Set Measures (in this manual immediately before this specification).
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Plan All-Cause Readmissions (PCR-AD)

This measure’s Value Set Directory includes the following coding systems for services, procedures, 

and diagnoses: CPT, HCPCS, ICD-9-PCS, ICD-10-CM, ICD-10-PCS, SNOMED, and UB. Refer to 

the Acknowledgments section at the beginning of the manual for copyright information.

B. DEFINITIONS

Index hospital stay (IHS) An acute inpatient or observation stay with a discharge on or 

between January 1 and December 1 of the measurement year as 

identified in the denominator.

Index admission date The IHS admission date.

Index discharge date The IHS discharge date. The index discharge date must occur on or 

between January 1 and December 1 of the measurement year.

Index readmission stay An acute inpatient or observation stay for any diagnosis with an 

admission date within 30 days of a previous Index Discharge Date.

Index readmission date The admission date associated with the Index Readmission Stay.

Planned hospital stay A hospital stay is considered planned if it meets criteria as 

described under step 3, Count of Observed 30-Day Readmissions.

Direct transfer A direct transfer is when the discharge date from the initial stay 

precedes the admission date to a subsequent stay by one calendar 

day or less. For example:

A discharge on June 1, followed by a subsequent admission on June 

1, is a direct transfer.

A discharge on June 1, followed by a subsequent admission on June 

2, is a direct transfer.

A discharge on June 1, followed by a subsequent admission on June 

3, is not a direct transfer; these are two distinct inpatient stays.

A discharge on June 1, followed by a subsequent admission on June 

2 (with discharge on June 3), followed by a subsequent 

admission on June 4, is a direct transfer.

Direct transfers may occur from and between different facilities 

and/or different services levels.

Medicaid population Beneficiaries [Clients] in the eligible population prior to exclusion 

of outliers (denominator steps 1-5). The Medicaid population is 

only used as a denominator for the Outlier rate.

Beneficiaries [Clients] must be ages 18 to 64 as of the earliest Index 

Discharge Date.

The Medicaid population is based on beneficiaries [clients], not 

discharges. Count beneficiaries [clients] only once in the Medicaid 

population.

Outliers Beneficiaries [Clients] in the eligible population with four or more 

index hospital stays between January 1 and December 1 of the 

measurement year. 

Nonoutliers Beneficiaries [Clients] in the eligible population who are not 

considered outliers. 

Classification period 365 days prior to and including an Index Discharge Date.
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Plan All-Cause Readmissions (PCR-AD)

Risk Adjustment Tables

The PCR measure leverages the Risk Adjustment Tables, which define condition-based riskadjustment variables. The table helps users determine a beneficiary [client]’s condition-based riskadjustment variables and select the proper risk weights.

Table Table Description

Table CC-Mapping Discharge Clinical Condition category codes for Risk Adjustment 

Determination.

Comorbid Clinical Condition category codes for Risk Adjustment 

Determination step 2.

Table HCC–Rank HCC rankings for Risk Adjustment Determination step 3.

Table HCC-Comb Combination HCCs for Risk Adjustment Determination step 5.

PCR Risk Adjustment 

Table, Medicaid

Medicaid primary discharge weights for Risk Adjustment 

Weighting step 3. 

Medicaid comorbidity weights for Risk Adjustment Weighting step 

4. 

Medicaid observation stay, surgery, age and gender weights for 

Risk Adjustment Weighting steps 1, 2, 5. 

Source: Please refer to the HEDIS® MY2022 Volume 2 Risk Adjustment Utilization Tables User 

Manual for technical detail on table format and content. [Use version current for the year 

reported.]

Note: The risk adjustment tables and Risk Adjustment Utilization Tables User Manual are 

available to order free of charge in the NCQA store at https://store.ncqa.org/hedis-my2022-risk-adjustment-tables.html. [Use version current for the year reported.] Once 

ordered, the risk adjustment tables can be accessed through the NCQA Download Center 

(https://my.ncqa.org/Downloads). The tables needed to calculate this measure are found in 

both the PCR Risk Adjustment Tables and the RAU Table - PCR Medicaid MY2022 

(which includes the CC-Mapping, HCC-Rank, and HCC-Comb tables). [Use version 

current for the year reported.]

C. ELIGIBLE POPULATION

Age Ages 18 to 64 as of the Index Discharge Date.

Continuous 

enrollment

365 days prior to the Index Discharge Date through 30 days after the Index 

Discharge Date.

Allowable gap No more than one gap in enrollment of up to 45 days during the 365 days prior 

to the Index Discharge Date and no gap during the 30 days following the 

Index Discharge Date.

Anchor date Index Discharge Date.

Benefit Medical.
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Plan All-Cause Readmissions (PCR-AD)

Event/

diagnosis

An acute inpatient or observation stay discharge on or between January 1 and 

December 1 of the measurement year.

The denominator for this measure is based on discharges, not beneficiaries

[clients]. Include all acute inpatient or observation stay discharges for 

nonoutlier beneficiaries [clients] who had one or more discharges on or 

between January 1 and December 1 of the measurement year.

Follow the steps below to identify acute inpatient and observation stays.

Required 

exclusion

Beneficiaries [Clients] in hospice or using hospice services anytime during the 

measurement year. For additional information, refer to the hospice exclusion 

guidance in Section II. Data Collection and Reporting of the Adult Core Set

[Section III. Technical Specification Components].

D. ADMINISTRATIVE SPECIFICATION

Count of Index Hospital Stays (IHS)

The eligible population as defined above. 

Step 1 

Identify all acute inpatient and observation stay discharges on or between January 1 and December 1 

of the measurement year. 

To identify acute inpatient and observation stay discharges:

1. Identify all acute and nonacute inpatient stays (Inpatient Stay Value Set) and observation stays 

(Observation Stay Value Set).

2. Exclude nonacute inpatient stays (Nonacute Inpatient Stay Value Set).

3. Identify the discharge date for the stay.

Inpatient and observation stays where the discharge date from the first setting and the admission date 

to the second setting are two or more calendar days apart must be considered distinct stays. 

This measure includes acute discharges from any type of facility (including behavioral healthcare 

facilities).

Step 2

Direct transfers: For discharges with one or more direct transfers, use the last discharge. 

Using the discharges identified in step 1, identify direct transfers between acute inpatient and 

observation or between observation and acute inpatient using the definition of “direct transfer” 

above.

Exclude the hospital stay if the direct transfer’s discharge date occurs after December 1 of the 

measurement year.

Step 3

Exclude hospital stays where the Index Admission Date is the same as the Index Discharge Date.

Step 4

Exclude hospital stays for the following reasons:

The beneficiary [client] died during the stay.

Female beneficiaries [clients] with a principal diagnosis of pregnancy (Pregnancy Value Set) on the 

discharge claim.
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Plan All-Cause Readmissions (PCR-AD)

A principal diagnosis of a condition originating in the perinatal period (Perinatal Conditions Value 

Set) on the discharge claim.

Note: For hospital stays where there was a direct transfer (identified in step 2), use the original stay 

and any direct transfer stays to identify exclusions in this step.

Step 5

Calculate continuous enrollment.

Step 6

Remove hospital stays for outlier beneficiaries [clients] and report these beneficiaries [clients] as 

outliers. 

Note: Count discharges with one or more direct transfers (identified in step 2) as one discharge when 

identifying outlier beneficiaries [clients]. 

Risk Adjustment Determination

For each IHS among nonoutlier beneficiaries [clients], use the following steps to identify risk 

adjustment categories based on presence of observation stay status at discharge, surgeries, discharge 

condition, comorbidity, age, and gender.

Observation Stay Determine if the IHS at discharge was an observation stay 

(Observation Stay Value Set). For direct transfers, determine the 

hospitalization status using the last discharge.

Surgeries Determine if the beneficiary [client] underwent surgery during the 

stay (Surgery Procedure Value Set). Consider an IHS to include a 

surgery if at least one procedure code is present from any provider 

between the admission and discharge dates.

Discharge Condition Assign a discharge Clinical Condition (CC) category code or codes 

to the IHS based on its principal discharge diagnosis, using Table 

CC-Mapping. For direct transfers, use the principal discharge 

diagnosis from the last discharge.

Exclude diagnoses that cannot be mapped to Table CC-Mapping.

Comorbidities Assign Risk Adjustment Comorbidity Category Determination based 

on all the encounters during the classification period, as described in 

the Steps for Risk Adjustment Comorbidity Category Determination.

Steps for Risk Adjustment Comorbidity Category Determination

Follow the steps below for Risk Adjustment Comorbidity Category Determination.

Step 1

Identify all diagnoses for encounters during the classification period. Include the following when 

identifying encounters: 

Outpatient visits (Outpatient Value Set) 

Telephone Visits (Telephone Visits Value Set)

Observation visits (Observation Value Set) 

ED visits (ED Value Set) 

Inpatient events:

- Nonacute inpatient encounters (Nonacute Inpatient Value Set) 
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Plan All-Cause Readmissions (PCR-AD)

- Acute inpatient encounters (Acute Inpatient Value Set)

- Acute and nonacute inpatient discharges (Inpatient Stay Value Set)

Use the date of service for outpatient, observation, and ED visits. Use the discharge date for inpatient 

events. 

Exclude the principal discharge diagnosis on the index hospital stay (IHS).

Step 2

Assign each diagnosis to a comorbid Clinical Condition (CC) category using Table CC—Mapping, 

available at https://store.ncqa.org/hedis-my-2022-risk-adjustment-tables.html. [Use version current 

for the year reported.] If the code appears more than once in Table CC—Mapping, it is assigned to 

multiple CCs.

Exclude all diagnoses that cannot be assigned to a comorbid CC category. For beneficiaries [clients] 

with no qualifying diagnoses from face-to-face encounters, skip to the Risk Adjustment Weighting 

section. 

All digits must match exactly when mapping diagnosis codes to the comorbid CCs. 

Step 3

Determine Hierarchical Condition Categories (HCCs) for each comorbid CC identified. Refer to 

Table HCC—Rank, available at https://store.ncqa.org/hedis-my-2022-risk-adjustment-tables.html. 

[Use version current for the year reported.]

For each denominator unit's comorbid CC list, match the comorbid CC code to the comorbid CC 

code in the table, and assign: 

The ranking group

The rank

The HCC

For comorbid CCs that do not match to Table HCC—Rank, use the comorbid CC as the HCC and 

assign a rank of 1. 

Note: One comorbid CC can map to multiple HCCs; each HCC can have one or more comorbid CCs. 

Step 4

Assess each ranking group separately and select only the highest ranked HCC in each ranking group 

using the “Rank” column (1 is the highest rank possible). 

Drop all other HCCs in each ranking group, and de-duplicate the HCC list if necessary.

Example

Assume a denominator unit with the following comorbid CCs: CC-85, CC-17, and CC-19 (assume 

no other CCs). 

CC-85 does not have a map to the ranking table and becomes HCC-85. 

HCC-17 and HCC-19 are part of Diabetes Ranking Group 1. Because CC-17 is ranked higher than 

CC-19 in Ranking Group Diabetes 1, the comorbidity is assigned as HCC-17 for Ranking Group 

1. 

The final comorbidities for this denominator unit are HCC-17 and HCC-85. 
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Plan All-Cause Readmissions (PCR-AD)

Example: Table HCC—Rank

Ranking Group CC Description Rank HCC

Not Applicable (NA) CC-85 Congestive Heart Failure NA HCC-85

Diabetes 1 CC-17 Diabetes With Acute 

Complications

1 HCC-17

CC-18 Diabetes With Chronic 

Complications 

2 HCC-18

CC-19 Diabetes without Complication 3 HCC-19

Step 5

Identify combination HCCs listed in Table HCC—Comb, available at https://store.ncqa.org/hedismy-2022-risk-adjustment-tables.html.[Use version current for the year reported.]

Some combinations suggest a greater amount of risk when observed together. For example, when 

diabetes and congestive heart failure are present, an increased amount of risk is evident. Additional 

HCCs are selected to account for these relationships.

Compare each denominator unit's list of unique HCCs to those in the Comorbid HCC columns in 

Table HCC—Comb and assign any additional HCC conditions.

If there are fully nested combinations, use only the more comprehensive pattern. For example, if the 

diabetes/CHF combination is nested in the diabetes/CHF/renal combination, count only the 

diabetes/CHF/renal combination.

If there are overlapping combinations, use both sets of combinations. Based on the combinations, a 

denominator unit can have none, one, or more than one of these added HCCs.

Example:

For a denominator unit with comorbidities HCC-17 and HCC-85 (assume no other HCCs), assign 

HCC-901 in addition to HCC-17 and HCC-85. This does not replace HCC-17 and HCC-85.

Example: Table HCC—Comb

Comorbid 

HCC 1

Comorbid 

HCC 2

Comorbid 

HCC 3

Combination 

HCC 4 

HCC-Comb Description

HCC-17 HCC-85 NA HCC-901 Combination: Diabetes 

and CHF

HCC-18 HCC-85 NA HCC-901 Combination: Diabetes 

and CHF

HCC-19 HCC-85 NA HCC-901 Combination: Diabetes 

and CHF

Risk Adjustment Weighting

For each IHS among nonoutlier beneficiaries [clients], use the following steps to identify risk 

adjustment weights based on observation stay status at discharge, surgeries, discharge condition, 

comorbidity, age, and gender. Refer to the reporting indicator column in the risk adjustment tables to 

ensure that weights are linked appropriately.
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Plan All-Cause Readmissions (PCR-AD)

Step 1 For each IHS discharge that is an observation stay, link the observation stay IHS 

weight.

Step 2 For each IHS with a surgery, link the surgery weight.

Step 3 For each IHS with a discharge CC Category, link the primary discharge weights.

Step 4 For each IHS with a comorbidity HCC Category, link the comorbidity weights.

Step 5 Link the age and gender weights for each IHS.

Step 6 Sum all weights associated with the IHS (e.g., observation stay status at discharge, 

presence of surgery, principal discharge diagnosis, comorbidities, age, and gender) 

and use the formula below to calculate the Estimated Readmission Risk for each 

IHS.

Estimated Readmission Risk

OR

Estimated Readmission Risk = [exp (sum of weights for IHS)] / [1 + exp (sum of 

weights for IHS)]

Note: “Exp” refers to the exponential or antilog function.

Step 7 Calculate the Count of Expected Readmissions. The Count of Expected 

Readmissions is the sum of the Estimated Readmissions Risk calculated in step 6 for 

each IHS.

Count of Expected Readmissions = (Estimated Readmission Risk)

Count of Observed 30-Day Readmissions

At least one acute readmission for any diagnosis within 30 days of the Index Discharge Date.

Step 1

Identify all acute inpatient and observation stays with an admission date on or between January 3 and 

December 31 of the measurement year. To identify acute inpatient and observation admissions:

Identify all acute and nonacute inpatient stays (Inpatient Stay Value Set) and observation stays 

(Observation Stay Value Set).

Exclude nonacute inpatient stays (Nonacute Inpatient Stay Value Set).

Identify the admission date for the stay.

Step 2

Direct transfers: For discharges with one or more direct transfers, use the last discharge

Using the discharges identified in step 1, identify direct transfers between acute inpatient and 

observation or between observation and acute inpatient using the definition of “direct transfer” 

above.

Step 3

Exclude acute hospitalizations meeting any of the following criteria on the discharge claim: 

Female beneficiaries [clients] with a principal diagnosis of pregnancy (Pregnancy Value Set)
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Plan All-Cause Readmissions (PCR-AD)

A principal diagnosis for a condition originating in the perinatal period (Perinatal Conditions Value 

Set)

A planned hospital stay using any of the following: 

- A principal diagnosis of maintenance chemotherapy (Chemotherapy Encounter Value Set)

- A principal diagnosis of rehabilitation (Rehabilitation Value Set) 

- An organ transplant (Kidney Transplant Value Set, Bone Marrow Transplant Value Set, 

Organ Transplant Other Than Kidney Value Set, Introduction of Autologous Pancreatic 

Cells Value Set)

- A potentially planned procedure (Potentially Planned Procedures Value Set) without a 

principal acute diagnosis (Acute Conditions Value Set)

Note: For hospital stays where there was a direct transfer (identified in step 2), use the original stay 

and any direct transfer stays to identify exclusions in this step.

Step 4

For each IHS identified in the denominator, determine if any of the acute inpatient and observation 

stays identified in the numerator have an admission date within 30 days after the Index Discharge 

Date.

Note: Count each acute hospitalization only once toward the numerator for the last denominator 

event.

If a single numerator event meets criteria for multiple denominator events, only count the last 

denominator event. For example, consider the following events: 

Acute Inpatient Stay 1: May 1-10

Acute Inpatient Stay 2: May 15-25 (principal diagnosis of maintenance chemotherapy)

Acute Inpatient Stay 3: May 30–June 5. 

All three acute inpatient stays are included as denominator events. Stay 2 is excluded from the 

numerator because it is a planned hospitalization. Stay 3 is within 30 days of Stay 1 and Stay 2. 

Count Stay 3 as a numerator event only toward the last denominator event (Stay 2, May 15-25).

Reporting: Count of Index Hospital Stays (IHS)

Count the number of IHS among nonoutlier beneficiaries [clients] and enter this value into the 

reporting table under Count of Index Stays (Table PCR-A, column 1).

Reporting: Count of 30-Day Readmissions

Count the number of observed IHS among nonoutlier beneficiaries [clients] with a readmission 

within 30 days of discharge and enter this value into the reporting table under Count of Observed 30-

Day Readmissions (Table PCR-A, column 2).

Reporting: Count of Expected 30-Day Readmissions 

Sum the Expected Readmission Risk for each IHS among nonoutlier beneficiaries [clients] to 

calculate the Count of Expected Readmissions. Round to four decimal places using the .5 rule and 

enter the Count of Expected Readmissions into the reporting table (Table PCR-A, column 4).

Reporting: Count of Beneficiaries [Clients] in Medicaid Population

Step 1

Determine the beneficiary [client]’s age as of the earliest Index Discharge Date.
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Step 2

Report the count of beneficiaries [clients] in the Medicaid population and enter this value into the 

reporting table under Count of Beneficiaries [Clients] in Medicaid Population (Table PCR-A, 

column 7).

Reporting: Number of Outliers

Step 1

Determine the beneficiary [client]’s age as of the earliest Index Discharge Date.

Step 2 

Report the count of outlier beneficiaries [clients] and enter this value into the reporting table under 

Number of Outliers (Table PCR-A, column 8).

E. ADDITIONAL NOTES

The following data elements will be calculated based on the five reported data elements:

Observed Readmission Rate: Count of Observed 30-Day Readmissions divided by the Count of 

Index Hospital Stays (Table PCR-A, column 3). 

Expected Readmission Rate: Count of Expected 30-Day Readmissions divided by the Count of Index 

Hospital Stays (Table PCR-A, column 5).

Observed-to-Expected Ratio (O/E): Count of Observed 30-Day Readmissions divided by Count of 

Expected 30-Day Readmissions (Table PCR-A, column 6).

Outlier Rate: Number of Outliers divided by Count of beneficiaries [clients] in Medicaid Population 

(Table PCR-A, column 9), displayed as a permillage (multiplied by 1,000).

Note: The O/E ratio is interpreted as “lower-is-better”:

- O/E ratio <1.0 means the state had fewer readmissions than expected given the case mix

- O/E ratio = 1.0 means that the number of readmissions was the same as expected given the 

case mix

- O/E ratio >1.0 means that the state had more readmissions than expected given the case mix
159

Plan All-Cause Readmissions (PCR-AD)

Table PCR-A. Plan All-Cause Readmissions Rates 

Count of 

Index 

Hospital 

Stays

(1)

Count of 

Observed

30-Day 

Readmissions

(2)

Observed 

Readmission 

Rate

(3)

Count of 

Expected

30-Day 

Readmissions

(4)

Expected 

Readmission 

Rate

(5)

O/E Ratio

(Count of 

Observed 30-Day 

Readmissions/ 

Count of Expected 

30-Day 

Readmissions)

(6)

Count of 

Beneficiaries in 

Medicaid 

Population

(7)

Number of 

Outliers

(8)

Outlier 

Rate

(9)

Total Calculated Calculated Calculated Calculated
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Supplemental Materials for Follow-Up Care for Children Prescribed AttentionDeficit/Hyperactivity Disorder (ADHD) Medication (ADD-CH)

Important Supplemental Materials for State-Collected Required

BHC Measures derived from CMS Medicaid Adult and/or Child 

Core Set Measures (ADD-CH)

These supplemental materials are necessary for implementation of the State-Collected Required 

BHC Measures that are derived from the CMS Medicaid Adult and/or Child Core Set Measures. 

This volume includes the exact specifications that are on the CMS website for the 2023 Medicaid 

Core Set, with simple modifications noted in the text. Limited additional needed modifications 

are included below, as well as supplemental useful materials.

Changes directly in the specifications: For all Core Set-derived measures, the changes in the 

specification from the CMS Medicaid Adult or Child Core Set reflect: (1) substitution of the 

word “client” for “beneficiary” or “patient”, unless the latter is part of a copyrighted code 

description; and (2) removal of most references to the Core Set.

Additional needed modifications specific to each measure are included below, as well as 

supplemental useful materials.

Measure ADD-CH: Follow-Up Care for Children Prescribed AttentionDeficit/Hyperactivity Disorder (ADHD) Medication

Additional information: The following material is provided to assist clinics using the 

specifications and follows the numbering system used in the non-Core derived BHC 

specifications:

A. DESCRIPTION

Important Reporting Guidance:

• The ADD-CH measure is to be used to measure performance related to clients seen at the 

BHC Provider during the Measurement Year.

• Current value sets are available on the CMS Medicaid Child Core Set Reporting 

Resource website. Use the version current for the year being reported.

• ADD-CH is stratified separately based on whether the client is:

o Medicaid only or Other (including those dually eligible for Medicare and 

Medicaid)

AND

o A member of which of the following ethnic groups: Not Hispanic or Latino, 

Hispanic or Latino, or Unknown

AND

o A member of which of the following racial groups: White or Caucasian, Black or 

African American, American Indian or Alaska Native, Asian, Native Hawaiian or 

Other Pacific Islander, More than one race, or Unknown
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Supplemental Materials for Follow-Up Care for Children Prescribed AttentionDeficit/Hyperactivity Disorder (ADHD) Medication (ADD-CH)

• Refer to the specific data-reporting template for the reporting requirements applicable to 

each measure.

Measurement Period: The Measurement Period is the period for which data are required for 

reporting purposes. For the ADD-CH denominator, two measurement periods are used:

• Index prescription start date (IPSD): The earliest prescription dispensing date for an 

ADHD medication where the date is in the Intake Period and there is a Negative Medication 

History.

• Negative medication history review: 120 days prior to the IPSD

For the ADD-CH numerator, two measurement periods are used:

• Initiation Phase: 30 days following the IPSD

• Continuation and Maintenance Phase: The time period between 300 days following the 

IPSD 

B. DEFINITIONS

TERM DEFINITION 

Measurement Period

The specific time period for which data are needed for the 

numerator and denominator of a given measure. The Measurement 

Period may differ for the numerator and denominator and for each 

measure and is specified in section A above.

Measurement Year The standard 12-month reporting period common to all measures 

being reported by the Provider.

Percentage A Percentage is calculated as follows: numerator divided by 

denominator (n/d).

Provider The Provider entity that is being measured (i.e., BHC) 

E. ADDITIONAL NOTES

Interpretation of scores: Better quality = Higher Percentage

F. FREQUENTLY ASKED QUESTIONS

None
162

Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder 

(ADHD) Medication (ADD-CH)

Measure ADD-CH: Follow-Up Care for Children Prescribed AttentionDeficit/Hyperactivity Disorder (ADHD) Medication8,18

Based on a CMS Medicaid Child Core Set Measure (2023), which is derived from a measure stewarded 

by the National Committee for Quality Assurance (NCQA)

A. DESCRIPTION

Percentage of children 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.

Initiation Phase: Percentage of children ages 6 to 12 with a prescription dispensed for ADHD

medication, who had one follow-up visit with a practitioner with prescribing authority during the 30-

day Initiation Phase.

Continuation and Maintenance (C&M) Phase: Percentage of children ages 6 to 12 with a prescription

dispensed for ADHD medication 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 (9 months) after the Initiation Phase ended.

Data Collection Method: Administrative or EHR19

Guidance for Reporting: 

Children who switch between Medicaid and CHIP and whom the state cannot identify as 

continuously enrolled between the Rate 1 and Rate 2 continuous enrollment periods should 

only be included in Rate 1 (initiation phase).

Many of the ADHD medications are also used in the treatment of narcolepsy. In order to have a 

precise ADHD measure, children with narcolepsy are removed from the denominator of both 

indicators.

Include all paid, suspended, pending, and denied claims.

This measure includes an optional exclusion for beneficiaries [clients] who die during the 

measurement year. For additional information, refer to the deceased beneficiary [client] 

exclusion guidance in Section II. Data Collection and Reporting of the Child Core Set [Section 

III. Technical Specification Components].

NCQA’s Medication List Directory (MLD) for ADHD Medications is available to order free of 

charge in the NCQA Store (https://store.ncqa.org/hedis-my-2022-medication-listdirectory.html). [Use version current for year reporting.] Once ordered, the Medication List 

Directory can be accessed through the NCQA Download Center 

(https://my.ncqa.org/Downloads).

8The NCQA HEDIS® measure specification has been adjusted pursuant to NCQA’s Rules for Allowable 

Adjustments of HEDIS. 

18Aside from the minor modifications noted in this specification, this specification is taken directly from the 2023 

CMS Medicaid Child Core Set Measures. Use the most current version for the year being reported.

See also Important Supplemental Materials for State-Collected Required BHC Measures derived from CMS 

Medicaid Adult and/or Child Core Set Measures (in this manual immediately before this specification).

19The Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication 

measure is also specified for Electronic Clinical Data System (ECDS) reporting for HEDIS reporting. ECDS 

specifications are not currently available for Child Core Set [or BHC] reporting.
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Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder 

(ADHD) Medication (ADD-CH)

The electronic specification for FFY 2023 is located on the eCQI resource center at 

https://ecqi.healthit.gov/ecqm/ec/2022/cms136v11. [Use version current for year reporting.] 

States that use electronic specifications should indicate this by selecting “Electronic Health 

Records” in the Data Source section of the online reporting system [template].

Refer to [Appendix D of this manual] for the definition of a prescribing practitioner.

This measure’s Value Set Directory includes the following coding systems for services, procedures, 

and diagnoses: CPT, HCPCS, ICD-9-CM, ICD-10-CM, POS, SNOMED, and UB. The Medication 

List Directory includes the following coding systems for medications: NDC and RxNorm. Refer to 

the Acknowledgments section at the beginning of the manual for copyright information.

B. DEFINITIONS

Intake period The 12-month window starting March 1 of the year prior to the 

measurement year and ending the last calendar day of February of the 

measurement year.

Negative 

medication history

A period of 120 days (4 months) prior to the IPSD when the beneficiary

[client] had no ADHD medications dispensed for either new or refill 

prescriptions.

IPSD Index Prescription Start Date (IPSD). The earliest prescription dispensing 

date for an ADHD medication where the date is in the Intake Period and 

there is a Negative Medication History.

Initiation phase The 30 days following the IPSD.

C&M phase The 300 days following the IPSD (10 months).

Continuous 

medication 

treatment 

The number of medication treatment days during the 301-day period must 

be ≥ 210 days (e.g., 301 treatment days – 91 gap days). 

Treatment days 

(Covered days)

The actual number of calendar days covered with prescriptions within the 

specified 301-day period (e.g., a prescription of a 90-day supply dispensed 

on the 220th day will have 82 days counted in the 301-day interval).

C. ELIGIBLE POPULATION

Eligible Population: Rate 1 – Initiation Phase

Age Age 6 as of March 1 of the year prior to the measurement year to age 12 as 

of the last calendar day of February of the measurement year.

Continuous 

enrollment

120 days (4 months) prior to the IPSD through 30 days after the IPSD.

Allowable gap No allowable gaps in the continuous enrollment period.

Anchor date None.

Benefits Medical and pharmacy.

Event/diagnosis Follow the steps under Administrative Specifications: Rate 1 – Initiation 

Phase (Section D) to identify the eligible population for the Initiation 

Phase.
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Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder 

(ADHD) Medication (ADD-CH)

Eligible Population: Rate 2 – Continuation and Maintenance Phase

Age Age 6 as of March 1 of the year prior to the measurement year to age 12 as 

of the last calendar day of February of the measurement year.

Continuous 

enrollment

120 days (4 months) prior to the index prescription start date (IPSD) and 

300 days (10 months) after the IPSD. 

Allowable gap One 45-day gap in enrollment between 31 days and 300 days (10 months) 

after the IPSD. To determine continuous enrollment for a beneficiary

[client] for whom enrollment is verified monthly, the child may not have 

more than a 1-month gap in coverage (e.g., a child whose coverage lapses 

for 2 months [60 days] is not considered continuously enrolled).

Anchor date None.

Benefits Medical and pharmacy.

Event/diagnosis Follow the steps under Administrative Specifications: Rate 2 –

Continuation and Maintenance (Section D) to identify the eligible 

population for the Continuation and Maintenance Phase.

D. ADMINISTRATIVE SPECIFICATION

Rate 1 – Initiation Phase

Denominator

The Rate 1 eligible population.

Step 1

Identify all children in the specified age range who were dispensed an ADHD medication (ADHD 

Medications List, see link to the Medication List Directory in Guidance for Reporting above) during 

the 12-month Intake Period.

Step 2

Test for Negative Medication History. For each child identified in step 1, test each ADHD 

prescription for a Negative Medication History. The IPSD is the dispensing date of the earliest 

ADHD prescription in the Intake Period with a Negative Medication History.

Step 3

Calculate continuous enrollment. Children must be continuously enrolled for 120 days (4 months) 

prior to the IPSD through 30 days after the IPSD.

Step 4

Remove children who had an acute inpatient encounter for a mental, behavioral, or 

neurodevelopmental disorder during the 30 days after the IPSD. Either of the following meet criteria:

An acute inpatient encounter (Acute Inpatient Value Set) with a principal diagnosis of mental, 

behavioral, or neurodevelopmental disorder (Mental, Behavioral and Neurodevelopmental 

Disorders Value Set)

An acute inpatient discharge with a principal diagnosis of mental, behavioral or neurodevelopmental 

disorder (Mental, Behavioral and Neurodevelopmental Disorders Value Set) on the discharge 

claim. To identify an acute inpatient discharge: 

Identify all acute and nonacute inpatient stays (Inpatient Stay Value Set).
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Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder 

(ADHD) Medication (ADD-CH)

Exclude nonacute inpatient stays (Nonacute Inpatient Stay Value Set).

Identify the discharge date for the stay.

Required Exclusions

Exclude beneficiaries [clients] who meet either of the following criteria:

Beneficiaries [Clients] with a diagnosis of narcolepsy (Narcolepsy Value Set) any time during their 

history through December 31 of the measurement year

Beneficiaries [Clients] in hospice or using hospice services anytime during the measurement year. 

Refer to the hospice exclusion guidance in Section II. Data Collection and Reporting of the Child 

Core Set [Section III. Technical Specification Components].

Numerator

A follow-up visit with a practitioner with prescribing authority, within 30 days after the IPSD. Any 

of the following code combinations billed by a practitioner with prescribing authority meet criteria:

An outpatient visit (Visit Setting Unspecified Value Set with Outpatient POS Value Set)

An outpatient visit (BH Outpatient Value Set)

An observation visit (Observation Value Set)

A health and behavior assessment or intervention (Health and Behavior Assessment or Intervention 

Value Set)

An intensive outpatient encounter or partial hospitalization (Visit Setting Unspecified Value Set with 

Partial Hospitalization POS Value Set)

An intensive outpatient encounter or partial hospitalization (Partial Hospitalization or Intensive 

Outpatient Value Set)

A community mental health center visit (Visit Setting Unspecified Value Set with Community 

Mental Health Center POS Value Set) 

A telehealth visit (Visit Setting Unspecified Value Set with Telehealth POS Value Set)

A telephone visit (Telephone Visits Value Set)

Note: Do not count a visit on the IPSD as the Initiation Phase visit.

Rate 2 – Continuation and Maintenance Phase

Denominator

The Rate 2 eligible population.

Step 1

Identify all children who meet the eligible population criteria for Rate 1 – Initiation Phase.

Step 2

Calculate continuous enrollment. Children must be continuously enrolled for 120 days (4 months) 

prior to the IPSD and 300 days (10 months) after the IPSD.

Step 3

Calculate the continuous medication treatment. Using the children in Step 2, determine if the child 

was dispensed a sufficient number of prescriptions to provide continuous treatment for at least 210 

days out of the 301-day period beginning on the IPSD through 300 days after the IPSD. The 
166

Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder 

(ADHD) Medication (ADD-CH)

definition of “continuous medication treatment” allows gaps in medication treatment, up to a total of 

91 days during the 301-day (10-month) period. 

Gaps can include either washout period gaps to change medication or treatment gaps to refill the 

same medication.

Regardless of the number of gaps, the total gap days may be no more than 91. Count any 

combination of gaps (e.g., one washout gap of 14 days and numerous weekend drug holidays).

Step 4

Remove children who had an acute inpatient encounter for a mental, behavioral, or 

neurodevelopmental disorder during the 300 days (10 months) after the IPSD. Either of the following 

meets criteria: 

An acute inpatient encounter (Acute Inpatient Value Set) with a principal diagnosis of mental, 

behavioral, or neurodevelopmental disorder (Mental, Behavioral, and Neurodevelopmental 

Disorders Value Set)

An acute inpatient discharge with a principal diagnosis of mental, behavioral, or neurodevelopmental 

disorder (Mental, Behavioral, and Neurodevelopmental Disorders Value Set) on the discharge 

claim. To identify an acute inpatient discharge: 

Identify all acute and nonacute inpatient stays (Inpatient Stay Value Set).

Exclude nonacute inpatient stays (Nonacute Inpatient Stay Value Set).

Identify the discharge date for the stay. 

Numerator

Identify all children who meet the following criteria: 

Numerator compliant for Rate 1 Initiation Phase, and

At least two follow-up visits on different dates of service with any practitioner, from 31–300 days (9 

months) after the IPSD

Any of the following code combinations identify follow-up visits:

An outpatient visit (Visit Setting Unspecified Value Set with Outpatient POS Value Set)

An outpatient visit (BH Outpatient Value Set)

An observation visit (Observation Value Set)

A health and behavior assessment or intervention (Health and Behavior Assessment or Intervention 

Value Set)

An intensive outpatient encounter or partial hospitalization (Visit Setting Unspecified Value Set with 

Partial Hospitalization POS Value Set)

An intensive outpatient encounter or partial hospitalization (Partial Hospitalization or Intensive 

Outpatient Value Set)

A community mental health center visit (Visit Setting Unspecified Value Set with Community 

Mental Health Center POS Value Set)

A telehealth visit (Visit Setting Unspecified Value Set with Telehealth POS Value Set)

A telephone visit (Telephone Visits Value Set)

An e-visit or virtual check-in (Online Assessments Value Set)

Only one of the two visits (during days 31–300 after the IPSD) may be an e-visit or virtual check-in 

(Online Assessments Value Set).
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Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder 

(ADHD) Medication (ADD-CH)

E. ADDITIONAL NOTES

For children who have multiple overlapping prescriptions, count the overlap days once toward the 

days supply (whether the overlap is for the same drug or for a different drug). 

There may be different methods for billing intensive outpatient encounters and partial 

hospitalizations. Some methods may be comparable to outpatient billing, with separate claims for 

each date of service; others may be comparable to inpatient billing, with an admission date, a 

discharge date and units of service. Where billing methods are comparable to inpatient billing, each 

unit of service may be counted as an individual visit. The unit of service must have occurred during 

the period required for the rate (e.g., within 30 days after or from 31–300 days after the IPSD).
168

Supplemental Materials for Hemoglobin A1C Control for Patients with Diabetes (HBDAD)

Important Supplemental Materials for State-Collected Required

BHC Measures derived from CMS Medicaid Adult and/or Child 

Core Set Measures (HBD-AD)

These supplemental materials are necessary for implementation of the State-Collected Required 

BHC Measures that are derived from the CMS Medicaid Adult and/or Child Core Set Measures. 

This volume includes the exact specifications that are on the CMS website for the 2023 Medicaid 

Core Set, with simple modifications noted in the text. Limited additional needed modifications 

are included below, as well as supplemental useful materials.

Changes directly in the specifications: For all Core Set-derived measures, the changes in the 

specification from the CMS Medicaid Adult or Child Core Set reflect: (1) substitution of the 

word “client” for “beneficiary” or “patient”, unless the latter is part of a copyrighted code 

description; (2) removal of age stratification for adults (i.e., applicable to adults ages 18 years 

and older); and (3) removal of most references to the Core Set.

Additional needed modifications specific to each measure are included below, as well as 

supplemental useful materials.

Measure HBD-AD: Hemoglobin A1C Control for Patients with Diabetes

Additional information: The following material is provided to assist clinics using the 

specifications and follows the numbering system used in the non-Core derived BHC 

specifications:

A. DESCRIPTION

Important Reporting Guidance:

• The HBD-AD measure is to be used to measure performance related to clients seen at the 

BHC Provider during the Measurement Year.

• Current value sets are available on the CMS Medicaid Adult Core Set Reporting 

Resource website. Use the version current for the year being reported.

• HBD-AD is stratified separately based on whether the client is:

o Medicaid only or Other (including those dually eligible for Medicare and 

Medicaid)

AND

o A member of which of the following ethnic groups: Not Hispanic or Latino, 

Hispanic or Latino, or Unknown

AND

o A member of which of the following racial groups: White or Caucasian, Black or 

African American, American Indian or Alaska Native, Asian, Native Hawaiian or 

Other Pacific Islander, More than one race, or Unknown
169

Supplemental Materials for Hemoglobin A1C Control for Patients with Diabetes (HBDAD)

• Refer to the specific data-reporting template for the reporting requirements applicable to 

each measure.

Measurement Period: The Measurement Period is the period for which data are required for 

reporting purposes. For the HBD-AD measure, the denominator Measurement Period is the 

Measurement Year but, data from the entire year previous to the Measurement Year also is 

used in order to identify the diabetes diagnosis. For the HBD-AD numerator, the 

Measurement Period is the Measurement Year.

B. DEFINITIONS

TERM DEFINITION 

Measurement Period

The specific time period for which data are needed for the 

numerator and denominator of a given measure. The Measurement 

Period may differ for the numerator and denominator and for each 

measure and is specified in section A above.

Measurement Year The standard 12-month reporting period common to all measures 

being reported by the Provider.

Percentage A Percentage is calculated as follows: numerator divided by 

denominator (n/d).

Provider The Provider entity that is being measured (i.e., BHC) 

E. ADDITIONAL NOTES

Interpretation of scores: Better quality = Higher Percentage

F. FREQUENTLY ASKED QUESTIONS

None
170

Hemoglobin A1C Control for Patients with Diabetes (HBD-AD) 

Measure HBD-AD: Hemoglobin A1c Control for Patients with Diabetes8,16

Based on a CMS Medicaid Adult Core Set Measure (2023), which is derived from a measure stewarded 

by the National Committee for Quality Assurance (NCQA) 

A. DESCRIPTION

Percentage of beneficiaries [clients] ages 18 to 75 with diabetes (type 1 and type 2) whose

hemoglobin A1c (HbA1c) was at the following levels during the measurement year:

• HbA1c control (<8.0%)

• HbA1c poor control (>9.0%)

Note: States must use the same data collection method (Administrative or Hybrid) to report these 

indicators.

Data Collection Method: Administrative, Hybrid, or EHR

Guidance for Reporting:

For HEDIS, this measure applies to beneficiaries [clients] ages 18 to 75. For the purpose of Adult 

Core Set reporting, states should calculate and report this measure for two age groups (as 

applicable): ages 18 to 64 and ages 65 to 75.

Include all paid, suspended, pending, and denied claims.

This measure includes an optional exclusion for beneficiaries [clients] who die during the 

measurement year. For additional information, refer to the deceased beneficiary [client] 

exclusion guidance in Section II. Data Collection and Reporting of the Adult Core Set 

[Section III. Technical Specification Components].

NCQA’s Medication List Directory (MLD) for Dementia Medications and Diabetes Medications 

is available to order free of charge in the NCQA Store (https://store.ncqa.org/hedis-my-2022-

medication-list-directory.html). [Use version current for year reporting.] Once ordered, the 

Medication List Directory can be accessed through the NCQA Download Center

(https://my.ncqa.org/Downloads). 

The electronic specification for FFY 2023 is located on the eCQI resource center at 

https://ecqi.healthit.gov/ecqm/ec/2022/cms122v10. [Use version current for year reporting.] 

States that use electronic specifications should indicate this by selecting “Electronic Health 

Records” in the Data Source section of the online reporting system [template].

This measure’s Value Set Directory includes the following coding systems for services, procedures, 

and diagnoses: CPT, HCPCS, ICD-10-CM, LOINC, Modifier, POS, SNOMED, and UB. The 

Medication List Directory includes the following coding systems for medications: NDC and 

RxNorm. Refer to the Acknowledgments section at the beginning of the manual for copyright 

information.

16Aside from the minor modifications noted in this specification, this specification is taken directly from the 2023 

CMS Medicaid Adult Core Set Measures. Use the most current version for the year being reported. 

See also Important Supplemental Materials for State-Collected Required BHC Measures derived from CMS 

Medicaid Adult and/or Child Core Set Measures (in this manual immediately before this specification). 

8 The NCQA HEDIS® measure specification has been adjusted pursuant to NCQA’s Rules for Allowable 

Adjustments of HEDIS. 
171

Hemoglobin A1C Control for Patients with Diabetes (HBD-AD)

B. ELIGIBLE POPULATION

Age Ages 18 to 75 as of December 31 of the measurement year.

Continuous 

enrollment

The measurement year.

Allowable gap No more than one gap in enrollment of up to 45 days during the measurement 

year. To determine continuous enrollment for a beneficiary [client] for whom 

enrollment is verified monthly, the beneficiary [client] may not have more 

than a 1-month gap in coverage (e.g., a beneficiary [client] whose coverage 

lapses for 2 months [60 days] is not considered continuously enrolled).

Anchor date December 31 of the measurement year.

Benefit Medical.

Event/diagnosis There are two ways to identify beneficiaries [clients] with diabetes: by 

claim/encounter data and by pharmacy data. The state must use both methods 

to identify the eligible population, but a beneficiary [client] only needs to be 

identified by one method to be included in this measure. Beneficiaries

[Clients] may be identified as having diabetes during the measurement year or 

the year prior to the measurement year.

Claim/encounter data. Beneficiaries [Clients] who met any of the following 

criteria during the measurement year or year prior to the measurement year 

(count services that occur over both years):

At least one acute inpatient encounter (Acute Inpatient Value Set) with a 

diagnosis of diabetes (Diabetes Value Set) without telehealth (Telehealth 

Modifier Value Set; Telehealth POS Value Set)

At least one acute inpatient discharge with a diagnosis of diabetes (Diabetes 

Value Set) on the discharge claim. To identify an acute inpatient discharge:

1. Identify all acute and nonacute inpatient stays (Inpatient Stay Value

Set).

2. Exclude nonacute inpatient stays (Nonacute Inpatient Stay Value Set).

3. Identify the discharge date for the stay.

At least two outpatient visits (Outpatient Value Set), observation visits 

(Observation Value Set), telephone visits (Telephone Visits Value Set), evisits or virtual check-ins (Online Assessments Value Set), ED visits (ED 

Value Set), nonacute inpatient encounters (Nonacute Inpatient Value Set), 

or nonacute inpatient discharges (instructions below; the diagnosis must be 

on the discharge claim), on different dates of service, with a diagnosis of 

diabetes (Diabetes Value Set). Visit type need not be the same for the two 

encounters. To identify a nonacute inpatient discharge:

1. Identify all acute and nonacute inpatient stays (Inpatient Stay Value

Set).

2. Confirm the stay was for nonacute care based on the presence of a

nonacute code (Nonacute Inpatient Stay Value Set) on the claim.

3. Identify the discharge date for the stay.

Only include nonacute inpatient encounters (Nonacute Inpatient Value Set) 

without telehealth (Telehealth Modifier Value Set; Telehealth POS Value 

Set).
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Hemoglobin A1C Control for Patients with Diabetes (HBD-AD)

Event/diagnosis 

(continued)

Pharmacy data. Beneficiaries [Clients] who were dispensed insulin or 

hypoglycemics/antihyperglycemics on an ambulatory basis during the 

measurement year or year prior to the measurement year (Diabetes 

Medications List, see link to the Medication List Guidance for Reporting 

above).

Required 

exclusions 

Exclude beneficiaries [clients] who meet any of the following criteria:

• Beneficiaries [Clients] who do not have a diagnosis of diabetes (Diabetes

Value Set), in any setting, during the measurement year or the year prior

to the measurement year and who had a diagnosis of polycystic ovarian

syndrome, gestational diabetes or steroid-induced diabetes (Diabetes

Exclusions Value Set), in any setting, during the measurement year or the

year prior to the measurement year.

• Beneficiaries [Clients] in hospice or using hospice services anytime

during the measurement year. If a state reports this measure using the

Hybrid method, and a beneficiary [client] is found to be in hospice or

using hospice services during medical record review, the beneficiary

[client] is removed from the sample and replaced by a beneficiary [client]

from the oversample. For additional information, refer to the hospice

exclusion guidance in Section II. Data Collection and Reporting of the

Adult Core Set [Section III. Technical Specification Components].

• Beneficiaries [Clients] receiving palliative care (Palliative Care

Assessment Value Set; Palliative Care Encounter Value Set; Palliative

Care Intervention Value Set) during the measurement year.

Optional 

exclusion

Note: Supplemental and medical record data may not be used for this 

exclusion.

Exclude beneficiaries [clients] who meet of the following criteria: 

Beneficiaries [Clients] age 66 and older as of December 31 of the 

measurement year with frailty and advanced illness. Beneficiaries [Clients] 

must meet both of the following frailty and advanced illness criteria to be 

excluded: 

3. At least one claim/encounter for frailty (Frailty Device Value Set; Frailty

Diagnosis Value Set; Frailty Encounter Value Set; Frailty Symptom Value

Set) during the measurement year

4. Any of the following during the measurement year or the year prior to the

measurement year (count services that occur over both years):

At least two outpatient visits (Outpatient Value Set), observation visits

(Observation Value Set), ED visits (ED Value Set), telephone visits 

(Telephone Visits Value Set), e-visits or virtual check-ins (Online 

Assessments Value Set), nonacute inpatient encounters (Nonacute 

Inpatient Value Set), or nonacute inpatient discharges (instructions 

below; the diagnosis must be on the discharge claim) on different dates 

of service, with an advanced illness diagnosis (Advanced Illness Value 

Set). Visit type need not be the same for the two visits. To identify a 

nonacute inpatient discharge:
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Hemoglobin A1C Control for Patients with Diabetes (HBD-AD)

Optional 

exclusion 

(continued)

Identify all acute and nonacute inpatient stays (Inpatient Stay Value Set).

Confirm the stay was for nonacute care based on the presence of a nonacute 

code (Nonacute Inpatient Stay Value Set) on the claim.

Identify the discharge date for the stay.

At least one acute inpatient encounter (Acute Inpatient Value Set) with an 

advanced illness diagnosis (Advanced Illness Value Set)

At least one acute inpatient discharge with an advanced illness diagnosis 

(Advanced Illness Value Set) on the discharge claim. To identify an 

acute inpatient discharge:

1. Identify all acute and nonacute inpatient stays (Inpatient Stay

Value Set).

2. Exclude nonacute inpatient stays (Nonacute Inpatient Stay Value

Set).

3. Identify the discharge date for the stay.

A dispensed dementia medication (Dementia Medications List, see link to 

the Medication List Directory in Guidance for Reporting above)

C. ADMINISTRATIVE SPECIFICATION

Denominator

The eligible population as defined above.

Numerators

Numerator 1: HbA1c Control <8%

Use codes (HbA1c Lab Test Value Set; HbA1c Test Result or Finding Value Set) to identify the

most recent HbA1c test during the measurement year. The beneficiary [client] is not numerator

compliant if the most recent HbA1c level is <8.0%. The beneficiary [client] is not numerator

compliant if the result for the most recent HbA1c test is ≥ 8.0% or is missing a result, or if an

HbA1c test was not done during the measurement year.

States that use CPT Category II codes to identify numerator compliance for this indicator must

search for all codes in the following value sets and use the most recent code during the measurement

year to evaluate whether the beneficiary [client] is numerator compliant.

Value Set Numerator 1 Compliance

HbA1c Level Less Than 7.0 Value Set Compliant

HbA1c Level Greater Than or Equal To 7.0 and 

Less Than 8.0 Value Set Compliant

HbA1c Level Greater Than or Equal To 8.0 and 

Less Than or Equal To 9.0 Value Set Not compliant

HbA1c Level Greater Than 9.0 Value Set Not compliant

Numerator 2: HbA1c Poor Control >9%

Use codes (HbA1c Lab Test Value Set; HbA1c Test Result or Finding Value Set) to identify the 

most recent HbA1c test during the measurement year. The beneficiary [client] is numerator 

compliant if the most recent HbA1c level is >9.0% or is missing a result, or if an HbA1c test was not 
174

Hemoglobin A1C Control for Patients with Diabetes (HBD-AD)

done during the measurement year. The beneficiary [client] is not numerator compliant if the result 

for the most recent HbA1c test during the measurement year is ≤ 9.0%.

States that use CPT Category II codes to identify numerator compliance for this indicator must 

search for all codes in the following value sets and use the most recent code during the measurement 

year to evaluate whether the beneficiary [client] is numerator compliant.

Value Set Numerator 2 Compliance

HbA1c Level Less Than 7.0 Value Set Not compliant

HbA1c Level Greater Than or Equal To 7.0 and 

Less Than 8.0 Value Set Not compliant

HbA1c Level Greater Than or Equal To 8.0 and 

Less Than or Equal To 9.0 Value Set Not compliant

HbA1c Level Greater Than 9.0 Value Set Compliant

Note: A lower rate indicates better performance for this indicator (e.g., low rates of poor control 

indicate better care). 

D. HYBRID SPECIFICATION

Denominator

A systematic sample drawn from the eligible population. Refer to the sampling guidance under

Section II. Data Collection and Reporting of the Behavioral Health Clinic Quality Measures for

additional information.

Numerators

Numerator 1: HbA1c Control <8%

The most recent HbA1c level (performed during the measurement year) is <8.0% as identified by

laboratory data or medical record review.

Administrative Data

Refer to the Administrative Specification to identify positive numerator hits from administrative

data.

Medical Record Review

At a minimum, documentation in the medical record must include a note indicating the date when the

HbA1c test was performed and the result. The beneficiary [client] is numerator compliant if the

result for the most recent HbA1c level during the measurement year is <8.0%. The beneficiary

[client] is not numerator compliant if the most recent HbA1c level during the measurement year is ≥

8.0% or is missing, or if an HbA1c test was not performed during the measurement year.

Ranges and thresholds do not meet criteria for this measure. A distinct numeric result is required for

numerator compliance.

Numerator 2: HbA1c Poor Control >9%

The most recent HbA1c level (performed during the measurement year) is >9.0% or is missing, or

was not done during the measurement year, as documented through laboratory data or medical record

review.

Note: A lower rate indicates better performance (e.g., low rates of poor control indicate better care).
175

Hemoglobin A1C Control for Patients with Diabetes (HBD-AD)

Administrative Data

Refer to the Administrative Specification to identify positive numerator hits from administrative 

data.

Medical Record Review

At a minimum, documentation in the medical record must include a note indicating the date when the 

HbA1c test was performed and the result. The beneficiary [client] is numerator compliant if the 

result for the most recent HbA1c level during the measurement year is >9.0% or is missing, or if an 

HbA1c test was not done during the measurement year. The beneficiary [client] is not numerator 

compliant if the most recent HbA1c level during the measurement year is ≤ 9.0%.

Ranges and thresholds do not meet criteria for this measure. A distinct numeric result is required for 

numerator compliance.

E. ADDITIONAL NOTES

If a combination of administrative, supplemental, or hybrid data are used, the most recent result must 

be used, regardless of data source. 
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Supplemental Materials for Initiation and Engagement of Substance Use Disorder 

Treatment (IET-AD)

Important Supplemental Materials for State-Collected Required

BHC Measures derived from CMS Medicaid Adult and/or Child 

Core Set Measures (IET-AD)

These supplemental materials are necessary for implementation of the State-Collected Required 

BHC Measures that are derived from the CMS Medicaid Adult and/or Child Core Set Measures. 

This volume includes the exact specifications that are on the CMS website for the 2023 Medicaid 

Core Set, with simple modifications noted in the text. Limited additional needed modifications 

are included below, as well as supplemental useful materials.

Changes directly in the specifications: For all Core Set-derived measures, the changes in the 

specification from the CMS Medicaid Adult or Child Core Set reflect: (1) substitution of the 

word “client” for “beneficiary” or “patient”, unless the latter is part of a copyrighted code 

description; (2) removal of age stratification for adults (i.e., applicable to adults ages 18 years 

and older); and (3) removal of most references to the Core Set.

Additional needed modifications specific to each measure are included below, as well as 

supplemental useful materials.

Measure IET-AD: Initiation and Engagement of Substance Use Disorder Treatment

Additional information: The following material is provided to assist clinics using the 

specifications and follows the numbering system used in the non-Core derived BHC 

specifications:

A. DESCRIPTION

Important Reporting Guidance:

• The IET-AD measure is to be used to measure performance related to clients seen at the 

BHC Provider during the Measurement Year.

• Current value sets are available on the CMS Medicaid Adult Core Set Reporting 

Resource website. Use the version current for the year being reported.

• IET-AD is stratified separately based on whether the client is:

o Medicaid only or Other (including those dually eligible for Medicare and 

Medicaid)

AND

o A member of which of the following ethnic groups: Not Hispanic or Latino, 

Hispanic or Latino, or Unknown

AND
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Supplemental Materials for Initiation and Engagement of Substance Use Disorder 

Treatment (IET-AD)

o A member of which of the following racial groups: White or Caucasian, Black or 

African American, American Indian or Alaska Native, Asian, Native Hawaiian or 

Other Pacific Islander, More than one race, or Unknown

• Refer to the specific data-reporting template for the reporting requirements applicable to 

each measure.

Measurement Period: The Measurement Period is the period for which data are required for 

reporting purposes. For the IET-AD measure denominator, two measurement periods are 

used:

• The SUD Episode Date Measurement Period is November 15 of the prior year 

through November 14 of the Measurement Year (using a calendar year as the 

Measurement Year).

• The Negative SUD Diagnosis and Medication History Review Measurement Period 

begins 194 days prior to the SUD Episode date.

For the numerator, two measurement periods are used:

• The Measurement Period for Initiation is the period within 14 days of the SUD 

Episode date

• The Measurement Period for Engagement is the period beginning the day after the 

Initiation encounter through 34 days after the Initiation event (inclusive).

B. DEFINITIONS

TERM DEFINITION 

Measurement Period

The specific time period for which data are needed for the 

numerator and denominator of a given measure. The Measurement 

Period may differ for the numerator and denominator and for each 

measure and is specified in section A above.

Measurement Year The standard 12-month reporting period common to all measures 

being reported by the Provider.

Percentage A Percentage is calculated as follows: numerator divided by 

denominator (n/d).

Provider The Provider entity that is being measured (i.e., BHC) 

E. ADDITIONAL NOTES

Interpretation of scores: Better quality = Higher Percentage

F. FREQUENTLY ASKED QUESTIONS

Question related to client age:

Q: What if the client is 17 when he or she is admitted but turns 18 within a week. How is that

client counted in the Initiation and Engagement measure?

A: For each measure, the Technical Specification Manual provides instructions on how to

ascertain age (e.g., the first day of the Measurement Year, the last day of the Measurement 
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Supplemental Materials for Initiation and Engagement of Substance Use Disorder 

Treatment (IET-AD)

Year, the day that a specific service is provided). For the IET-AD measure, age is 

determined as of the “SUD Episode Date.” The measure defines the SUD Episode Date 

variously as the date of service or the date of discharge, depending on the setting. So, if, on 

July 17, a 17-year old is admitted to an inpatient stay, turns 18 on July 19, and is 

discharged on July 20, the person is 18 for purposes of the IET-AD denominator. In 

contrast, if the 17-year old seen in an outpatient setting on July 17, he or she is treated as 

17 and not included in the denominator.

Question related to using alternatives to SNOMED codes:

Q: CCBHCs in our state provide services identified in the Value Sets using SNOMED codes 

but our CCBHCs do not use SNOMED codes. Are they allowed to interpret the

SNOMED codes into codes that they actually use?

A: For purposes of the CCBHC demonstration, because this is a measure that is calculated 

and reported by the state, if the CCBHCs use other codes, the state will want to make sure

it has a mechanism to capture them. In situations such as this, the state should identify

these codes and make them available to all CCBHCs so that reporting is consistent. We 

ask for consistency and transparency and that the state provide this information to 

SAMHSA in the section of the reporting template for “Additional Notes,” so that the 

national evaluator has accurate information.
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Initiation and Engagement of Substance Use Disorder Treatment (IET-AD)

Measure IET-AD: Initiation and Engagement of Substance Use Disorder 

Treatment8,16

Based on a CMS Medicaid Adult Core Set Measure (2023), which is derived from a measure 

stewarded by the National Committee for Quality Assurance (NCQA) 

A. DESCRIPTION

Percentage of new substance use disorder (SUD) episodes that result in treatment initiation and

engagement. Two rates are reported:

• Initiation of SUD Treatment. The percentage of new SUD episodes that result in treatment

initiation through an inpatient SUD admission, outpatient visit, intensive outpatient encounter,

partial hospitalization, telehealth visit, or medication treatment within 14 days.

• Engagement of SUD Treatment. The percentage of new SUD episodes that have evidence of

treatment engagement within 34 days of initiation.

Data Collection Method: Administrative or EHR

16Aside from the minor modifications noted in this specification, this specification is taken directly from the 2023 

CMS Medicaid Adult Core Set Measures. Use the most current version for the year being reported. 

See also Important Supplemental Materials for State-Collected Required BHC Measures derived from CMS 

Medicaid Adult and/or Child Core Set Measures (in this manual immediately before this specification). 

8The NCQA HEDIS® measure specification has been adjusted pursuant to NCQA’s Rules for Allowable 

Adjustments of HEDIS. 
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Initiation and Engagement of Substance Use Disorder Treatment (IET-AD)

Guidance for Reporting:

For HEDIS, this measure has three reportable age groups and a total rate: ages 13 to 17, ages 18 to 

64, age 65 and older, and total (age 13 and older). For the purpose of Adult Core Set [BHC] 

reporting, this measure should be calculated for beneficiaries [clients] age 18 and older. States 

should calculate and report each of the rates for two age groups (as applicable): ages 18 to 64 

and age 65 and older.

Two rates are reported: initiation of SUD treatment and engagement of SUD treatment. For each 

rate, report the following SUD diagnosis cohorts for each age group:

- Alcohol use disorder

- Opioid use disorder

- Other substance use disorder

- Total (The total is the sum of the SUD diagnosis cohort stratifications)

Exclude beneficiaries [clients] from the denominator for both rates (initiation of SUD treatment 

and engagement of SUD treatment) if the initiation of treatment event is an inpatient stay with 

a discharge date after November 27 of the measurement year.

Include all paid, suspended, pending, and denied claims.

This measure includes an optional exclusion for beneficiaries [clients] who die during the 

measurement year. For additional information, refer to the deceased beneficiary [client] 

exclusion guidance in Section II. Data Collection and Reporting of the Adult Core Set 

[Section III. Technical Specification Components].

This measure requires that medication assisted treatment (MAT) services match the diagnosis 

category of the index episode identified in the denominator in order to count towards the 

numerator of the engagement rate. Depending on the diagnosis used in the denominator (e.g., 

opioid abuse or dependence and alcohol abuse and dependence), a corresponding MAT 

medication should be used to satisfy the numerator.

NCQA’s Medication List Directory (MLD) for Alcohol Use Disorder Treatment Medications and 

Opioid Use Disorder Treatment Medications is available to order free of charge in the NCQA 

Store (https://store.ncqa.org/hedis-my-2022-medication-list-directory.html). [Use version 

current for year reporting.] Once ordered, the Medication List Directory can be accessed 

through the NCQA Download Center (https://my.ncqa.org/Downloads).

The electronic specification for FFY 2023 is located on the eCQI resource center at 

https://ecqi.healthit.gov/ecqm/ec/2022/cms137v10. [Use version current for year reporting.] 

States that use electronic specifications should indicate this by selecting “Electronic Health 

Records” in the Data Source section of the online reporting [template]system.

This measure’s Value Set Directory includes the following coding systems for services, procedures, 

and diagnoses: CPT, HCPCS, ICD-10-CM, ICD-10-PCS, POS, SNOMED, and UB. The Medication 

List Directory includes the following coding systems for medications: NDC and RxNorm. Refer to 

the Acknowledgments section at the beginning of the manual for copyright information. 
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Initiation and Engagement of Substance Use Disorder Treatment (IET-AD)

B. DEFINITIONS

Intake period November 15 of the year prior to the measurement year to November 14 of the 

measurement year. The Intake Period is used to capture new SUD episodes 

SUD Episode An encounter during the Intake Period with a diagnosis of SUD.

For visits that result in an inpatient stay, the inpatient discharge is the SUD 

Episode (an SUD diagnosis is not required for the inpatient stay; use the 

diagnosis from the visit that resulted in the inpatient stay to determine the 

diagnosis cohort).

SUD Episode 

Date

The date of service for an encounter during the Intake period with a diagnosis 

of SUD.

For an outpatient, intensive outpatient, partial hospitalization, observation, 

telehealth, or ED visit (not resulting in an inpatient stay), the SUD Episode 

Date is the date of service.

For an inpatient stay or for medically managed withdrawal events (i.e., 

detoxification) that occurred during an inpatient stay, the SUD Episode Date is 

the date of discharge.

For medically managed withdrawal (i.e., detoxification), other than those that 

occurred during an inpatient stay, the SUD Episode Date is the date of service.

For direct transfers, the SUD Episode Date is the discharge date from the last 

admission (an SUD diagnosis is not required for the transfer; use the diagnosis 

from the initial admission to determine the diagnosis cohort).

Dates of service 

for services 

billed weekly or 

monthly

For an opioid treatment service that bills monthly or weekly (OUD Weekly 

Non Drug Service Value Set; OUD Monthly Office Based Treatment Value 

Set; OUD Weekly Drug Treatment Service Value Set), if the service includes 

a range of dates, then use the earliest date as the date of service. Use this date 

for all relevant events (the SUD Episode Date, negative diagnosis history and 

numerator events). 

Direct transfer A direct transfer is when the discharge date from the first inpatient setting 

precedes the admission date to a second inpatient setting by one calendar day 

or less. For example: 

An inpatient discharge on June 1, followed by an admission to another 

inpatient setting on June 1, is a direct transfer.

An inpatient discharge on June 1, followed by an admission to an inpatient 

setting on June 2, is a direct transfer.

An inpatient discharge on June 1, followed by an admission to another 

inpatient setting on June 3, is not a direct transfer; these are two distinct 

inpatient stays.

Use the following method to identify admissions to and discharges from 

inpatient settings.

1. Identify all acute and nonacute inpatient stays (Inpatient Stay Value Set).

2. Identify the admission and discharge dates for the stay.
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Initiation and Engagement of Substance Use Disorder Treatment (IET-AD)

C. ELIGIBLE POPULATION

Age Age 18 and older as of the SUD Episode Date. 

SUD diagnosis 

cohort 

stratification

Report the following SUD diagnosis cohort stratifications and a total:

• Alcohol use disorder

• Opioid use disorder

• Other substance use disorder

• Total (The total is the sum of the SUD diagnosis cohort stratifications)

Continuous 

enrollment

194 days prior to the SUD Episode Date through 47 days after the SUD Episode 

Date (242 total days).

Allowable gap No allowable gaps in the continuous enrollment period.

Anchor date None.

Benefits Medical, pharmacy, and chemical dependency (inpatient and outpatient).

Note: Beneficiaries [Clients] with detoxification-only chemical dependency 

benefits do not meet these criteria.
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Initiation and Engagement of Substance Use Disorder Treatment (IET-AD)

Event/

diagnosis

New episode of SUD during the Intake Period.

Follow the steps below to identify the denominator for both rates.

Step 1

Identify all SUD episodes. Any of the following meet criteria:

An outpatient visit (Visit Setting Unspecified Value Set) with (Outpatient POS

Value Set) and with one of the following: Alcohol Abuse and Dependence

Value Set, Opioid Abuse and Dependence Value Set, Other Drug Abuse and 

Dependence Value Set

An outpatient visit (BH Outpatient Value Set) with one of the following: Alcohol 

Abuse and Dependence Value Set, Opioid Abuse and Dependence Value Set, 

Other Drug Abuse and Dependence Value Set

An intensive outpatient encounter or partial hospitalization (Visit Setting 

Unspecified Value Set) with (Partial Hospitalization POS Value Set) and with

one of the following: Alcohol Abuse and Dependence Value Set, Opioid Abuse 

and Dependence Value Set, Other Drug Abuse and Dependence Value Set

An intensive outpatient encounter or partial hospitalization (Partial Hospitalization 

or Intensive Outpatient Value Set) with one of the following: Alcohol Abuse and 

Dependence Value Set, Opioid Abuse and Dependence Value Set, Other Drug 

Abuse and Dependence Value Set

A non-residential substance abuse treatment facility visit (Visit Setting Unspecified 

Value Set) with (Non-residential Substance Abuse Treatment Facility POS 

Value Set) and with one of the following: Alcohol Abuse and Dependence 

Value Set, Opioid Abuse and Dependence Value Set, Other Drug Abuse and 

Dependence Value Set

A community mental health center visit (Visit Setting Unspecified Value Set) with 

(Community Mental Health Center POS Value Set) and with one of the 

following: Alcohol Abuse and Dependence Value Set, Opioid Abuse and 

Dependence Value Set, Other Drug Abuse and Dependence Value Set

A telehealth visit (Visit Setting Unspecified Value Set) with (Telehealth POS Value 

Set) and with one of the following: Alcohol Abuse and Dependence Value Set, 

Opioid Abuse and Dependence Value Set, Other Drug Abuse and Dependence 

Value Set

A substance use disorder service (Substance Use Disorder Services Value Set) with 

one of the following: Alcohol Abuse and Dependence Value Set, Opioid Abuse 

and Dependence Value Set, Other Drug Abuse and Dependence Value Set

A medically managed withdrawal (i.e., detoxification) event (Detoxification Value 

Set) with one of the following: Alcohol Abuse and Dependence Value Set, 

Opioid Abuse and Dependence Value Set, Other Drug Abuse and Dependence 

Value Set
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Initiation and Engagement of Substance Use Disorder Treatment (IET-AD)

Event/

diagnosis 

(continued)

An ED visit (ED Value Set) with one of the following: Alcohol Abuse and 

Dependence Value Set, Opioid Abuse and Dependence Value Set, Other Drug 

Abuse and Dependence Value Set.

An observation visit (Observation Value Set) with one of the following: Alcohol 

Abuse and Dependence Value Set, Opioid Abuse and Dependence Value Set, 

Other Drug Abuse and Dependence Value Set.

An acute or nonacute inpatient discharge with one of the following on the discharge 

claim: Alcohol Abuse and Dependence Value Set, Opioid Abuse and 

Dependence Value Set, Other Drug Abuse and Dependence Value Set. To 

identify acute and nonacute inpatient discharges:

1. Identify all acute and nonacute inpatient stays (Inpatient Stay Value Set).

Identify the discharge date for the stay.

A telephone visit (Telephone Visits Value Set) with one of the following: Alcohol 

Abuse and Dependence Value Set, Opioid Abuse and Dependence Value Set, 

Other Drug Abuse and Dependence Value Set.

An e-visit or virtual check-in (Online Assessments Value Set) with one of the 

following: Alcohol Abuse and Dependence Value Set, Opioid Abuse and 

Dependence Value Set, Other Drug Abuse and Dependence Value Set.

An opioid treatment service (OUD Weekly Non Drug Service Value Set; OUD 

Monthly Office Based Treatment Value Set; OUD Weekly Drug Treatment 

Service Value Set) with a diagnosis of opioid abuse or dependence (Opioid 

Abuse and Dependence Value Set).

Step 2

Test for Negative SUD Diagnosis History. Exclude SUD episodes if there was an 

encounter in any setting other than an ED visit (ED Value Set) or a medically 

managed withdrawal (i.e., detoxification) event (Detoxification Value Set) with a 

diagnosis of SUD (Alcohol Abuse and Dependence Value Set, Opioid Abuse and 

Dependence Value Set, Other Drug Abuse and Dependence Value Set) during the 

194 days prior to the SUD Episode Date.

If the SUD Episode was an inpatient stay, use the admission date to determine 

Negative SUD History.

For visits with an SUD diagnosis that resulted in an inpatient stay (where the 

inpatient stay becomes the SUD Episode), use the earliest date of service to 

determine the Negative SUD Diagnosis History (so that the visit that resulted in the 

inpatient stay is not considered a positive diagnosis history).

For direct transfers, use the first admission date to determine the Negative SUD 

Diagnosis History.

Step 3

Test for Negative SUD Medication History. Exclude SUD episodes if either of the 

following occurred during the 194 days prior to the SUD Episode Date:
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Initiation and Engagement of Substance Use Disorder Treatment (IET-AD)

Event/

diagnosis

(continued)

An SUD medication treatment dispensing event (Alcohol Use Disorder Treatment 

Medications List; Naltrexone Injection Medications List; Buprenorphine Oral 

Medications List; Buprenorphine Injection Medications List; Buprenorphine 

Implant Medications List; Buprenorphine Naloxone Medications List, see link 

to the Medication List Directory in Guidance for Reporting above)

An SUD medication administration event (Naltrexone Injection Value Set, 

Buprenorphine Oral Value Set; Buprenorphine Oral Weekly Value Set; 

Buprenorphine Injection Value Set; Buprenorphine Naloxone Value Set; 

Buprenorphine Implant Value Set; Methadone Oral Value Set; Methadone Oral 

Weekly Value Set)

Step 4

Exclude SUD Episodes that do not meet continuous enrollment criteria. 

Beneficiaries [Clients] must be continuously enrolled from 194 days before the 

SUD Episode Date through 47 days after the SUD Episode Date (242 total days), 

with no gaps.

Note: The denominator for this measure is based on episodes, not on beneficiaries

[clients]. All eligible episodes that were not excluded remain in the denominator.

Step 5

Identify the SUD diagnosis cohort for each SUD Episode.

If the SUD Episode has a diagnosis of alcohol use disorder (Alcohol Abuse and 

Dependence Value Set), include the episode in the alcohol use disorder cohort.

If the SUD Episode has a diagnosis of opioid use disorder (Opioid Abuse and 

Dependence Value Set), include the episode in the opioid use disorder cohort.

If the SUD Episode has a diagnosis of SUD that is neither for opioid or alcohol 

(Other Drug Abuse and Dependence Value Set), place the beneficiary [client] in 

the other substance use disorder cohort.

Include SUD Episodes in all SUD diagnosis cohorts for which they meet criteria.

For example, if the SUD Episode has a diagnosis of alcohol use disorder and opioid 

use disorder, include the episode in the alcohol use disorder and opioid use disorder 

cohorts.

Required 

exclusion

Beneficiaries [Clients] in hospice or using hospice services anytime during the 

measurement year. For additional information, refer to the hospice exclusion 

guidance in Section II. Data Collection and Reporting of the Adult Core Set

[Section III. Technical Specification Components].

D. ADMINISTRATIVE SPECIFICATION

Denominator

The eligible population as defined above.

Numerators

Numerator 1: Initiation of SUD Treatment

Initiation of SUD treatment within 14 days of the SUD Episode Date.

Follow the steps below to identify numerator compliance.

Step 1

If the SUD Episode was an inpatient discharge, the inpatient stay is considered initiation of treatment

and the SUD Episode is compliant.
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Initiation and Engagement of Substance Use Disorder Treatment (IET-AD)

Step 2

If the SUD Episode was an opioid treatment service that bills monthly (OUD Monthly Office Based 

Treatment Value Set), the opioid treatment service is considered initiation of treatment and the SUD 

Episode is compliant.

Step 3

For remaining SUD Episodes (those not compliant after steps 1–2), identify episodes with at least 

one of the following on the SUD Episode Date or during the 13 days after the SUD Episode Date (14 

total days).

An acute or nonacute inpatient admission with a diagnosis (on the discharge claim) of one of the 

following: Alcohol Abuse and Dependence Value Set, Opioid Abuse and Dependence Value Set, 

Other Drug Abuse and Dependence Value Set. To identify acute and nonacute inpatient 

admissions:

Identify all acute and nonacute inpatient stays (Inpatient Stay Value Set).

Identify the admission date for the stay.

An outpatient visit (Visit Setting Unspecified Value Set) with (Outpatient POS Value Set) with one 

of the following: Alcohol Abuse and Dependence Value Set, Opioid Abuse and Dependence 

Value Set, Other Drug Abuse and Dependence Value Set

• An outpatient visit (BH Outpatient Value Set) with one of the following: Alcohol Abuse and 

Dependence Value Set, Opioid Abuse and Dependence Value Set, Other Drug Abuse and 

Dependence Value Set

• An intensive outpatient encounter or partial hospitalization (Visit Setting Unspecified Value Set) 

with (Partial Hospitalization POS Value Set) with one of the following: Alcohol Abuse and 

Dependence Value Set, Opioid Abuse and Dependence Value Set, Other Drug Abuse and 

Dependence Value Set

• An intensive outpatient encounter or partial hospitalization (Partial Hospitalization or Intensive 

Outpatient Value Set) with one of the following: Alcohol Abuse and Dependence Value Set, 

Opioid Abuse and Dependence Value Set, Other Drug Abuse and Dependence Value Set

• A non-residential substance abuse treatment Facility visit (Visit Setting Unspecified Value Set) 

with (Non-residential Substance Abuse Treatment Facility POS Value Set) with one of the 

following: Alcohol Abuse and Dependence Value Set, Opioid Abuse and Dependence Value 

Set, Other Drug Abuse and Dependence Value Set

• A community mental health center visit (Visit Setting Unspecified Value Set) with (Community 

Mental Health Center POS Value Set) with one of the following: Alcohol Abuse and 

Dependence Value Set, Opioid Abuse and Dependence Value Set, Other Drug Abuse and 

Dependence Value Set

• A telehealth visit: (Visit Setting Unspecified Value Set) with (Telehealth POS Value Set) with

one of the following: Alcohol Abuse and Dependence Value Set, Opioid Abuse and Dependence 

Value Set, Other Drug Abuse and Dependence Value Set

• A substance use disorder service (Substance Use Disorder Services Value Set) with one of the 

following: Alcohol Abuse and Dependence Value Set, Opioid Abuse and Dependence Value 

Set, Other Drug Abuse and Dependence Value Set

• Observation Value Set with one of the following: Alcohol Abuse and Dependence Value Set, 

Opioid Abuse and Dependence Value Set, Other Drug Abuse and Dependence Value Set
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Initiation and Engagement of Substance Use Disorder Treatment (IET-AD)

• A telephone visit (Telephone Visits Value Set) with one of the following: Alcohol Abuse and 

Dependence Value Set, Opioid Abuse and Dependence Value Set, Other Drug Abuse and 

Dependence Value Set 

• An e-visit or virtual check-in (Online Assessments Value Set) with one of the following: 

Alcohol Abuse and Dependence Value Set, Opioid Abuse and Dependence Value Set, Other 

Drug Abuse and Dependence Value Set

• A weekly or monthly opioid treatment service (OUD Weekly Non Drug Service Value Set; 

OUD Monthly Office Based Treatment Value Set; OUD Weekly Drug Treatment Service Value 

Set)

• For SUD Episodes in the alcohol use disorder cohort, an alcohol use disorder medication 

treatment dispensing event (Alcohol Use Disorder Treatment Medications List, see link to the 

Medication List Directory in Guidance for Reporting above) or a medication administration 

event (Naltrexone Injection Value Set)

• For SUD Episodes in the opioid use disorder cohort, an opioid use disorder medication treatment 

dispensing event (Naltrexone Oral Medications List; Naltrexone Injection Medications List; 

Buprenorphine Oral Medications List; Buprenorphine Injection Medications List; 

Buprenorphine Implant Medications List; Buprenorphine Naloxone Medications List, see link to 

the Medication List Directory in Guidance for Reporting above) or a medication administration 

event (Naltrexone Injection Value Set, Buprenorphine Oral Value Set, Buprenorphine Oral 

Weekly Value Set, Buprenorphine Injection Value Set, Buprenorphine Implant Value Set, 

Buprenorphine Naloxone Value Set, Methadone Oral Value Set, Methadone Oral Weekly Value 

Set)

For all initiation events except medication treatment dispensing events and medication 

administration events, initiation on the same day as the SUD Episode Date must be with different 

providers in order to count.

Exclude the beneficiary [client] from the denominator for both indicators (Initiation of SUD 

Treatment and Engagement of SUD Treatment) if the initiation of treatment event is an inpatient stay 

with a discharge date after November 27 of the measurement year.

Numerator 2: Engagement of SUD Treatment

Follow the steps below to identify numerator compliance. 

If Initiation of SUD Treatment was an inpatient admission, the 34-day period for engagement begins 

the day after discharge.

Step 1

Identify all SUD Episodes compliant for the Initiation of SUD Treatment numerator. SUD Episodes 

that are not compliant for Initiation of SUD Treatment are not compliant for Engagement of SUD 

Treatment.

Step 2

Identify SUD Episodes that had at least one weekly or monthly opioid treatment service with 

medication administration (OUD Monthly Office Based Treatment Value Set; OUD Weekly Drug 

Treatment Service Value Set) on the day after the initiation encounter through 34 days after the 

initiation event. The opioid treatment service is considered engagement of treatment and the SUD 

Episode is compliant.
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Initiation and Engagement of Substance Use Disorder Treatment (IET-AD)

Step 3

Identify SUD Episodes with long-acting SUD medication administration events on the day after the 

initiation encounter through 34 days after the initiation event. The long-acting SUD medication 

administration event is considered engagement of treatment and the SUD Episode is compliant. Any 

of the following meet criteria:

For SUD Episodes in the alcohol use disorder cohort, an alcohol use disorder medication treatment 

dispensing event (Naltrexone Injection Medications List, see link to the Medication List 

Directory in Guidance for Reporting above) or a medication administration event (Naltrexone 

Injection Value Set)

For SUD Episodes in the opioid use disorder cohort, an opioid use disorder medication treatment 

dispensing event (Naltrexone Injection Medications List; Buprenorphine Injection Medications 

List; Buprenorphine Implant Medications List, see link to the Medication List Directory in 

Guidance for Reporting above) or a medication administration event (Naltrexone Injection Value 

Set; Buprenorphine Injection Value Set; Buprenorphine Implant Value Set)

Step 4

For remaining SUD Episodes identify episodes with at least two of the following (any combination) 

on the day after the initiation encounter through 34 days after the initiation event:

• Engagement visit

• Engagement medication treatment event

Two engagement visits may 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 (there is no requirement that they be with different 

providers).

Refer to the descriptions below to identify engagement visits and engagement medication treatment 

events.

Engagement Visits

Any of the following meet criteria for an engagement visit:

An acute or nonacute inpatient admission with a diagnosis (on the discharge claim) of one of the 

following: Alcohol Abuse and Dependence Value Set, Opioid Abuse and Dependence Value Set, 

Other Drug Abuse and Dependence Value Set. To identify acute or nonacute inpatient 

admissions:

1. Identify all acute and nonacute inpatient stays (Inpatient Stay Value Set).

2. Identify the admission date for the stay.

An outpatient visit (Visit Setting Unspecified Value Set) with (Outpatient POS Value Set) with one 

of the following: Alcohol Abuse and Dependence Value Set, Opioid Abuse and Dependence 

Value Set, Other Drug Abuse and Dependence Value Set

An outpatient visit (BH Outpatient Value Set) with one of the following: Alcohol Abuse and 

Dependence Value Set, Opioid Abuse and Dependence Value Set, Other Drug Abuse and 

Dependence Value Set

An intensive outpatient encounter or partial hospitalization (Visit Setting Unspecified Value Set) 

with (Partial Hospitalization POS Value Set) with one of the following: Alcohol Abuse and 

Dependence Value Set, Opioid Abuse and Dependence Value Set, Other Drug Abuse and 

Dependence Value Set
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Initiation and Engagement of Substance Use Disorder Treatment (IET-AD)

An intensive outpatient encounter or partial hospitalization (Partial Hospitalization or Intensive 

Outpatient Value Set) with one of the following: Alcohol Abuse and Dependence Value Set, 

Opioid Abuse and Dependence Value Set, Other Drug Abuse and Dependence Value Set

A non-residential substance abuse treatment Facility visit (Visit Setting Unspecified Value Set) with 

(Non-residential Substance Abuse Treatment Facility POS Value Set) with one of the following: 

Alcohol Abuse and Dependence Value Set, Opioid Abuse and Dependence Value Set, Other 

Drug Abuse and Dependence Value Set

A community mental health center visit (Visit Setting Unspecified Value Set) with (Community 

Mental Health Center POS Value Set) with one of the following: Alcohol Abuse and 

Dependence Value Set, Opioid Abuse and Dependence Value Set, Other Drug Abuse and 

Dependence Value Set

A telehealth visit: (Visit Setting Unspecified Value Set) with (Telehealth POS Value Set) with one of 

the following: Alcohol Abuse and Dependence Value Set, Opioid Abuse and Dependence Value 

Set, Other Drug Abuse and Dependence Value Set

A substance use disorder service (Substance Use Disorder Services Value Set) with one of the 

following: Alcohol Abuse and Dependence Value Set, Opioid Abuse and Dependence Value Set, 

Other Drug Abuse and Dependence Value Set

Observation Value Set with one of the following: Alcohol Abuse and Dependence Value Set, Opioid 

Abuse and Dependence Value Set, Other Drug Abuse and Dependence Value Set

A telephone visit (Telephone Visits Value Set) with one of the following: Alcohol Abuse and 

Dependence Value Set, Opioid Abuse and Dependence Value Set, Other Drug Abuse and 

Dependence Value Set

An e-visit or virtual check-in (Online Assessments Value Set) with one of the following: Alcohol 

Abuse and Dependence Value Set, Opioid Abuse and Dependence Value Set, Other Drug Abuse 

and Dependence Value Set

An opioid treatment service (OUD Weekly Non Drug Service Value Set)

Engagement Medication Treatment Events

Either of the following meets criteria for an engagement medication treatment event:

For SUD Episodes in the alcohol use disorder cohort, an alcohol use disorder medication treatment 

dispensing event (Alcohol Use Disorder Treatment Medications List, see link to the Medication 

List Directory in Guidance for Reporting above)

For SUD Episodes in the opioid use disorder cohort, an opioid use disorder medication treatment 

dispensing event (Naltrexone Oral Medications List; Buprenorphine Oral Medications List; 

Buprenorphine Naloxone Medications List, see link to the Medication List Directory in 

Guidance for Reporting above) or a medication administration event (Buprenorphine Oral Value 

Set; Buprenorphine Oral Weekly Value Set; Buprenorphine Naloxone Value Set; Methadone 

Oral Value Set; Methadone Oral Weekly Value Set)

Opioid Use Disorder Treatment Medications 

Description Prescription Medication Lists

Antagonist Naltrexone (oral) Naltrexone Oral Medications List

Antagonist Naltrexone (injectable) Naltrexone Injection Medications List

Partial agonist Buprenorphine (sublingual tablet) Buprenorphine Oral Medications List
190

Initiation and Engagement of Substance Use Disorder Treatment (IET-AD)

Description Prescription Medication Lists

Partial agonist Buprenorphine (injection) Buprenorphine Injection Medications 

List

Partial agonist Buprenorphine (implant) Buprenorphine Implant Medications List

Partial agonist Buprenorphine/naloxone 

(sublingual tablet, buccal film, 

sublingual film)

Buprenorphine Naloxone Medications 

List 

E. ADDITIONAL NOTES

There may be different methods for billing intensive outpatient encounters and partial 

hospitalizations. Some methods may be comparable to outpatient billing, with separate claims 

for each date of service; others may be comparable to inpatient billing, with an admission date, a 

discharge date, and units of service. Where billing methods are comparable to inpatient billing, 

each unit of service may be counted as an individual visit. The unit of service must have 

occurred during the required time frame for the rate. 

Methadone is not included on the medication lists for this measure. Methadone for opioid use 

disorder (OUD) administered or dispensed by federally certified opioid treatment programs 

(OTP) is billed on a medical claim. A pharmacy claim for methadone would be indicative of 

treatment for pain rather than OUD.
191

Supplemental Materials for Follow-Up After Hospitalization for Mental Illness (FUH-AD

AND FUH-CH)

Important Supplemental Materials for State-Collected Required BHC 

Measures derived from CMS Medicaid Adult and/or Child Core Set 

Measures (FUH-AD and FUH-CH)

These supplemental materials are necessary for implementation of the State-Collected Required 

BHC Measures that are derived from the CMS Medicaid Adult and/or Child Core Set Measures. 

This volume includes the exact specifications that are on the CMS website for the 2023 Medicaid 

Core Set, with simple modifications noted in the text. Limited additional needed modifications 

are included below, as well as supplemental useful materials.

1. Measure FUH-AD: Follow-Up After Hospitalization for Mental Illness: Age 18 and 

Older

2. Measure FUH-CH: Follow-Up After Hospitalization for Mental Illness: Ages 6 to 17

Changes within the specifications: For both FUH measures, the changes within the CMS 

Medicaid Adult and Child Core Sets specifications reflect: (1) substitution of the word “client” 

for “beneficiary” or “patient”, unless the latter is part of a copyrighted code description; (2) 

removal of age stratification in the adult measure (i.e., applicable to adults ages 18 years and 

older); and (3) removal of references to the Core Set.

Additional information: For both the FUH measures, the following material is provided to assist 

clinics in using the specifications and follows the numbering system used in the non-Medicaid 

Core Set-derived BHC specifications:

A. DESCRIPTION

Important Reporting Guidance:

• Both the FUH-AD and FUD-CH measures are to be used by states to measure 

performance related to clients seen at the Provider during the Measurement Year. 

• Current value sets are available on the CMS Medicaid Adult Core Set Reporting 

Resource website and the CMS Medicaid Child Core Set Reporting Resource website. 

Use the version current for the year being reported.

• Both FUH-AD and FUH-CH are to be stratified separately based on whether the client is:

o Medicaid only or Other (including those dually eligible for Medicare and 

Medicaid)

AND

o A member of which of the following ethnic groups: Not Hispanic or Latino, 

Hispanic or Latino, or Unknown

AND

o A member of which of the following racial groups: White or Caucasian, Black or 

African American, American Indian or Alaska Native, Asian, Native Hawaiian or 

Other Pacific Islander, More than one race, or Unknown
192

Supplemental Materials for Follow-Up After Hospitalization for Mental Illness (FUH-AD

AND FUH-CH)

• Refer to the specific data-reporting template for the reporting requirements applicable to 

each measure.

Measurement Period: The Measurement Period is the period for which data are required for 

reporting purposes. The FUH-AD and FUH-CH measure denominators are both January 1 

through December 1, if the Measurement Year (MY) is the calendar year. The FUH-AD and 

FUH-CH measures include two submeasures, both of which are defined in the specification 

and both of which have a distinct Measurement Period for the numerator: (a) 7-Day Followup (7 days after discharge date) and (b) 30-Day Follow-up (30 days after discharge date).

B. DEFINITIONS

TERM DEFINITION 

Measurement Period

The specific time period for which data are needed for the 

numerator and denominator of a given measure. The Measurement 

Period may differ for the numerator and denominator and for each 

measure and is specified in section A above.

Measurement Year The standard 12-month reporting period common to all measures 

being reported by the Provider.

Percentage A Percentage is calculated as follows: numerator divided by 

denominator (n/d).

Provider The Provider entity that is being measured (i.e., BHC) 

E. ADDITIONAL NOTES

Interpretation of scores: Better quality = Higher Percentage

F. FREQUENTLY ASKED QUESTIONS

None
193

Follow-Up After Hospitalization for Mental Illness: Age 18 and Older (FUH-AD) 

Measure FUH-AD: Follow-Up After Hospitalization for Mental Illness: Age 18 and 

Older8,16

Based on a CMS Medicaid Adult Core Set Measure (2023), which is derived from a measure stewarded 

by the National Committee for Quality Assurance (NCQA) 

A. DESCRIPTION

Percentage of discharges for beneficiaries [clients] age 18 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 provider. Two rates are reported:

Percentage of discharges for which the beneficiary [client] received follow-up within 30 days after

discharge

Percentage of discharges for which the beneficiary [client] received follow-up within 7 days after

discharge

Data Collection Method: Administrative

16 Aside from the minor modifications noted in this specification, this specification is taken directly from the 2023 

CMS Medicaid Adult Core Set Measures. Use the most current version for the year being reported. 

See also Important Supplemental Materials for State-Collected Required BHC Measures derived from CMS 

Medicaid Adult and/or Child Core Set Measures (in this manual immediately before this specification). 

8 The NCQA HEDIS® measure specification has been adjusted pursuant to NCQA’s Rules for Allowable 

Adjustments of HEDIS. 
194

Follow-Up After Hospitalization for Mental Illness: Age 18 and Older (FUH-AD)

Guidance for Reporting:

For HEDIS, this measure has three reportable age groups and a total rate: ages 6 to 17, ages 18 to 

64, age 65 and older, and total (age 6 and older). The [Medicaid] Child Core Set measure 

applies to beneficiaries ages 6 to 17 and the {Medicaid] Adult Core Set measure applies to 

beneficiaries age 18 and older. For the purpose of Adult Core Set reporting, states should 

calculate and report this measure for two age groups (as applicable): ages 18 to 64 and age 65 

and older. . [For the purpose of Behavioral Health Clinic (BHC) reporting, states should 

calculate and report this adult measure as one age group: clients ages 18 years and older.]

Follow the detailed specifications to (1) include the appropriate discharge when the beneficiary

[client] was transferred directly or readmitted to an acute or non-acute care facility for a mental 

health diagnosis, and (2) exclude discharges in which the beneficiary [client] was transferred 

directly or readmitted to an acute or non-acute care facility for a non-mental health diagnosis.

The denominator for this measure should be the same for the 30-day rate and the 7-day rate. 

The 30-day follow-up rate should be greater than or equal to the 7-day follow-up rate within each 

age group.

This measure specifies that when a visit code or procedure code must be used in conjunction with 

a diagnosis code, both the visit/procedure code and the diagnosis code must be on the same 

claim or from the same visit.

This measure references value sets that include codes used on professional claims (e.g., CPT, 

HCPCS) and codes used on facility claims (e.g., UB). Diagnosis and procedure codes from 

both facility and professional claims should be used to identify services and diagnoses (the 

codes can be on the same claim or from the same visit).

For value sets that include codes used only on facility claims (e.g., UB), use facility claims 

only to identify services and diagnoses (the codes must be on the same claim).

Include all paid, suspended, pending, and denied claims.

This measure includes an optional exclusion for beneficiaries [clients] who die during the 

measurement year. For additional information, refer to the deceased beneficiary [client] 

exclusion guidance in Section II. Data Collection and Reporting of the Adult Core Set [Section 

III. Technical Specification Components].

Refer to [Appendix D of this manual] for the definition of a mental health provider. States must 

develop their own methods to identify mental health providers. 

This measure’s Value Set Directory includes the following coding systems for services, procedures, 

and diagnoses: CPT, HCPCS, ICD-10-CM, ICD-10-PCS, POS, SNOMED, and UB. Refer to the 

Acknowledgments section at the beginning of the manual for copyright information.

B. ELIGIBLE POPULATION

Age Age 18 and older as of date of discharge.

Continuous 

enrollment

Date of discharge through 30 days after discharge.

Allowable gap No allowable gaps in the continuous enrollment period.

Anchor date None.

Benefit Medical and mental health (inpatient and outpatient).
195

Follow-Up After Hospitalization for Mental Illness: Age 18 and Older (FUH-AD)

Event/diagnosis An acute inpatient discharge with a principal diagnosis of mental illness or 

intentional self-harm (Mental Illness Value Set; Intentional Self-Harm Value 

Set) on the discharge claim on or between January 1 and December 1 of the 

measurement year. 

To identify acute inpatient discharges:

1. Identify all acute and nonacute inpatient stays (Inpatient Stay Value Set).

Exclude nonacute inpatient stays (Nonacute Inpatient Stay Value Set).

Identify the discharge date for the stay.

The denominator for this measure is based on discharges, not on beneficiaries

[clients]. If beneficiaries [clients] have more than one discharge, include all 

discharges on or between January 1 and December 1 of the measurement year.

Acute 

readmission or 

direct transfer

Identify readmissions and direct transfers to an acute inpatient care setting 

during the 30-day follow-up period:

1. Identify all acute and nonacute inpatient stays (Inpatient Stay Value Set).

2. Exclude nonacute inpatient stays (Nonacute Inpatient Stay Value Set). 

3. Identify the admission date for the stay (the admission date must occur 

during the 30-day follow-up period).

4. Identify the discharge date for the stay.

Acute 

readmission or 

direct transfer 

(continued)

Exclude both the initial discharge and the readmission/direct transfer 

discharge if the last discharge occurs after December 1 of the measurement 

year.

If the readmission/direct transfer to the acute inpatient care setting was for a 

principal diagnosis (use only the principal diagnosis on the discharge claim) of 

mental health disorder or intentional self-harm (Mental Health Diagnosis 

Value Set; Intentional Self-Harm Value Set), count only the last discharge.

If the readmission/direct transfer to the acute inpatient care setting was for any 

other principal diagnosis (use only the principal diagnosis on the discharge 

claim) exclude both the original and the readmission/direct transfer discharge.

Nonacute 

readmission or 

direct transfer

Exclude discharges followed by readmission or direct transfer to a nonacute 

inpatient care setting within the 30-day follow-up period, regardless of 

principal diagnosis for the readmission. To identify readmissions and direct 

transfers to a nonacute inpatient care setting:

1. Identify all acute and nonacute inpatient stays (Inpatient Stay Value Set).

2. Confirm the stay was for nonacute care based on the presence of a 

nonacute code (Nonacute Inpatient Stay Value Set) on the claim. 

3. Identify the admission date for the stay.

These discharges are excluded from this measure because rehospitalization or 

direct transfer may prevent an outpatient follow-up visit from taking place.

Required 

exclusion

Beneficiaries [Clients] in hospice or using hospice services anytime during the 

measurement year. For additional information, refer to the hospice exclusion 

guidance in Section II. Data Collection and Reporting of the Adult Core Set

[Section III. Technical Specification Components].
196

Follow-Up After Hospitalization for Mental Illness: Age 18 and Older (FUH-AD)

C. ADMINISTRATIVE SPECIFICATION

Denominator

The eligible population as defined above. 

Numerators 

30-Day Follow-Up: A follow-up visit with a mental health provider within 30 days after discharge. 

Do not include visits that occur on the date of discharge.

7-Day Follow-Up: A follow-up visit with a mental health provider within 7 days after discharge. Do 

not include visits that occur on the date of discharge.

For both indicators, any of the following meet criteria for a follow-up visit.

An outpatient visit (Visit Setting Unspecified Value Set) with (Outpatient POS Value Set) with a 

mental health provider

An outpatient visit (BH Outpatient Value Set) with a mental health provider

An intensive outpatient encounter or partial hospitalization (Visit Setting Unspecified Value Set)

with (Partial Hospitalization POS Value Set)

An intensive outpatient encounter or partial hospitalization (Partial Hospitalization or Intensive 

Outpatient Value Set) 

A community mental health center visit (Visit Setting Unspecified Value Set; BH Outpatient Value 

Set; Observation Value Set; Transitional Care Management Services Value Set) with 

(Community Mental Health Center POS Value Set)

Electroconvulsive therapy (Electroconvulsive Therapy Value Set) with (Ambulatory Surgical Center 

POS Value Set; Community Mental Health Center POS Value Set; Outpatient POS Value Set; 

Partial Hospitalization POS Value Set)

A telehealth visit (Visit Setting Unspecified Value Set with Telehealth POS Value Set) with a mental 

health provider

An observation visit (Observation Value Set) with a mental health provider

Transitional care management services (Transitional Care Management Services Value Set) with a 

mental health provider

A visit in a behavioral healthcare setting (Behavioral Healthcare Setting Value Set)

A telephone visit (Telephone Visits Value Set) with a mental health provider

Psychiatric collaborative care management (Psychiatric Collaborative Care Management Value Set)

D. ADDITIONAL NOTES

There may be different methods for billing intensive outpatient visits and partial hospitalizations. 

Some methods may be comparable to outpatient billing, with separate claims for each date of 

service; others may be comparable to inpatient billing, with an admission date, a discharge date, and 

units of service. Where billing methods are comparable to inpatient billing, each unit of service may 

be counted as an individual visit. The unit of service must have occurred during the required period 

for the rate (e.g., within 30 days after discharge or within 7 days after discharge).
197

Follow-Up After Hospitalization for Mental Illness: Ages 6 to 17 (FUH-CH)

Measure FUH-CH: Follow-Up After Hospitalization for Mental Illness: Ages 6 to 

178,18

Based on a CMS Medicaid Child Core Set Measure (2023), which is derived from a measure 

stewarded by the National Committee for Quality Assurance (NCQA)

A. DESCRIPTION

Percentage of discharges for beneficiaries [clients] ages 6 to 17 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 provider. Two rates are reported:

Percentage of discharges for which the beneficiary [client] received follow-up within 30 days after

discharge

Percentage of discharges for which the beneficiary [client] received follow-up within 7 days after

discharge

Data Collection Method: Administrative

Guidance for Reporting: 

For HEDIS, this measure has three reportable age groups and a total rate: ages 6 to 17, ages 18 to 

64, age 65 and older, and total (age 6 and older). The [Medicaid] Child Core Set measure 

applies to beneficiaries ages 6 to 17 and the [Medicaid] Adult Core Set measure applies to 

beneficiaries age 18 and older. [For the purpose of Behavioral Health Clinic (BHC) reporting, 

states should calculate and report this child measure as one age group: clients ages 6 to 17 

years.]

Follow the detailed specifications to (1) include the appropriate discharge when the beneficiary

[client] was transferred directly or readmitted to an acute or non-acute care facility for a mental 

health diagnosis, and (2) exclude discharges in which the beneficiary [client] was transferred 

directly or readmitted to an acute or non-acute care facility for a non-mental health diagnosis.

The denominator for this measure should be the same for the 30-day rate and the 7-day rate. 

The 30-day follow-up rate should be greater than (or equal to) the 7-day follow-up rate.

This measure specifies that when a visit code or procedure code must be used in conjunction with 

a diagnosis code, both the visit/procedure code and the diagnosis code must be on the same 

claim or from the same visit.

This measure references value sets that include codes used on professional claims (e.g., CPT, 

HCPCS) and codes used on facility claims (e.g., UB). Diagnosis and procedure codes from 

both facility and professional claims should be used to identify services and diagnoses (the 

codes can be on the same claim or from the same visit). 

For value sets that include codes used only on facility claims (e.g., UB), use facility claims 

only to identify services and diagnoses (the codes must be on the same claim).

8The NCQA HEDIS® measure specification has been adjusted pursuant to NCQA’s Rules for Allowable 

Adjustments of HEDIS.

18Aside from the minor modifications noted in this specification, this specification is taken directly from the 2023 

CMS Medicaid Child Core Set Measures. Use the most current version for the year being reported. See also 

Important Supplemental Materials for State-Collected Required BHC Measures derived from CMS Medicaid Adult 

and/or Child Core Set Measures (in this manual immediately before this specification).
198

Follow-Up After Hospitalization for Mental Illness: Ages 6 to 17 (FUH-CH)

Include all paid, suspended, pending, and denied claims.

This measure includes an optional exclusion for beneficiaries [clients] who die during the 

measurement year. For additional information, refer to the deceased beneficiary [client]

exclusion guidance in Section II. Data Collection and Reporting of the Adult Core Set [Section 

III. Technical Specification Components].

Refer to [Appendix D of this manual] for the definition of a mental health provider. States must 

develop their own methods to identify mental health providers.

This measure’s Value Set Directory includes the following coding systems for services, procedures, 

and diagnoses: CPT, HCPCS, ICD-10-CM, ICD-10-PCS, POS, SNOMED, and UB. Refer to the 

Acknowledgments section at the beginning of the manual for copyright information. 

B. ELIGIBLE POPULATION

Age Ages 6 to 17 as of date of discharge.

Continuous 

enrollment

Date of discharge through 30 days after discharge.

Allowable gap No allowable gaps in the continuous enrollment period.

Anchor date None.

Benefit Medical and mental health (inpatient and outpatient).

Event/diagnosis An acute inpatient discharge with a principal diagnosis of mental illness or 

intentional self-harm (Mental Illness Value Set; Intentional Self-Harm Value 

Set) on the discharge claim on or between January 1 and December 1 of the 

measurement year. 

To identify acute inpatient discharges:

1. Identify all acute and nonacute inpatient stays (Inpatient Stay Value Set).

2. Exclude nonacute inpatient stays (Nonacute Inpatient Stay Value Set).

3. Identify the discharge date for the stay.

The denominator for this measure is based on discharges, not on beneficiaries

[clients]. If beneficiaries [clients] have more than one discharge, include all 

discharges on or between January 1 and December 1 of the measurement year.

Acute readmission 

or direct transfer

Identify readmissions and direct transfers to an acute inpatient care setting 

during the 30-day follow-up period: 

1. Identify all acute and nonacute inpatient stays (Inpatient Stay Value Set).

1. Exclude nonacute inpatient stays (Nonacute Inpatient Stay Value Set). 

2. Identify the admission date for the stay (the admission date must occur 

during the 30-day follow-up period).

3. Identify the discharge date for the stay.

Exclude both the initial discharge and the readmission/direct transfer discharge 

if the last discharge occurs after December 1 of the measurement year. 

If the readmission/direct transfer to the acute inpatient care setting was for a 

principal diagnosis (use only the principal diagnosis on the discharge claim) of 

mental health disorder or intentional self-harm (Mental Health Diagnosis Value 

Set; Intentional Self-Harm Value Set), count only the last discharge. 
199

Follow-Up After Hospitalization for Mental Illness: Ages 6 to 17 (FUH-CH)

Acute readmission 

or direct transfer 

(continued)

If the readmission/direct transfer to the acute inpatient care setting was for any 

other principal diagnosis (use only the principal diagnosis on the discharge 

claim) exclude both the original and the readmission/direct transfer discharge. 

Nonacute 

readmission or 

direct transfer

Exclude discharges followed by readmission or direct transfer to a nonacute 

inpatient care setting within the 30-day follow-up period, regardless of 

principal diagnosis for the readmission. To identify readmissions and direct 

transfers to a nonacute inpatient care setting:

Identify all acute and nonacute inpatient stays (Inpatient Stay Value Set).

4. Confirm the stay was for nonacute care based on the presence of a nonacute 

code (Nonacute Inpatient Stay Value Set) on the claim.

5. Identify the admission date for the stay.

These discharges are excluded from this measure because rehospitalization or 

direct transfer may prevent an outpatient follow-up visit from taking place.

Required exclusion Beneficiaries [Clients] in hospice or using hospice services anytime during the 

measurement year. For additional information, refer to the hospice exclusion 

guidance in Section II. Data Collection and Reporting of the Child Core Set

[Section III. Technical Specification Components]. 

C. ADMINISTRATIVE SPECIFICATION

Denominator

The eligible population as defined above.

Numerators

30 Day Follow-up: A follow-up visit with a mental health provider within 30 days after discharge. 

Do not include visits that occur on the date of discharge.

7 Day Follow-up: A follow-up visit with a mental health provider within 7 days after discharge. Do 

not include visits that occur on the date of discharge.

For both indicators, any of the following meet criteria for a follow-up visit.

An outpatient visit (Visit Setting Unspecified Value Set) with (Outpatient POS Value Set) with a 

mental health provider

An outpatient visit (BH Outpatient Value Set) with a mental health provider 

An intensive outpatient encounter or partial hospitalization (Visit Setting Unspecified Value Set)

with (Partial Hospitalization POS Value Set) 

An intensive outpatient encounter or partial hospitalization (Partial Hospitalization or Intensive 

Outpatient Value Set) 

A community mental health center visit (Visit Setting Unspecified Value Set; BH Outpatient Value 

Set; Observation Value Set; Transitional Care Management Services Value Set) with 

(Community Mental Health Center POS Value Set)

Electroconvulsive therapy (Electroconvulsive Therapy Value Set) with (Ambulatory Surgical Center 

POS Value Set; Community Mental Health Center POS Value Set; Outpatient POS Value Set; 

Partial Hospitalization POS Value Set) 

A telehealth visit (Visit Setting Unspecified Value Set) with (Telehealth POS Value Set) with a 

mental health provider 

An observation visit (Observation Value Set) with a mental health provider 
200

Follow-Up After Hospitalization for Mental Illness: Ages 6 to 17 (FUH-CH)

Transitional care management services (Transitional Care Management Services Value Set) with a 

mental health provider 

A visit in a behavioral healthcare setting (Behavioral Healthcare Setting Value Set)

A telephone visit (Telephone Visits Value Set) with a mental health provider

Psychiatric collaborative care management (Psychiatric Collaborative Care Management Value Set)

D. ADDITIONAL NOTES

There may be different methods for billing intensive outpatient visits and partial hospitalizations. 

Some methods may be comparable to outpatient billing, with separate claims for each date of 

service; others may be comparable to inpatient billing, with an admission date, a discharge date, and 

units of service. Where billing methods are comparable to inpatient billing, each unit of service may 

be counted as an individual visit. The unit of service must have occurred during the required period 

for the rate (e.g., within 30 days after discharge or within 7 days after discharge).
201

Supplemental Materials for Follow-Up After Emergency Department Visit for Mental 

Illness FUM-AD AND FUM-CH)

Important Supplemental Materials for State-Collected Required

BHC Measures derived from CMS Medicaid Adult and/or Child 

Core Set Measures (FUM-AD and FUM-CH)

These supplemental materials are necessary for implementation of the State-Collected Required 

BHC Measures that are derived from the CMS Medicaid Adult and/or Child Core Set Measures. 

This volume includes the exact specifications that are on the CMS website for the 2023 Medicaid 

Core Set, with simple modifications noted in the text. Limited additional needed modifications 

are included below, as well as supplemental useful materials.

1. Measure FUM-AD: Follow-Up After Emergency Department Visit for Mental 

Illness: Age 18 and Older

2. Measure FUM-CH: Follow-Up After Emergency Department Visit for Mental 

Illness: Ages 6 TO 17

For both FUM measures, the changes within the CMS Medicaid Adult and Child Core Sets 

specifications reflect: (1) substitution of the word “client” for “beneficiary” or “patient”, unless 

the latter is part of a copyrighted code description; (2) removal of age stratification in the adult 

measure (i.e., applicable to adults ages 18 years and older); and (3) removal of references to the 

Core Set.

Additional information: For both the FUM measures, the following material is provided to assist 

clinics in using the specifications and follows the numbering system used in the non-Medicaid 

Core Set-derived BHC specifications:

A. DESCRIPTION

Important Reporting Guidance:

• Both the FUM-AD and FUM-CH measures are to be used by states to measure 

performance related to clients seen at the Provider during the Measurement Year.

• Current value sets are available on the CMS Medicaid Adult Core Set Reporting 

Resource website and the CMS Medicaid Child Core Set Reporting Resource website. 

Use the version current for the year being reported.

• Both FUM-AD and FUM-CH are to be stratified separately based on whether the client 

is:

o Medicaid only or Other (including those dually eligible for Medicare and 

Medicaid)

AND

o A member of which of the following ethnic groups: Not Hispanic or Latino, 

Hispanic or Latino, or Unknown

AND
202

Supplemental Materials for Follow-Up After Emergency Department Visit for Mental 

Illness FUM-AD AND FUM-CH)

o A member of which of the following racial groups: White or Caucasian, Black or 

African American, American Indian or Alaska Native, Asian, Native Hawaiian or 

Other Pacific Islander, More than one race, or Unknown

• Refer to the specific data-reporting template for the reporting requirements applicable to 

each measure.

Measurement Period: The Measurement Period is the period for which data are required for 

reporting purposes. The FUM-AD and FUM-CH measure denominators are both January 1 

through December 1, if the Measurement Year (MY) is the calendar year. The FUM-AD and 

FUM-CH measure include two submeasures, both of which are defined in the specification 

and both of which have a distinct Measurement Period for the numerator: (a) 7-Day Followup (ED visit date through 7 days after visit date) and (b) 30-Day Follow-up (ED visit date 

through 30 days after visit date).

B. DEFINITIONS

TERM DEFINITION 

Measurement Period

The specific time period for which data are needed for the 

numerator and denominator of a given measure. The Measurement 

Period may differ for the numerator and denominator and for each 

measure and is specified in section A above.

Measurement Year The standard 12-month reporting period common to all measures 

being reported by the Provider.

Percentage A Percentage is calculated as follows: numerator divided by 

denominator (n/d).

Provider The Provider entity that is being measured (i.e., BHC) 

E. ADDITIONAL NOTES

Interpretation of scores: Better quality = Higher Percentage

F. FREQUENTLY ASKED QUESTIONS

None
203

Follow-Up After Emergency Department Visit for Mental Illness: Age 18 and Older (FUMAD) 

Measure FUM-AD: Follow-Up After Emergency Department Visit for Mental 

Illness: Age 18 and Older8,16

Based on a CMS Medicaid Adult Core Set Measure (2023), which is derived from a measure stewarded 

by the National Committee for Quality Assurance (NCQA)20

A. DESCRIPTION

Percentage of emergency department (ED) visits for beneficiaries [clients] age 18 and older with a

principal diagnosis of mental illness or intentional self-harm and who had a follow-up visit for

mental illness. Two rates are reported:

Percentage of ED visits for mental illness for which the beneficiary [client] received follow-up

within 30 days of the ED visit (31 total days)

Percentage of ED visits for mental illness for which the beneficiary [client] received follow-up

within 7 days of the ED visit (8 total days)

Data Collection Method: Administrative

16Aside from the minor modifications noted in this specification, this specification is taken directly from the 2023 

CMS Medicaid Adult Core Set Measures. Use the most current version for the year being reported. 

See also Important Supplemental Materials for State-Collected Required BHC Measures derived from CMS 

Medicaid Adult and/or Child Core Set Measures (in this manual immediately before this specification). 

8The NCQA HEDIS® measure specification has been adjusted pursuant to NCQA’s Rules for Allowable 

Adjustments of HEDIS. 

20Adapted from an NCQA measure with financial support from the Office of the Assistant Secretary for Planning 

and Evaluation (ASPE) under Prime Contract No. HHSP23320100019WI/HHSP23337001T, in which NCQA was a 

subcontractor to Mathematica. Additional financial support was provided by the Substance Abuse and Mental 

Health Services Administration (SAMHSA). 
204

Follow-Up After Emergency Department Visit for Mental Illness: Age 18 and Older (FUMAD)

Guidance for Reporting:

For HEDIS, this measure has three reportable age groups and a total rate: ages 6 to 17, ages 18 to 

64, age 65 and older, and total (age 6 and older). The [Medicaid] Child Core Set measure 

applies to beneficiaries ages 6 to 17 and the [Medicaid] Adult Core Set measure applies to 

beneficiaries age 18 and older. For the purpose of Adult Core Set reporting, states should 

calculate and report this measure for two age groups (as applicable): ages 18 to 64 and age 65 

and older. [For the purpose of Behavioral Health Clinic (BHC) reporting, states should 

calculate and report this adult measure as one age group: clients ages 18 years and older.]

The denominator should be the same for the 30-day rate and the 7-day rate.

The 30-day follow-up rate should be greater than or equal to the 7-day follow-up rate within each 

age group.

When a visit code or procedure code must be used in conjunction with a diagnosis code, the codes 

must be on the same claim or from the same visit.

If a value set includes codes used on professional claims (e.g., CPT, HCPCS) and includes 

codes used on facility claims (e.g., UB), use diagnosis and procedure codes from both 

facility and professional claims to identify services and diagnoses (the codes can be on the 

same claim or from the same visit).

If a value set includes codes used only on facility claims (e.g., UB) then only use facility 

claims to identify services and diagnoses (the codes must be on the same claim).

Include all paid, suspended, pending and denied claims. 

This measure includes an optional exclusion for beneficiaries [clients] who die during the 

measurement year. For additional information, refer to the deceased beneficiary [client] 

exclusion guidance in Section II. Data Collection and Reporting of the Adult Core Set 

[Section III. Technical Specification Components].

This measure’s Value Set Directory includes the following coding systems for services, procedures, 

and diagnoses: CPT, HCPCS, ICD-10-CM, ICD-10-PCS, POS, SNOMED, and UB. Refer to the 

Acknowledgments section at the beginning of the manual for copyright information.

B. ELIGIBLE POPULATION

Age Age 18 and older as of the date of the ED visit.

Continuous 

enrollment

Date of the ED visit through 30 days after the ED visit (31 total days).

Allowable gap No allowable gaps in the continuous enrollment period.

Anchor date None.

Benefit Medical and mental health.

Event/diagnosis An ED visit (ED Value Set) with a principal diagnosis of mental illness or 

intentional self-harm (Mental Illness Value Set; Intentional Self-Harm 

Value Set) on or between January 1 and December 1 of the measurement 

year where the beneficiary [client] was age 18 or older on the date of the 

visit.

The denominator for this measure is based on ED visits, not on 

beneficiaries [clients]. If a beneficiary [client] has more than one ED visit, 

identify all eligible ED visits between January 1 and December 1 of the 

measurement year and do not include more than one visit per 31-day 

period as described below.
205

Follow-Up After Emergency Department Visit for Mental Illness: Age 18 and Older (FUMAD)

Multiple visits in a 

31-day period

If a beneficiary [client] has more than one ED visit in a 31-day period, 

include only the first eligible ED visit. For example, if a beneficiary

[client] has an ED visit on January 1, include the January 1 visit and do not 

include ED visits that occur on or between January 2 and January 31; then, 

if applicable, include the next ED visit that occurs on or after February 1. 

Identify visits chronologically, including only one per 31-day period. 

Note: Removal of multiple visits in a 31-day period is based on eligible 

visits. Assess each ED visit for exclusions before removing multiple visits 

in a 31-day period.

ED visits followed 

by inpatient 

admission

Exclude ED visits that result in an inpatient stay and ED visits followed by 

admission to an acute or nonacute inpatient care setting on the date of the 

ED visit or within the 30 days after the ED visit (31 total days), regardless 

of the principal diagnosis for the admission. To identify admissions to an 

acute or nonacute inpatient care setting: 

2. Identify all acute and nonacute inpatient stays (Inpatient Stay Value 

Set). 

Identify the admission date for the stay. 

An ED or observation visit billed on the same claim as an inpatient stay is 

considered a visit that resulted in an inpatient stay. 

These events are excluded from this measure because admission to an 

acute or nonacute inpatient setting may prevent an outpatient follow-up 

visit from taking place. 

Required exclusion Beneficiaries [Clients] in hospice or using hospice services anytime during 

the measurement year. For additional information, refer to the hospice 

exclusion guidance in Section II. Data Collection and Reporting of the 

Adult Core Set [Section III. Technical Specification Components].

C. ADMINISTRATIVE SPECIFICATION

Denominator

The eligible population as defined above.

Numerator

30-Day Follow-Up 

A follow-up visit with any practitioner, with a principal diagnosis of a mental health disorder or with 

a principal diagnosis of intentional self-harm and any diagnosis of mental health disorder within 30 

days after the ED visit (31 total days). Include visits that occur on the date of the ED visit.

7-Day Follow-Up 

A follow-up visit with any practitioner, with a principal diagnosis of a mental health disorder or with 

a principal diagnosis of intentional self-harm and any diagnosis of a mental health disorder within 7 

days after the ED visit (8 total days). Include visits that occur on the date of the ED visit.

For both indicators, any of the following meet criteria for a follow-up visit. 

An outpatient visit (Visit Setting Unspecified Value Set with Outpatient POS Value Set) with a 

principal diagnosis of a mental health disorder (Mental Health Diagnosis Value Set)

An outpatient visit (BH Outpatient Value Set) with a principal diagnosis of a mental health disorder 

(Mental Health Diagnosis Value Set)
206

Follow-Up After Emergency Department Visit for Mental Illness: Age 18 and Older (FUMAD)

An intensive outpatient encounter or partial hospitalization (Visit Setting Unspecified Value Set with 

Partial Hospitalization POS Value Set), with a principal diagnosis of mental health disorder 

(Mental Health Diagnosis Value Set)

An intensive outpatient encounter or partial hospitalization (Partial Hospitalization or Intensive 

Outpatient Value Set) with a principal diagnosis of a mental health disorder (Mental Health 

Diagnosis Value Set)

A community mental health center visit (Visit Setting Unspecified Value Set with Community 

Mental Health Center POS Value Set), with a principal diagnosis of a mental health disorder 

(Mental Health Diagnosis Value Set) 

Electroconvulsive therapy (Electroconvulsive Therapy Value Set) with (Ambulatory Surgical Center 

POS Value Set; Community Mental Health Center POS Value Set; Outpatient POS Value Set; 

Partial Hospitalization POS Value Set) with a principal diagnosis of a mental health disorder 

(Mental Health Diagnosis Value Set)

A telehealth visit (Visit Setting Unspecified Value Set with Telehealth POS Value Set), with a 

principal diagnosis of a mental health disorder (Mental Health Diagnosis Value Set)

An observation visit (Observation Value Set) with a principal diagnosis of a mental health disorder 

(Mental Health Diagnosis Value Set)

A telephone visit (Telephone Visits Value Set) with a principal diagnosis of a mental health disorder 

(Mental Health Diagnosis Value Set)

An e-visit or virtual check-in (Online Assessments Value Set) with a principal diagnosis of a mental 

health disorder (Mental Health Diagnosis Value Set)

An outpatient visit (Visit Setting Unspecified Value Set with Outpatient POS Value Set) with a 

principal diagnosis of intentional self-harm (Intentional Self-Harm Value Set) with any diagnosis 

of a mental health disorder (Mental Health Diagnosis Value Set)

An outpatient visit (BH Outpatient Value Set) with a principal diagnosis of intentional self-harm 

(Intentional Self-Harm Value Set), with any diagnosis of a mental health disorder (Mental Health 

Diagnosis Value Set)

An intensive outpatient encounter or partial hospitalization (Visit Setting Unspecified Value Set with 

Partial Hospitalization POS Value Set), with a principal diagnosis of intentional self-harm 

(Intentional Self-Harm Value Set), with any diagnosis of a mental health disorder (Mental Health 

Diagnosis Value Set)

An intensive outpatient encounter or partial hospitalization (Partial Hospitalization or Intensive 

Outpatient Value Set) with a principal diagnosis of intentional self-harm (Intentional Self-Harm 

Value Set), with any diagnosis of a mental health disorder (Mental Health Diagnosis Value Set)

A community mental health center visit (Visit Setting Unspecified Value Set with Community 

Mental Health Center POS Value Set), with a principal diagnosis of intentional self-harm 

(Intentional Self-Harm Value Set), with any diagnosis of a mental health disorder (Mental Health 

Diagnosis Value Set)

Electroconvulsive therapy (Electroconvulsive Therapy Value Set) with (Ambulatory Surgical Center 

POS Value Set; Community Mental Health Center POS Value Set; Outpatient POS Value Set; 

Partial Hospitalization POS Value Set) with a principal diagnosis of intentional self-harm 

(Intentional Self-Harm Value Set), with any diagnosis of a mental health disorder (Mental Health 

Diagnosis Value Set)

A telehealth visit (Visit Setting Unspecified Value Set with Telehealth POS Value Set), with a 

principal diagnosis of intentional self-harm (Intentional Self-Harm Value Set), with any 

diagnosis of a mental health disorder (Mental Health Diagnosis Value Set)
207

Follow-Up After Emergency Department Visit for Mental Illness: Age 18 and Older (FUMAD)

An observation visit (Observation Value Set) with a principal diagnosis of intentional self-harm 

(Intentional Self-Harm Value Set), with any diagnosis of a mental health disorder (Mental Health 

Diagnosis Value Set)

A telephone visit (Telephone Visits Value Set) with a principal diagnosis of intentional self-harm 

(Intentional Self-Harm Value Set), with any diagnosis of a mental health disorder (Mental Health 

Diagnosis Value Set)

An e-visit or virtual check-in (Online Assessments Value Set) with a principal diagnosis of 

intentional self-harm (Intentional Self-Harm Value Set), with any diagnosis of a mental health 

disorder (Mental Health Diagnosis Value Set)

D. ADDITIONAL NOTES

There may be different methods for billing intensive outpatient visits and partial hospitalizations. 

Some methods may be comparable to outpatient billing, with separate claims for each date of 

service; others may be comparable to inpatient billing, with an admission date, a discharge date, and 

units of service. Where billing methods are comparable to inpatient billing, each unit of service may 

be counted as an individual visit. The unit of service must have occurred during the required period 

specified for the rate (within 30 days after discharge or within 7 days after discharge).
Follow-Up After Emergency Department Visit for Mental Illness: Ages 6 to 17 (FUM-CH)

208

Measure FUM-CH: Follow-Up After Emergency Department Visit for Mental Illness: 

Ages 6 to 178,18

Based on a CMS Medicaid Child Core Set Measure (2023), which is derived from a measure stewarded by the 

National Committee for Quality Assurance (NCQA)20

A. DESCRIPTION

Percentage of emergency department (ED) visits for beneficiaries [clients] ages 6 to 17 with a principal

diagnosis of mental illness or intentional self-harm and who had a follow-up visit for mental illness. Two

rates are reported:

Percentage of ED visits for mental illness for which the beneficiary [client] received follow-up within 30

days of the ED visit (31 total days)

Percentage of ED visits for mental illness for which the beneficiary [client] received follow-up within 7

days of the ED visit (8 total days)

Data Collection Method: Administrative

Guidance for Reporting:

For HEDIS, this measure has three reportable age groups and a total rate: ages 6 to 17, ages 18 to 

64, age 65 and older, and total (age 6 and older). The {Medicaid] Child Core Set measure 

applies to beneficiaries ages 6 to 17 and the [Medicaid] Adult Core Set measure applies to 

beneficiaries age 18 and older. [For the purpose of Behavioral Health Clinic (BHC) reporting, 

states should calculate and report this child measure as one age group: clients ages 6 to 17 

years.]

The denominator should be the same for the 30-day rate and the 7-day rate.

The 30-day follow-up rate should be greater than or equal to the 7-day follow-up rate within each 

age group.

When a visit code or procedure code must be used in conjunction with a diagnosis code, the codes 

must be on the same claim or from the same visit.

If a value set includes codes used on professional claims (e.g., CPT, HCPCS) and includes 

codes used on facility claims (e.g., UB), use diagnosis and procedure codes from both 

facility and professional claims to identify services and diagnoses (the codes can be on the 

same claim or from the same visit).

If a value set includes codes used only on facility claims (e.g., UB) then only use facility 

claims to identify services and diagnoses (the codes must be on the same claim).

Include all paid, suspended, pending and denied claims. 

This measure includes an optional exclusion for beneficiaries [clients] who die during the 

measurement year. For additional information, refer to the deceased beneficiary [client]

exclusion guidance in Section II. Data Collection and Reporting of the Child Core Set [Section 

III. Technical Specification Components].

8The NCQA HEDIS® measure specification has been adjusted pursuant to NCQA’s Rules for Allowable Adjustments of 

HEDIS.

18Aside from the minor modifications noted in this specification, this specification is taken directly from the 2023 CMS 

Medicaid Child Core Set Measures. Use the most current version for the year being reported. See also Important 

Supplemental Materials for State-Collected Required BHC Measures derived from CMS Medicaid Adult and/or Child 

Core Set Measures (in this manual immediately before this specification).

20Adapted from an NCQA measure with financial support from the Office of the Assistant Secretary for Planning and 

Evaluation (ASPE) under Prime Contract No. HHSP23320100019WI/HHSP23337001T, in which NCQA was a 

subcontractor to Mathematica. Additional financial support was provided by the Substance Abuse and Mental Health 

Services Administration (SAMHSA).
Follow-Up After Emergency Department Visit for Mental Illness: Ages 6 to 17 (FUM-CH)

209

This measure’s Value Set Directory includes the following coding systems for services, procedures, and 

diagnoses: CPT, HCPCS, ICD-10-CM, ICD-10-PCS, POS, SNOMED, and UB. Refer to the 

Acknowledgments section at the beginning of the manual for copyright information.

B. ELIGIBLE POPULATION

Age Ages 6 to 17 as of the date of the ED visit.

Continuous 

enrollment

Date of the ED visit through 30 days after the ED visit (31 total days).

Allowable gap No allowable gaps in the continuous enrollment period.

Anchor date None.

Benefit Medical and mental health.

Event/diagnosis An ED visit (ED Value Set) with a principal diagnosis of mental illness or 

intentional self-harm (Mental Illness Value Set; Intentional Self-Harm Value Set) 

on or between January 1 and December 1 of the measurement year where the 

beneficiary [client] was between ages 6 and 17 on the date of the visit.

The denominator for this measure is based on ED visits, not on beneficiaries

[clients]. If a beneficiary [client] has more than one ED visit, identify all eligible 

ED visits between January 1 and December 1 of the measurement year and do not 

include more than one visit per 31-day period as described below.

Multiple visits in a 

31-day period

If a beneficiary [client] has more than one ED visit in a 31-day period, include 

only the first eligible ED visit. For example, if a beneficiary [client] has an ED 

visit on January 1, include the January 1 visit and do not include ED visits that 

occur on or between January 2 and January 31; then, if applicable, include the next 

ED visit that occurs on or after February 1. Identify visits chronologically, 

including only one per 31-day period. 

Note: Removal of multiple visits in a 31-day period is based on eligible visits. 

Assess each ED visit for exclusions before removing multiple visits in a 31-day 

period.

ED visits followed 

by inpatient 

admission

Exclude ED visits that result in an inpatient stay and ED visits followed by 

admission to an acute or nonacute inpatient care setting on the date of the ED visit 

or within the 30 days after the ED visit (31 total days), regardless of the principal 

diagnosis for the admission. To identify admissions to an acute or nonacute 

inpatient care setting: 

Identify all acute and nonacute inpatient stays (Inpatient Stay Value Set). 

6. Identify the admission date for the stay. 

An ED or observation visit billed on the same claim as an inpatient stay is 

considered a visit that resulted in an inpatient stay. 

These events are excluded from this measure because admission to an acute or 

nonacute inpatient setting may prevent an outpatient follow-up visit from taking 

place. 

Required exclusion Beneficiaries [Clients] in hospice or using hospice services anytime during the 

measurement year. For additional information, refer to the hospice exclusion 

guidance in Section II. Data Collection and Reporting of the Child Core Set

[Section III. Technical Specification Components].
Follow-Up After Emergency Department Visit for Mental Illness: Ages 6 to 17 (FUM-CH)

210

C. ADMINISTRATIVE SPECIFICATION

Denominator

The eligible population as defined above.

Numerator

30-Day Follow-Up 

A follow-up visit with any practitioner, with a principal diagnosis of a mental health disorder or with a 

principal diagnosis of intentional self-harm and any diagnosis of mental health disorder within 30 days 

after the ED visit (31 total days). Include visits that occur on the date of the ED visit.

7-Day Follow-Up 

A follow-up visit with any practitioner, with a principal diagnosis of a mental health disorder or with a 

principal diagnosis of intentional self-harm and any diagnosis of a mental health disorder within 7 days 

after the ED visit (8 total days). Include visits that occur on the date of the ED visit.

For both indicators, any of the following meet criteria for a follow-up visit. 

An outpatient visit (Visit Setting Unspecified Value Set with Outpatient POS Value Set) with a principal 

diagnosis of a mental health disorder (Mental Health Diagnosis Value Set)

An outpatient visit (BH Outpatient Value Set) with a principal diagnosis of a mental health disorder 

(Mental Health Diagnosis Value Set)

An intensive outpatient encounter or partial hospitalization (Visit Setting Unspecified Value Set with 

Partial Hospitalization POS Value Set), with a principal diagnosis of mental health disorder (Mental 

Health Diagnosis Value Set)

An intensive outpatient encounter or partial hospitalization (Partial Hospitalization or Intensive Outpatient 

Value Set) with a principal diagnosis of a mental health disorder (Mental Health Diagnosis Value Set)

A community mental health center visit (Visit Setting Unspecified Value Set with Community Mental 

Health Center POS Value Set), with a principal diagnosis of a mental health disorder (Mental Health 

Diagnosis Value Set) 

Electroconvulsive therapy (Electroconvulsive Therapy Value Set) with (Ambulatory Surgical Center POS 

Value Set; Community Mental Health Center POS Value Set; Outpatient POS Value Set; Partial 

Hospitalization POS Value Set) with a principal diagnosis of a mental health disorder (Mental Health 

Diagnosis Value Set)

A telehealth visit (Visit Setting Unspecified Value Set with Telehealth POS Value Set), with a principal 

diagnosis of a mental health disorder (Mental Health Diagnosis Value Set)

An observation visit (Observation Value Set) with a principal diagnosis of a mental health disorder 

(Mental Health Diagnosis Value Set)

A telephone visit (Telephone Visits Value Set) with a principal diagnosis of a mental health disorder 

(Mental Health Diagnosis Value Set)

An e-visit or virtual check-in (Online Assessments Value Set) with a principal diagnosis of a mental 

health disorder (Mental Health Diagnosis Value Set)

An outpatient visit (Visit Setting Unspecified Value Set with Outpatient POS Value Set) with a principal 

diagnosis of intentional self-harm (Intentional Self-Harm Value Set) with any diagnosis of a mental 

health disorder (Mental Health Diagnosis Value Set)

An outpatient visit (BH Outpatient Value Set) with a principal diagnosis of intentional self-harm 

(Intentional Self-Harm Value Set), with any diagnosis of a mental health disorder (Mental Health 

Diagnosis Value Set)
Follow-Up After Emergency Department Visit for Mental Illness: Ages 6 to 17 (FUM-CH)

211

An intensive outpatient encounter or partial hospitalization (Visit Setting Unspecified Value Set with 

Partial Hospitalization POS Value Set), with a principal diagnosis of intentional self-harm (Intentional 

Self-Harm Value Set), with any diagnosis of a mental health disorder (Mental Health Diagnosis Value 

Set)

An intensive outpatient encounter or partial hospitalization (Partial Hospitalization or Intensive Outpatient 

Value Set) with a principal diagnosis of intentional self-harm (Intentional Self-Harm Value Set), with 

any diagnosis of a mental health disorder (Mental Health Diagnosis Value Set)

A community mental health center visit (Visit Setting Unspecified Value Set with Community Mental 

Health Center POS Value Set), with a principal diagnosis of intentional self-harm (Intentional SelfHarm Value Set), with any diagnosis of a mental health disorder (Mental Health Diagnosis Value Set)

Electroconvulsive therapy (Electroconvulsive Therapy Value Set) with (Ambulatory Surgical Center POS 

Value Set; Community Mental Health Center POS Value Set; Outpatient POS Value Set; Partial 

Hospitalization POS Value Set) with a principal diagnosis of intentional self-harm (Intentional SelfHarm Value Set), with any diagnosis of a mental health disorder (Mental Health Diagnosis Value Set)

A telehealth visit (Visit Setting Unspecified Value Set with Telehealth POS Value Set), with a principal 

diagnosis of intentional self-harm (Intentional Self-Harm Value Set), with any diagnosis of a mental 

health disorder (Mental Health Diagnosis Value Set)

An observation visit (Observation Value Set) with a principal diagnosis of intentional self-harm 

(Intentional Self-Harm Value Set), with any diagnosis of a mental health disorder (Mental Health 

Diagnosis Value Set)

A telephone visit (Telephone Visits Value Set) with a principal diagnosis of intentional self-harm 

(Intentional Self-Harm Value Set), with any diagnosis of a mental health disorder (Mental Health 

Diagnosis Value Set)

An e-visit or virtual check-in (Online Assessments Value Set) with a principal diagnosis of intentional 

self-harm (Intentional Self-Harm Value Set), with any diagnosis of a mental health disorder (Mental 

Health Diagnosis Value Set)

D. ADDITIONAL NOTES

There may be different methods for billing intensive outpatient visits and partial hospitalizations. Some 

methods may be comparable to outpatient billing, with separate claims for each date of service; others 

may be comparable to inpatient billing, with an admission date, a discharge date, and units of service. 

Where billing methods are comparable to inpatient billing, each unit of service may be counted as an 

individual visit. The unit of service must have occurred during the required period specified for the rate 

(within 30 days after discharge or within 7 days after discharge).
Supplemental Materials For Follow-Up After Emergency Department Visit For Substance 

Use (FUA-AD AND FUA-CH)

212

Important Supplemental Materials for State-Collected Required

BHC Measures derived from CMS Medicaid Adult and/or Child 

Core Set Measures (FUA-AD and FUA-CH)

These supplemental materials are necessary for implementation of the State-Collected Required 

BHC Measures that are derived from the CMS Medicaid Adult and/or Child Core Set Measures. 

This volume includes the exact specifications that are on the CMS website for the 2023 Medicaid 

Core Set, with simple modifications noted in the text. Limited additional needed modifications 

are included below, as well as supplemental useful materials.

1. Measure FUA-AD: Follow-Up After Emergency Department Visit for Substance 

Use: Age 18 and Older

2. Measure FUA-CH: Follow-Up After Emergency Department Visit for Substance 

Use: Ages 6 TO 17

For both FUA measures, the changes within the CMS Medicaid Adult and Child Core Sets 

specifications reflect: (1) substitution of the word “client” for “beneficiary” or “patient”, unless 

the latter is part of a copyrighted code description; (2) removal of age stratification in the adult 

measure (i.e., applicable to adults ages 18 years and older); and (3) removal of references to the 

Core Set.

Additional information: For both the FUA measures, the following material is provided to assist 

clinics in using the specifications and follows the numbering system used in the non-Medicaid 

Core Set-derived BHC specifications

A. DESCRIPTION

Important Reporting Guidance:

• The FUA-AD and FUA-CH measures are to be used by states to measure performance 

related to clients seen at the Provider during the Measurement Year.

• Current value sets are available on the CMS Medicaid Adult Core Set Reporting 

Resource website and the CMS Medicaid Child Core Set Reporting Resource website. 

Use the version current for the year being reported.

• Both FUH-AD and FUD-CH are to be stratified separately based on whether the client is:

o Medicaid only or Other (including those dually eligible for Medicare and 

Medicaid)

AND

o A member of which of the following ethnic groups: Not Hispanic or Latino, 

Hispanic or Latino, or Unknown

AND

o A member of which of the following racial groups: White or Caucasian, Black or 

African American, American Indian or Alaska Native, Asian, Native Hawaiian or 

Other Pacific Islander, More than one race, or Unknown
Supplemental Materials For Follow-Up After Emergency Department Visit For Substance 

Use (FUA-AD AND FUA-CH)

213

• Refer to the specific data-reporting template for the reporting requirements applicable to 

each measure.

Measurement Period: The Measurement Period is the period for which data are required for 

reporting purposes. The FUA-AD and FUA-CH measure denominators are both January 1 

through December 1, if the Measurement Year (MY) is the calendar year. The FUA-AD and 

FUA-CH measures include two submeasures, both of which are defined in the specification 

and both of which have a distinct Measurement Period for the numerator: (a) 7-Day Followup (ED visit date through 7 days after visit date) and (b) 30-Day Follow-up (ED visit date 

through 30 days after visit date).

B. DEFINITIONS

TERM DEFINITION 

Measurement Period

The specific time period for which data are needed for the 

numerator and denominator of a given measure. The Measurement 

Period may differ for the numerator and denominator and for each 

measure and is specified in section A above.

Measurement Year The standard 12-month reporting period common to all measures 

being reported by the Provider.

Percentage A Percentage is calculated as follows: numerator divided by 

denominator (n/d).

Provider The Provider entity that is being measured (i.e., BHC) 

E. ADDITIONAL NOTES

Interpretation of scores: Better quality = Higher Percentage

F. FREQUENTLY ASKED QUESTIONS

None
214

Follow-Up After Emergency Department Visit For Substance Use: Age 18 And Older 

(FUA-AD)

Measure FUA-AD: Follow-up After Emergency Department Visit for Substance 

Use: Age 18 and Older8,16

Based on a CMS Medicaid Adult Core Set Measure (2023), which is derived from a measure 

stewarded by the National Committee for Quality Assurance (NCQA)20

A. DESCRIPTION

Percentage of emergency department (ED) visits for beneficiaries [clients] age 18 and older with a

principal diagnosis of substance use disorder (SUD), or any diagnosis of drug overdose, for which

there was follow-up. Two rates are reported:

Percentage of ED visits for which the beneficiary [client] received follow-up within 30 days of the

ED visit (31 total days)

Percentage of ED visits for which the beneficiary [client] follow-up within 7 days of the ED visit (8

total days)

Data Collection Method: Administrative

Guidance for Reporting: 

For HEDIS, this measure has three reportable age groups and a total rate: ages 13 to 17, ages 18 to 

64, age 65 and older, and total (age 13 and older). The [Medicaid] Child Core Set measure 

applies to beneficiaries ages 13 to 17 and the [Medicaid] Adult Core Set measure applies to 

beneficiaries age 18 and older. For the purpose of Adult Core Set reporting, states should 

calculate and report this measure for two age groups (as applicable): ages 18 to 64 and age 65 

and older. [For the purpose of Behavioral Health Clinic (BHC) reporting, states should 

calculate and report this adult measure as one age group: clients ages 18 years and older.]

The denominator should be the same for the 30-day rate and the 7-day rate within each age group. 

The 30-day follow-up rate should be greater than or equal to the 7-day follow-up rate.

When a visit code or procedure code must be used in conjunction with a diagnosis code, the codes 

must be on the same claim or from the same visit. 

If a value set includes codes used on professional claims (e.g., CPT, HCPCS) and includes 

codes used on facility claims (e.g., UB), use diagnosis and procedure codes from both 

facility and professional claims to identify services and diagnoses (the codes can be on the 

same claim or from the same visit).

If a value set includes codes used only on facility claims (e.g., UB) then use only facility 

claims to identify services and diagnoses (the codes must be on the same claim).

16Aside from the minor modifications noted in this specification, this specification is taken directly from the 2023 

CMS Medicaid Adult Core Set Measures. Use the most current version for the year being reported. 

See also Important Supplemental Materials for State-Collected Required BHC Measures derived from CMS 

Medicaid Adult and/or Child Core Set Measures (in this manual immediately before this specification). 

8The NCQA HEDIS® measure specification has been adjusted pursuant to NCQA’s Rules for Allowable 

Adjustments of HEDIS. 

20Adapted from an NCQA measure with financial support from the Office of the Assistant Secretary for Planning 

and Evaluation (ASPE) under Prime Contract No. HHSP23320100019WI/HHSP23337001T, in which NCQA was a 

subcontractor to Mathematica. Additional financial support was provided by the Substance Abuse and Mental 

Health Services Administration (SAMHSA). 
Follow-Up After Emergency Department Visit For Substance Use: Age 18 And Older

(FUA-AD)

215

Include all paid, suspended, pending, and denied claims. 

Refer to [Appendix D of this manual] for the definition of a mental health provider. States must 

develop their own methods to identify mental health providers. 

NCQA’s Medication List Directory (MLD) for Alcohol Use Disorder Treatment and Opioid Use 

Disorder Treatment medications are available to order free of charge in the NCQA Store 

(https://store.ncqa.org/hedis-my-2022-medication-list-directory.html). [Use version current for 

year reporting.] Once ordered, the Medication List Directory can be accessed through the 

NCQA Download Center (https://my.ncqa.org/Downloads).

This measure includes an optional exclusion for beneficiaries [clients] who die during the 

measurement year. For additional information, refer to the deceased beneficiary [client] exclusion 

guidance in Section II. Data Collection and Reporting of the Adult Core Set [Section III. 

Technical Specification Components].

This measure’s Value Set Directory includes the following coding systems for services, procedures, 

and diagnoses: CPT, HCPCS, ICD-10-CM, POS, SNOMED, and UB. The Medication List Directory 

includes the following coding systems for medications: NDC and RxNorm. Refer to the 

Acknowledgments section at the beginning of the manual for copyright information.

B. ELIGIBLE POPULATION

Age Age 18 and older as of the ED visit.

Continuous 

enrollment

Date of the ED visit through 30 days after the ED visit (31 total days).

Allowable gap No allowable gaps in the continuous enrollment period.

Anchor date None.

Benefit Medical, chemical dependency, and pharmacy.

Note: Beneficiaries [Clients] with detoxification-only chemical 

dependency benefits do not meet these criteria.

Event/diagnosis An ED visit (ED Value Set) with a principal diagnosis of SUD (AOD 

Abuse and Dependence Value Set) or any diagnosis of drug overdose 

(Unintentional Drug Overdose Value Set) on or between January 1 and 

December 1 of the measurement year where the beneficiary [client] was 

age 18 or older on the date of the visit.

The denominator for this measure is based on ED visits, not on 

beneficiaries [clients]. If a beneficiary [client] has more than one ED visit, 

identify all eligible ED visits between January 1 and December 1 of the 

measurement year and do not include more than one visit per 31-day 

period as described below.
Follow-Up After Emergency Department Visit For Substance Use: Age 18 And Older

(FUA-AD)

216

Multiple visits in a 

31-day period

If a beneficiary [client] has more than one ED visit in a 31-day period, 

include only the first eligible ED visit. For example, if a beneficiary

[client] has an ED visit on January 1, include the January 1 visit and do 

not include ED visits that occur on or between January 2 and January 31; 

then, if applicable, include the next ED visit that occurs on or after 

February 1. Identify visits chronologically, including only one per 31-day 

period. 

Note: Removal of multiple visits in a 31-day period is based on eligible 

visits. Assess each ED visit for exclusions before removing multiple visits 

in a 31-day period.

ED visits followed 

by inpatient 

admission

Exclude ED visits that result in an inpatient stay and ED visits followed by 

an admission to an acute or nonacute inpatient care setting on the date of 

the ED visit or within the 30 days after the ED visit, regardless of the 

principal diagnosis for the admission. To identify admissions to an acute 

or nonacute inpatient care setting: 

1. Identify all acute and nonacute inpatient stays (Inpatient Stay Value 

Set). 

2. Identify the admission date for the stay. 

An ED or observation visit billed on the same claim as an inpatient stay is 

considered a visit that resulted in an inpatient stay. These events are 

excluded from this measure because admission to an acute or nonacute 

inpatient setting may prevent an outpatient follow-up visit from taking 

place. 

Required exclusion Beneficiaries [Clients] in hospice or using hospice services anytime during 

the measurement year. For additional information, refer to the hospice 

exclusion guidance in Section II. Data Collection and Reporting of the 

Child Core Set [Section III. Technical Specification Components].

C. ADMINISTRATIVE SPECIFICATION

Denominator

The eligible population as defined above.

Numerator

30-Day Follow-Up 

A follow-up visit or pharmacotherapy dispensing event within 30 days after the ED visit (31 total 

days). Include visits and pharmacotherapy events that occur on the date of the ED visit.

7-Day Follow-Up 

A follow-up visit or pharmacotherapy dispensing event within 7 days after the ED visit (8 total 

days). Include visits and pharmacotherapy events that occur on the date of the ED visit.

For both indicators, any of the following meet criteria for a follow-up visit:

An outpatient visit (Visit Setting Unspecified Value Set) with (Outpatient POS Value Set) with any 

diagnosis of SUD (AOD Abuse and Dependence Value Set), substance use (Substance Induced 

Disorders Value Set) or drug overdose (Unintentional Drug Overdose Value Set)

An outpatient visit (Visit Setting Unspecified Value Set) with (Outpatient POS Value Set) with a 

mental health provider
Follow-Up After Emergency Department Visit For Substance Use: Age 18 And Older

(FUA-AD)

217

An outpatient visit (BH Outpatient Value Set) with any diagnosis of SUD (AOD Abuse and 

Dependence Value Set), substance use (Substance Induced Disorders Value Set) or drug 

overdose (Unintentional Drug Overdose Value Set)

An outpatient visit (BH Outpatient Value Set) with a mental health provider

An intensive outpatient encounter or partial hospitalization (Visit Setting Unspecified Value Set) 

with (Partial Hospitalization POS Value Set) with any diagnosis of SUD (AOD Abuse and 

Dependence Value Set), substance use (Substance Induced Disorders Value Set) or drug 

overdose (Unintentional Drug Overdose Value Set)

An intensive outpatient encounter or partial hospitalization (Visit Setting Unspecified Value Set) 

with (Partial Hospitalization POS Value Set) with a mental health provider

An intensive outpatient encounter or partial hospitalization (Partial Hospitalization or Intensive 

Outpatient Value Set) with any diagnosis of SUD (AOD Abuse and Dependence Value Set), 

substance use (Substance Induced Disorders Value Set) or drug overdose (Unintentional Drug 

Overdose Value Set)

An intensive outpatient encounter or partial hospitalization (Partial Hospitalization or Intensive 

Outpatient Value Set) with a mental health provider

A non-residential substance abuse treatment facility visit (Visit Setting Unspecified Value Set) with 

(Non-residential Substance Abuse Treatment Facility POS Value Set) with any diagnosis of 

SUD (AOD Abuse and Dependence Value Set), substance use (Substance Induced Disorders 

Value Set) or drug overdose (Unintentional Drug Overdose Value Set)

A non-residential substance abuse treatment facility visit (Visit Setting Unspecified Value Set) with 

(Non-residential Substance Abuse Treatment Facility POS Value Set) with a mental health 

provider

A community mental health center visit (Visit Setting Unspecified Value Set) with (Community 

Mental Health Center POS Value Set) with any diagnosis of SUD (AOD Abuse and Dependence 

Value Set), substance use (Substance Induced Disorders Value Set) or drug overdose 

(Unintentional Drug Overdose Value Set)

A community mental health center visit (Visit Setting Unspecified Value Set) with (Community 

Mental Health Center POS Value Set) with a mental health provider

An observation visit (Observation Value Set) with any diagnosis of SUD (AOD Abuse and 

Dependence Value Set), substance use (Substance Induced Disorders Value Set) or drug 

overdose (Unintentional Drug Overdose Value Set)

An observation visit (Observation Value Set) with a mental health provider

A peer support service (Peer Support Services Value Set) with any diagnosis of SUD (AOD Abuse 

and Dependence Value Set), substance use (Substance Induced Disorders Value Set) or drug 

overdose (Unintentional Drug Overdose Value Set)

An opioid treatment service that bills monthly or weekly (OUD Weekly Non Drug Service Value 

Set; OUD Monthly Office Based Treatment Value Set) with any diagnosis of SUD (AOD Abuse 

and Dependence Value Set), substance use (Substance Induced Disorders Value Set) or drug 

overdose (Unintentional Drug Overdose Value Set)

A telehealth visit (Visit Setting Unspecified Value Set) with (Telehealth POS Value Set) with any 

diagnosis of SUD (AOD Abuse and Dependence Value Set), substance use (Substance Induced 

Disorders Value Set) or drug overdose (Unintentional Drug Overdose Value Set)

A telehealth visit (Visit Setting Unspecified Value Set) with (Telehealth POS Value Set) with a 

mental health provider
Follow-Up After Emergency Department Visit For Substance Use: Age 18 And Older

(FUA-AD)

218

A telephone visit (Telephone Visits Value Set), with any diagnosis of SUD (AOD Abuse and 

Dependence Value Set), substance use (Substance Induced Disorders Value Set) or drug 

overdose (Unintentional Drug Overdose Value Set)

A telephone visit (Telephone Visits Value Set), with a mental health provider

An e-visit or virtual check-in (Online Assessments Value Set), with any diagnosis of SUD (AOD 

Abuse and Dependence Value Set), substance use (Substance Induced Disorders Value Set) or 

drug overdose (Unintentional Drug Overdose Value Set)

An e-visit or virtual check-in (Online Assessments Value Set), with a mental health provider

A substance use disorder service (Substance Use Disorder Services Value Set)

A behavioral health screening or assessment for SUD or mental health disorders (Behavioral Health 

Assessment Value Set)

A substance use service (Substance Use Services Value Set)

A pharmacotherapy dispensing event (Alcohol Use Disorder Treatment Medications List, Opioid 

Use Disorder Treatment Medications List, see link to the Medication List Directory in Guidance 

for Reporting above) or medication treatment event (AOD Medication Treatment Value Set; 

OUD Weekly Drug Treatment Service Value Set)

D. ADDITIONAL NOTES

There may be different methods for billing intensive outpatient visits and partial hospitalizations. 

Some methods may be comparable to outpatient billing, with separate claims for each date of 

service; others may be comparable to inpatient billing, with an admission date, a discharge date, and 

units of service. Where billing methods are comparable to inpatient billing, each unit of service may 

be counted as an individual visit. The unit of service must have occurred during the required period 

for the rate (e.g., within 30 days after the ED visit or within 7 days after the ED visit).
219

Follow-Up After Emergency Department Visit for Substance Use: Ages 13 to 17 (FUA-CH)

Measure FUA-CH: Follow-Up After Emergency Department Visit for Substance 

Use: Ages 13 to 178,18

Based on a CMS Medicaid Child Core Set Measure (2023), which is derived from a measure stewarded 

by the National Committee for Quality Assurance (NCQA)20

A. DESCRIPTION

Percentage of emergency department (ED) visits for beneficiaries [clients] ages 13 to 17 years with a

principal diagnosis of substance use disorder (SUD), or any diagnosis of drug overdose, for which

there was follow-up. Two rates are reported:

• Percentage of ED visits for which the beneficiary [client] received follow-up within 30 days of

the ED visit (31 total days)

• Percentage of ED visits for which the beneficiary [client] received follow-up within 7 days of the

ED visit (8 total days)

Data Collection Method: Administrative

8The NCQA HEDIS® measure specification has been adjusted pursuant to NCQA’s Rules for Allowable 

Adjustments of HEDIS. 

20Adapted from an NCQA measure with financial support from the Office of the Assistant Secretary for Planning 

and Evaluation (ASPE) under Prime Contract No. HSP23320100019WI/HHSP23337001T, in which NCQA was a 

subcontractor to Mathematica. Additional financial support was provided by the Substance Abuse and Mental 

Health Services Administration (SAMHSA). 

18Aside from the minor modifications noted in this specification, this specification is taken directly from the 2023 

CMS Medicaid Child Core Set Measures. Use the most current version for the year being reported. See also 

Important Supplemental Materials for State-Collected Required BHC Measures derived from CMS Medicaid Adult 

and/or Child Core Set Measures (in this manual immediately before this specification). 
Follow-Up After Emergency Department Visit for Substance Use: Ages 13 to 17 (FUA-CH)

220

Guidance for Reporting: 

• For HEDIS, this measure has three reportable age groups and a total rate: ages 13 to 17, ages 

18 to 64, age 65 and older, and total (age 13 and older). The [Medicaid] Child Core Set 

measure applies to beneficiaries ages 13 to 17 and the [Medicaid] Adult Core Set measure 

applies to beneficiaries age 18 and older. [For the purpose of Behavioral Health Clinic (BHC) 

reporting, states should calculate and report this child measure as one age group: clients ages 

13 to 17 years.]

• The denominator should be the same for the 30-day rate and the 7-day rate within each age 

group. 

• The 30-day follow-up rate should be greater than or equal to the 7-day follow-up rate.

• When a visit code or procedure code must be used in conjunction with a diagnosis code, the 

codes must be on the same claim or from the same visit. 

- If a value set includes codes used on professional claims (e.g., CPT, HCPCS) and includes 

codes used on facility claims (e.g., UB), use diagnosis and procedure codes from both 

facility and professional claims to identify services and diagnoses (the codes can be on the 

same claim or from the same visit).

- If a value set includes codes used only on facility claims (e.g., UB) then use only facility 

claims to identify services and diagnoses (the codes must be on the same claim).

• Include all paid, suspended, pending and denied claims. 

• Refer to [Appendix D of this manual] for the definition of a mental health provider. States must 

develop their own methods to identify mental health providers. 

• NCQA’s Medication List Directory (MLD) for Alcohol Use Disorder Treatment and Opioid 

Use Disorder Treatment medications are available to order free of charge in the NCQA Store 

(https://store.ncqa.org/hedis-my-2022-medication-list-directory.html). [Use version current for 

year reporting.] Once ordered, the Medication List Directory can be accessed through the 

NCQA Download Center (https://my.ncqa.org/Downloads).

• This measure includes an optional exclusion for beneficiaries [clients] who die during the 

measurement year. For additional information, refer to the deceased beneficiary [client]

exclusion guidance in Section II. Data Collection and Reporting of the Child Core Set [Section 

III. Technical Specification Components].

This measure’s Value Set Directory includes the following coding systems for services, procedures, 

and diagnoses: CPT, HCPCS, ICD-10-CM, POS, SNOMED, and UB. The Medication List Directory 

includes the following coding systems for medications: NDC and RxNorm. Refer to the 

Acknowledgments section at the beginning of the manual for copyright information.

B. ELIGIBLE POPULATION

Age Ages 13 to 17 as of the ED visit.

Continuous 

enrollment

Date of the ED visit through 30 days after the ED visit (31 total days).

Allowable gap No allowable gaps in the continuous enrollment period.

Anchor date None.

Benefit Medical, chemical dependency, and pharmacy.

Note: Beneficiaries [Clients] with detoxification-only chemical dependency 

benefits do not meet these criteria.
Follow-Up After Emergency Department Visit for Substance Use: Ages 13 to 17 (FUA-CH)

221

Event/diagnosis An ED visit (ED Value Set) with a principal diagnosis of SUD (AOD 

Abuse and Dependence Value Set) or any diagnosis of drug overdose 

(Unintentional Drug Overdose Value Set) on or between January 1 and 

December 1 of the measurement year where the beneficiary [client] was 

between ages 13 and 17 on the date of the visit.

The denominator for this measure is based on ED visits, not on 

beneficiaries [clients]. If a beneficiary [client] has more than one ED visit, 

identify all eligible ED visits between January 1 and December 1 of the 

measurement year and do not include more than one visit per 31-day period 

as described below.

Multiple visits in a 

31-day period

If a beneficiary [client] has more than one ED visit in a 31-day period, 

include only the first eligible ED visit. For example, if a beneficiary [client] 

has an ED visit on January 1, include the January 1 visit and do not include 

ED visits that occur on or between January 2 and January 31; then, if 

applicable, include the next ED visit that occurs on or after February 1. 

Identify visits chronologically, including only one per 31-day period. 

Note: Removal of multiple visits in a 31-day period is based on eligible 

visits. Assess each ED visit for exclusions before removing multiple visits 

in a 31-day period.

ED visits followed 

by inpatient 

admission

Exclude ED visits that result in an inpatient stay and ED visits followed by 

an admission to an acute or nonacute inpatient care setting on the date of 

the ED visit or within the 30 days after the ED visit, regardless of the 

principal diagnosis for the admission. To identify admissions to an acute or 

nonacute inpatient care setting: 

7. Identify all acute and nonacute inpatient stays (Inpatient Stay Value 

Set). 

8. Identify the admission date for the stay. 

An ED or observation visit billed on the same claim as an inpatient stay is 

considered a visit that resulted in an inpatient stay. These events are 

excluded from this measure because admission to an acute or nonacute 

inpatient setting may prevent an outpatient follow-up visit from taking 

place. 

Required exclusion Beneficiaries [Clients] in hospice or using hospice services anytime during 

the measurement year. For additional information, refer to the hospice 

exclusion guidance in Section II. Data Collection and Reporting of the 

Child Core Set [Section III. Technical Specification Components].

C. ADMINISTRATIVE SPECIFICATION

Denominator

The eligible population as defined above.

Numerator

30-Day Follow-Up 

A follow-up visit or pharmacotherapy dispensing event within 30 days after the ED visit (31 total 

days). Include visits and pharmacotherapy events that occur on the date of the ED visit.

7-Day Follow-Up 
Follow-Up After Emergency Department Visit for Substance Use: Ages 13 to 17 (FUA-CH)

222

A follow-up visit or pharmacotherapy dispensing event within 7 days after the ED visit (8 total 

days). Include visits and pharmacotherapy events that occur on the date of the ED visit.

For both indicators, any of the following meet criteria for a follow-up visit:

• An outpatient visit (Visit Setting Unspecified Value Set) with (Outpatient POS Value Set) with

any diagnosis of SUD (AOD Abuse and Dependence Value Set), substance use (Substance

Induced Disorders Value Set) or drug overdose (Unintentional Drug Overdose Value Set)

• An outpatient visit (Visit Setting Unspecified Value Set) with (Outpatient POS Value Set) with a

mental health provider

• An outpatient visit (BH Outpatient Value Set) with any diagnosis of SUD (AOD Abuse and

Dependence Value Set), substance use (Substance Induced Disorders Value Set) or drug

overdose (Unintentional Drug Overdose Value Set)

• An outpatient visit (BH Outpatient Value Set) with a mental health provider

• An intensive outpatient encounter or partial hospitalization (Visit Setting Unspecified Value Set)

with (Partial Hospitalization POS Value Set) with any diagnosis of SUD (AOD Abuse and

Dependence Value Set), substance use (Substance Induced Disorders Value Set) or drug

overdose (Unintentional Drug Overdose Value Set)

• An intensive outpatient encounter or partial hospitalization (Visit Setting Unspecified Value Set)

with (Partial Hospitalization POS Value Set) with a mental health provider

• An intensive outpatient encounter or partial hospitalization (Partial Hospitalization or Intensive

Outpatient Value Set) with any diagnosis of SUD (AOD Abuse and Dependence Value Set),

substance use (Substance Induced Disorders Value Set) or drug overdose (Unintentional Drug

Overdose Value Set)

• An intensive outpatient encounter or partial hospitalization (Partial Hospitalization or Intensive

Outpatient Value Set) with a mental health provider

• A non-residential substance abuse treatment facility visit (Visit Setting Unspecified Value Set)

with (Non-residential Substance Abuse Treatment Facility POS Value Set) with any diagnosis of

SUD (AOD Abuse and Dependence Value Set), substance use (Substance Induced Disorders

Value Set) or drug overdose (Unintentional Drug Overdose Value Set)

• A non-residential substance abuse treatment facility visit (Visit Setting Unspecified Value Set)

with (Non-residential Substance Abuse Treatment Facility POS Value Set) with a mental health

provider

• A community mental health center visit (Visit Setting Unspecified Value Set) with (Community

Mental Health Center POS Value Set) with any diagnosis of SUD (AOD Abuse and Dependence

Value Set), substance use (Substance Induced Disorders Value Set) or drug overdose

(Unintentional Drug Overdose Value Set)

• A community mental health center visit (Visit Setting Unspecified Value Set) with (Community

Mental Health Center POS Value Set) with a mental health provider

• An observation visit (Observation Value Set) with any diagnosis of SUD (AOD Abuse and

Dependence Value Set), substance use (Substance Induced Disorders Value Set) or drug

overdose (Unintentional Drug Overdose Value Set)

• An observation visit (Observation Value Set) with a mental health provider

• A peer support service (Peer Support Services Value Set) with any diagnosis of SUD (AOD

Abuse and Dependence Value Set), substance use (Substance Induced Disorders Value Set) or

drug overdose (Unintentional Drug Overdose Value Set)
Follow-Up After Emergency Department Visit for Substance Use: Ages 13 to 17 (FUA-CH)

• An opioid treatment service that bills monthly or weekly (OUD Weekly Non Drug Service Value

Set; OUD Monthly Office Based Treatment Value Set) with any diagnosis of SUD (AOD Abuse

and Dependence Value Set), substance use (Substance Induced Disorders Value Set) or drug

overdose (Unintentional Drug Overdose Value Set)

• A telehealth visit (Visit Setting Unspecified Value Set) with (Telehealth POS Value Set) with

any diagnosis of SUD (AOD Abuse and Dependence Value Set), substance use (Substance

Induced Disorders Value Set) or drug overdose (Unintentional Drug Overdose Value Set)

• A telehealth visit (Visit Setting Unspecified Value Set) with (Telehealth POS Value Set) with a

mental health provider

• A telephone visit (Telephone Visits Value Set), with any diagnosis of SUD (AOD Abuse and

Dependence Value Set), substance use (Substance Induced Disorders Value Set) or drug

overdose (Unintentional Drug Overdose Value Set)

• A telephone visit (Telephone Visits Value Set), with a mental health provider

• An e-visit or virtual check-in (Online Assessments Value Set), with any diagnosis of SUD (AOD

Abuse and Dependence Value Set), substance use (Substance Induced Disorders Value Set) or

drug overdose (Unintentional Drug Overdose Value Set)

• An e-visit or virtual check-in (Online Assessments Value Set), with a mental health provider

• A substance use disorder service (Substance Use Disorder Services Value Set)

• A behavioral health screening or assessment for SUD or mental health disorders (Behavioral

Health Assessment Value Set)

• A substance use service (Substance Use Services Value Set)

• A pharmacotherapy dispensing event (Alcohol Use Disorder Treatment Medications List, Opioid

Use Disorder Treatment Medications List, see link to the Medication List Directory in Guidance

for Reporting above) or medication treatment event (AOD Medication Treatment Value Set;

OUD Weekly Drug Treatment Service Value Set)

D. ADDITIONAL NOTES

There may be different methods for billing intensive outpatient visits and partial hospitalizations.

Some methods may be comparable to outpatient billing, with separate claims for each date of

service; others may be comparable to inpatient billing, with an admission date, a discharge date, and

units of service. Where billing methods are comparable to inpatient billing, each unit of service may

be counted as an individual visit. The unit of service must have occurred during the required period

for the rate (e.g., within 30 days after the ED visit or within 7 days after the ED visit).

223
State-Collected Measures Optional for Submission as Part of CCBHC 

Demonstration 

State-Collected Measures Optional for Submission as Part of CCBHC 

Demonstration

This section of Chapter V includes the following State-Collected optional measures:

1. Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics 

(APP-CH) — including supplemental materials

2. Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM-CH) —

including supplemental materials

224
Supplemental Materials for State-Collected Measures Optional for 

Submission as Part of CCBHC Demonstration (APP-CH and APM-CH)

Important Supplemental Materials for State-Collected Optional BHC 

Measures derived from CMS Medicaid Adult and/or Child Core Set 

Measures (APP-CH and APM-CH)

These supplemental materials are necessary for implementation of the StateCollected Optional BHC Measures that are derived from the CMS Medicaid Adult and/or Child 

Core Set Measures. This volume includes the exact specifications that are on the CMS website 

for the 2023 Medicaid Core Set, with all simple modifications noted in the text. Additional 

needed modifications are included below, as well as supplemental useful materials.

1. Measure APP-CH: Use of First-Line Psychosocial Care for Children and 

Adolescents on Antipsychotics

2. Measure APM-CH: Metabolic Monitoring for Children and Adolescents on 

Antipsychotics

Changes within the specification: For both the APP-CH and APM-CH measures, the changes in 

the specification from the CMS Medicaid Child Core Set reflects: (1) substitution of the word 

“client” for “beneficiary” or “patient”, unless the latter is part of a copyrighted code description; 

(2) removal of age stratification included in the Core Set measures (i.e., applicable here to 

children ages 1 to 17 years); and (3) removal of references to the Core Set.

Additional information: For both the APP-CH and APM-CH measures, the following material is 

provided to assist clinics using the specifications and follows the numbering system used in the 

non-Core derived BHC specifications:

A. DESCRIPTION

Important Reporting Guidance:

• Both the APP-CH and APM-CH measures are optionally available to be used by 

states to measure performance related to clients seen at the Provider during the 

Measurement Year.

• Current value sets are available on the CMS Medicaid Child Core Set Reporting 

Resource website. Use the version current for the year being reported.

• Both APP-CH and APM-CH may be stratified separately based on whether the client 

is:

o Medicaid only or Other (including those dually eligible for Medicare and 

Medicaid)

AND

o A member of which of the following ethnic groups: Not Hispanic or Latino, 

Hispanic or Latino, or Unknown

AND

225
Supplemental Materials for State-Collected Measures Optional for 

Submission as Part of CCBHC Demonstration (APP-CH and APM-CH)

o A member of which of the following racial groups: White or Caucasian, Black or 

African American, American Indian or Alaska Native, Asian, Native Hawaiian or 

Other Pacific Islander, More than one race, or Unknown

• Refer to the specific data-reporting template for the reporting requirements applicable 

to each measure.

Measurement Period: The Measurement Period is the period for which data are required for 

reporting purposes. 

• The APP-CH Measurement Period for the denominator has two components: (1) the 

Index Prescription Start Date (IPSD), which is January 1 through December 1, if the 

Measurement Year is the Calendar Year; and (2) the period of Negative Medication 

Review, which is the 120 days before the IPSD. The Measurement Period for the 

numerator is 90 days prior to the IPSD through 30 days after the IPSD.

• The APM-CH Measurement Period for both the denominator and numerator are the 

Measurement Year. 

B. DEFINITIONS

TERM DEFINITION 

Measurement Period

The specific time period for which data are needed for the 

numerator and denominator of a given measure. The Measurement 

Period may differ for the numerator and denominator and for each 

measure and is specified in section A above.

Measurement Year The standard 12-month reporting period common to all measures 

being reported by the Provider.

Percentage A Percentage is calculated as follows: numerator divided by 

denominator (n/d).

Provider The Provider entity that is being measured (i.e., BHC) 

E. ADDITIONAL NOTES

Interpretation of scores: Better quality = Higher Percentage

F. FREQUENTLY ASKED QUESTIONS

None

226
Measure APP-CH: Use of First-Line Psychosocial Care for Children and 

Adolescents on Antipsychotics

Measure APP-CH: Use of First-Line Psychosocial Care for Children and 

Adolescents on Antipsychotics8,18

Based on a CMS Medicaid Child Core Set Measure (2023), which is derived from a measure 

stewarded by the National Committee for Quality Assurance (NCQA)21

A. DESCRIPTION

Percentage of children and adolescents ages 1 to 17 who had a new prescription for an antipsychotic

medication and had documentation of psychosocial care as first-line treatment.

Data Collection Method: Administrative

Guidance for Reporting: 

This measure applies to beneficiaries [clients] ages 1 to 17. For the purpose of [Medicaid] Child 

Core Set reporting, states should calculate and report this measure for two age groups and a 

total rate: ages 1 to 11, ages 12 to 17, and total (ages 1 to 17). [For the purpose of Behavioral 

Health Clinic reporting, states should report only the total rate.]

This measure intends to assess use of psychosocial care as a first-line treatment for conditions for 

which antipsychotic medications are not indicated. This measure’s value set contains typical 

forms of psychological services, such as behavioral interventions, psychological therapies, and 

crisis intervention.

Include all paid, suspended, pending, and denied claims.

This measure includes an optional exclusion for beneficiaries [clients] who die during the 

measurement year. For additional information, refer to the deceased beneficiary [client] 

exclusion guidance in Section II. Data Collection and Reporting of the Child Core Set [Section 

III. Technical Specification Components].

NCQA’s Medication List Directory (MLD) for Antipsychotic Medications and Antipsychotic 

Combination Medications is available to order free of charge in the NCQA Store 

(https://store.ncqa.org/hedis-my-2022-medication-list-directory.html). [Use version current for 

year reporting.] Once ordered, the Medication List Directory can be accessed through the 

NCQA Download Center (https://my.ncqa.org/Downloads).

This measure’s Value Set Directory includes the following coding systems for services, procedures, 

and diagnoses: CPT, HCPCS, ICD-10-CM, ICD-10-PCS, POS, SNOMED, and UB. The Medication 

List Directory includes the following coding systems for medications: NDC and RxNorm. Refer to 

the Acknowledgments section at the beginning of the manual for copyright information. 

B. DEFINITIONS

Intake Period January 1 through December 1 of the measurement year. 

18Aside from the minor modifications noted in this specification, this specification is taken directly from the 2023 

CMS Medicaid Child Core Set Measures. Use the most current version for the year being reported. See also 

Important Supplemental Materials for State-Collected Optional BHC Measures derived from CMS Medicaid Adult 

and/or Child Core Set Measures (in this manual immediately before this specification).

8The NCQA HEDIS® measure specification has been adjusted pursuant to NCQA’s Rules for Allowable 

Adjustments of HEDIS.

21The original measure was developed with financial support from the Agency for Healthcare Research and Quality 

(AHRQ) and CMS under the CHIPRA Pediatric Quality Measures Program Centers of Excellence grant number 

U18 HS020503, from a measure developed by MedNet Medical Solutions.

227
Measure APP-CH: Use of First-Line Psychosocial Care for Children and 

Adolescents on Antipsychotics

IPSD Index Prescription Start Date (IPSD). The earliest prescription dispensing 

date for an antipsychotic medication where the date is in the Intake Period 

and there is a Negative Medication History. 

Negative 

Medication History

A period of 120 days (4 months) prior to the IPSD when the beneficiary

[client] had no antipsychotic medications dispensed for either new or refill 

prescriptions. 

C. ELIGIBLE POPULATION

Age Ages 1 to 17 as of December 31 of the measurement year. 

Continuous 

enrollment

120 days (4 months) prior to the IPSD through 30 days after the IPSD.

Allowable gap No allowable gaps in the continuous enrollment period.

Anchor date IPSD.

Benefit Medical, mental health, and pharmacy.

Event/diagnosis Follow the steps below to identify the eligible population.

Step 1

Identify all beneficiaries [clients] in the specified age range who were 

dispensed an antipsychotic medication (Antipsychotic Medications List and 

Antipsychotic Combination Medications List, see link to the Medication 

List Directory in Guidance for Reporting above) during the Intake Period.

Step 2

Test for Negative Medication History. For each beneficiary [client]

identified in step 1, test each antipsychotic prescription for a Negative 

Medication History. The IPSD is the dispensing date of the earliest 

antipsychotic prescription in the Intake Period with a Negative Medication 

History.

Step 3

Calculate continuous enrollment. Beneficiaries [Clients] must be 

continuously enrolled for 120 days (4 months) prior to the IPSD through 30 

days after the IPSD.

Step 4: Required exclusions 

Exclude beneficiaries [clients] for whom first-line antipsychotic 

medications may be clinically appropriate. Any of the following during the 

measurement year meet criteria:

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. 

Either of the following code combinations meet criteria:

BH Stand Alone Acute Inpatient Value Set with (Schizophrenia Value 

Set; Bipolar Disorder Value Set; Other Psychotic and Developmental 

Disorders Value Set).

Visit Setting Unspecified Value Set with Acute Inpatient POS Value Set

with (Schizophrenia Value Set; Bipolar Disorder Value Set; Other 

Psychotic and Developmental Disorders Value Set).

228
Measure APP-CH: Use of First-Line Psychosocial Care for Children and 

Adolescents on Antipsychotics

Event/diagnosis

(continued)

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 of the following code combinations with 

(Schizophrenia Value Set; Bipolar Disorder Value Set; Other Psychotic 

and Developmental Disorders Value Set), meet criteria:

An outpatient visit (Visit Setting Unspecified Value Set with Outpatient 

POS Value Set).

An outpatient visit (BH Outpatient Value Set).

An intensive outpatient encounter or partial hospitalization (Visit 

Setting Unspecified Value Set with Partial Hospitalization POS 

Value Set).

An intensive outpatient encounter or partial hospitalization (Partial 

Hospitalization or Intensive Outpatient Value Set).

A community mental health center visit (Visit Setting Unspecified 

Value Set with Community Mental Health Center POS Value Set).

Electroconvulsive therapy (Electroconvulsive Therapy Value Set).

An observation visit (Observation Value Set).

A telehealth visit (Visit Setting Unspecified Value Set with Telehealth 

POS Value Set).

A telephone visit (Telephone Visits Value Set).

An e-visit or virtual check-in (Online Assessments Value Set).

Beneficiaries [Clients] in hospice or using hospice services anytime during 

the measurement year. For additional information, refer to the hospice 

exclusion guidance in Section II. Data Collection and Reporting of the 

Child Core Set [Section III. Technical Specification Components].

D. ADMINISTRATIVE SPECIFICATION

Denominator

The eligible population as defined above.

Numerator

Documentation of psychosocial care (Psychosocial Care Value Set) in the 121-day period from 90 

days prior to the IPSD through 30 days after the IPSD.

229
Measure APM-CH: Metabolic Monitoring for Children and Adolescents on 

Antipsychotics

Measure APM-CH: Metabolic Monitoring for Children and Adolescents on 

Antipsychotics8,18

Based on a CMS Medicaid Child Core Set Measure (2023), which is derived from a measure 

stewarded by the National Committee for Quality Assurance (NCQA)21

A. DESCRIPTION

Percentage of children and adolescents ages 1 to 17 who had two or more antipsychotic prescriptions

and had metabolic testing. Three rates are reported:

Percentage of children and adolescents on antipsychotics who received blood glucose testing

Percentage of children and adolescents on antipsychotics who received cholesterol testing

Percentage of children and adolescents on antipsychotics who received blood glucose and cholesterol

testing

Data Collection Method: Administrative22

Guidance for Reporting: 

This measure applies to beneficiaries [clients] ages 1 to 17. For the purpose of [Medicaid] Child 

Core Set reporting, states should calculate and report this measure for two age groups and a 

total rate: ages 1 to 11, ages 12 to 17, and total (ages 1 to 17). [For the purpose of Behavioral 

Health Clinic reporting, states should report only the total rate.]

Include all paid, suspended, pending, and denied claims.

This measure includes an optional exclusion for beneficiaries [clients] who die during the 

measurement year. For additional information, refer to the deceased beneficiary [client] 

exclusion guidance in Section II. Data Collection and Reporting of the Child Core Set [Section 

III. Technical Specification Components].

NCQA’s Medication List Directory (MLD) for Antipsychotic, Antipsychotic Combination, and 

Prochlorperazine medications are available to order free of charge in the NCQA Store 

(https://store.ncqa.org/hedis-my-2022-medication-list-directory.html). [Use version current for 

year reporting.] Once ordered, the Medication List Directory can be accessed through the 

NCQA Download Center (https://my.ncqa.org/Downloads).

This measure’s Value Set Directory includes the following coding systems for services, procedures, 

and diagnoses: CPT, HCPCS, LOINC, SNOMED, and UB. The Medication List Directory includes 

the following coding systems for medications: NDC and RxNorm. Refer to the Acknowledgments 

section at the beginning of the manual for copyright information. 

18Aside from the minor modifications noted in this specification, this specification is taken directly from the 2023 

CMS Medicaid Child Core Set Measures. Use the most current version for the year being reported. See also Important 

Supplemental Materials for State-Collected Optional BHC Measures derived from CMS Medicaid Adult and/or Child 

Core Set Measures (in this manual immediately before the APP-CH specification). 

8The NCQA HEDIS® measure specification has been adjusted pursuant to NCQA’s Rules for Allowable Adjustments

of HEDIS. 

21The original measures was developed with financial support from the Agency for Healthcare Research and Quality 

(AHRQ) and CMS under the CHIPRA Pediatric Quality Measures Program Centers of Excellence grant number U18 

HS020503, from a measure developed by MedNet Medical Solutions. 

22The Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM) measure is also specified for 

Electronic Clinical Data System (ECDS) reporting for HEDIS. ECDS specifications are not currently available for 

Child Core Set reporting. 

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Measure APM-CH: Metabolic Monitoring for Children and Adolescents on 

Antipsychotics

B. ELIGIBLE POPULATION

Age Ages 1 to 17 as of December 31 of the measurement year. 

Continuous 

enrollment

The measurement year.

Allowable gap No more than one gap in enrollment of up to 45 days during the 

measurement year. 

Anchor date December 31 of the measurement year.

Benefit Medical and pharmacy.

Event/diagnosis At least two antipsychotic medication dispensing events (Antipsychotic 

Medications List, Antipsychotic Combination Medications List, 

Prochlorperazine Medications List, see link to the Medication List 

Directory in Guidance for Reporting above) of the same or different 

medications, on different dates of service during the measurement year.

Required exclusion Beneficiaries [Clients] in hospice or using hospice services anytime during 

the measurement year. For additional information, refer to the hospice 

exclusion guidance in Section II. Data Collection and Reporting of the 

Child Core Set [Section III. Technical Specification Components].

C. ADMINISTRATIVE SPECIFICATION

Denominator

The eligible population as defined above.

Numerator

Blood Glucose

Beneficiaries [Clients] who received at least one test for blood glucose (Glucose Lab Test Value Set; 

Glucose Test Result or Finding Value Set) or HbA1c (HbA1c Lab Test Value Set; HbA1c Test 

Result or Finding Value Set) during the measurement year.

Cholesterol

Beneficiaries [Clients] who received at least one test for LDL-C (LDL-C Lab Test Value Set; LDL-C 

Test Result or Finding Value Set) or cholesterol (Cholesterol Lab Test Value Set; Cholesterol Test 

Result or Finding Value Set) during the measurement year.

Blood Glucose and Cholesterol 

Beneficiaries [Clients] who received both the following during the measurement year on the same or 

different dates of service.

At least one test for blood glucose (Glucose Lab Test Value Set, Glucose Test Result or Finding 

Value Set) or HbA1c (HbA1c Lab Test Value Set, HbA1c Test Result or Finding Value Set). 

At least one test for LDL-C (LDL-C Lab Test Value Set; LDL-C Test Result or Finding Value Set) 

or cholesterol (Cholesterol Lab Test Value Set; Cholesterol Test Result or Finding Value Set). 

231
Appendices

VI. Appendices

Appendix A. Glossary of Terms

Appendix B. Denominator and Numerator Measurement Periods for BHC Quality Measures

Appendix C. Guidance for Selecting Sample Sizes for Hybrid Measures

Appendix D. Definitions of Medicaid/CHIP Core Set Practitioner Types

Appendix E. Core Set Value Set Directory User Manual

232
Appendix A. Glossary of Terms

Appendix A. Glossary of Terms

BHC. A BHC is a Behavioral Health Clinic (including but not limited to CCBHCs and 

CCBHC-Es). BHC measures are broadly specified to be calculated at the BHC level.

BHC Provider. Any entity (provider) engaged in the delivery of health care services and 

who is legally authorized to do so by the state in which the individual or entity delivers the

services and who delivers services as a BHC (entity) or part of a BHC (provider). See 

Appendix D for definitions of certain practitioner types.

CCBHC. A Certified Community Behavioral Health Clinic (CCBHC) is a BHC 

certified by the state to participate in the Section 223 Demonstration to improve

community mental health services authorized by Section 223 of the federal Protecting 

Access to Medicare Act (PAMA). See the CCBHC Certification Criteria for more 

information.

CCBHC-E. A CCBHC-E is a BHC that has received a SAMHSA discretionary grant 

to operate as a CCBHC-Expansion clinic and that has self-attested to meeting the 

CCBHC Certification Criteria. Some CCBHC-Es may be required by the terms of their 

grant to report clinic-reported quality measures. Additionally, some CCBHC-Es also 

are Section 223 Demonstration CCBHCs and, therefore, required to report according to 

that Demonstration.

Client, Patient, or Person Receiving Services. An individual (adult or child) receiving

services from a BHC program.

Data-Reporting Template. In addition to the measures specified in this manual, datareporting templates have been developed for reporting these measures. Those templates 

will be available on the SAMHSA website. Within each template, specific fields are 

provided for required data elements. Those fields are as follows:

• Measurement Year: Identifies the year to which the report corresponds (e.g., 

Demonstration Year 6, Fiscal Year 2023)

• Data Source: Identifies whether the data are derived from administration claims 

data, medical records, a hybrid source, or a survey

• Date Range for Measurement Period: Identifies the Measurement Period in which

data were collected that are used in calculating the denominator and numerator of 

a measure (not necessarily the same as the Measurement Year)

• Performance Measure: The description of, and table for calculation of and 

reporting, the measure rate

• Adherence to Measure Specifications: Allows the reporter to indicate the 

population measured and ways in which data collection or reporting might differ 

233
Appendix A. Glossary of Terms

from the specifications

• Additional Notes: Allows the reporter to provide additional information

Designated Collaborating Organization. Briefly, a Designated Collaborating 

Organization (DCO) is an entity that is not under the direct supervision of the CCBHC but 

is engaged in a formal relationship with the CCBHC to deliver one or more (or elements of) 

of the required services as described in CCBHC certification criteria 4. Appendix A of the 

CCBHC certification criteria include a full definition.

Eligible Population for Measurement. In the broadest sense, the eligible population for 

these measures includes all BHC clients served by a BHC provider. The

• denominator-eligible population for each measure includes BHC clients who 

satisfy the measure-specific eligibility criteria, which may include requirements 

such as age or continuous enrollment. The specifications in Chapters IV and V 

indicate the population that should be included in each measure. For all measures, 

the denominator includes clients (or visits) that satisfy measure-specific eligibility 

criteria (e.g., all clients aged 18 years and older who were seen at the BHC during 

the Measurement Year for a specified number of coded encounters (Preventive 

Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling 

(ASC)).

• States will, for all state-collected measures, except the experience of care survey 

measures (PEC and Y/FEC), obtain data on populations eligible for measurement 

from claims and encounter data in their Transformed Medicaid Statistical 

Information System (T-MSIS). Behavioral health clinics will rely on internal

records for data to support clinic-collected measures. 

Measure. Quality or performance measures follow a particular formula; the denominator 

indicates the eligible population (with the exceptions of any exclusions specific to the 

measure), and the numerator indicates the part of the eligible population that received the 

service or had the outcome to which the measure relates. There are a few exceptions 

included in the BHC measures, including I-SERV, PEC, and Y/FEC, where the 

denominator and numerator do not follow this formula.

Measure Steward. The measure steward is the organization responsible for maintaining a 

particular measure or measure set. Responsibilities of the measure steward include updating 

codes that are included in technical specifications and adjusting measures as the clinical 

evidence changes.

Measurement Period. The specific time period for which data are needed for the 

numerator and denominator of a given measure. Measurement Periods may differ for the 

numerator and denominator or they may be the same and they may or may not be the same 

234
Appendix A. Glossary of Terms

as the Measurement Year.

Measurement Year. The standard 12-month reporting period common to all measures 

being reported by the Provider.

Quality Bonus Measure (QBM). QBMs are the subset of measures that have been 

selected for incentive payments (Quality Bonus Payments or QBPs) as part of the Section 

223 Demonstration Program (see Tables 1 and 2 in this manual).

235
Appendix B. Denominator and Numerator Measurement Periods for BHC 

Quality Measures

Appendix B. Denominator and Numerator Measurement Periods for 

BHC Quality Measures

For all BHC measures sourced from the CMS Medicaid Adult and/or Child Core Set Measures, 

please see the most current information on measure-specific Measurement Periods on the 

CMS website at Link to CMS Adult and Child Health Care Quality Measures. 

For the FFY 2023 Measurement Period Tables, which correspond to the BHC measures as 

published in 2023, links to the tables are at Link to Adult Medicaid Core Set Measurement 

Period Table and Link to Child Medicaid Core Set Measurement Period Table. 

For the BHC measures, as published in 2023, the measures sourced from the Medicaid Core Sets

include those listed in Table B1.

Table B1. BHC Measures Sourced from CMS Medicaid Adult and/or Child Core Sets in 2023

Clinic-Collected Measures

Screening for Clinical Depression and Follow-Up Plan (CDF-AD and CDF-CH)

Weight Assessment and Counseling for Nutrition and Physical Activity for 

Children/Adolescents (WCC-CH) (optional for clinics)

Controlling High Blood Pressure (CBP-AD) (optional for clinics)

State-Collected Measures

Adherence to Antipsychotic Medications for Individuals with Schizophrenia (SAA-AD) 

Follow-Up After Hospitalization for Mental Illness, ages 18+ (adult) (FUH-AD and FUH-CH)

Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (IET-AD) 

Follow-Up After Emergency Department Visit for Mental Illness (FUM-AD and FUM-CH)

Follow-Up After Emergency Department Visit for Alcohol and Other Drug Dependence (FUA-AD 

and FUA-CH)

Plan All-Cause Readmissions Rate (PCR-AD)

Follow-Up Care for Children Prescribed Attention-Deficit Hyperactivity Disorder (ADHD) 

Medication (ADD-CH)

Antidepressant Medication Management (AMM-BH)

Use of Pharmacotherapy for Opioid Use Disorder (OUD-AD) 

Hemoglobin A1c Control for Patients with Diabetes (HBD-AD)

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

(optional for states)

Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM-CH) (optional for 

states)

The Measurement Periods for all other BHC measures are identified in Table B2. 

236
Appendix B. Denominator and Numerator Measurement Periods for BHC 

Quality Measures

Table B2. Measurement Periods for BHC Measures NOT Sourced from CMS Medicaid Adult 

and/or Child Core Set Measures

Measure Denominator Numerator

Clinic-Collected Measures

Time to Services (I-SERV)

• I-SERV Submeasures 1 and 2 MY, excluding the 

last month of the 

MY, and including 

the 6 months 

preceding the MY

MY

• I-SERV Submeasure 3 MY, excluding the 

last 24 hours, and 

including the 24 

hours immediately 

preceding the MY

MY

Depression Remission at Six Months (DEPREM-6)MY Four months after 

the beginning of the 

MY through eight 

(8) months past the 

end of the MY

Preventive Care and Screening: Unhealthy

Alcohol Use: Screening and Brief Counseling

(ASC)

MY MY and the prior 

year

Screening for Social Drivers of Health (SDOH) MY MY

Preventive Care & Screening: Tobacco Use:

Screening & Cessation Intervention (TSC)

(optional for clinics)

• TSC Submeasure 1 MY MY

• TSC Submeasures 2 and 3 MY MY and the prior 6 

months

Adult Major Depressive Disorder (MDD): 

Suicide Risk Assessment (SRA-A) (optional for 

clinics)

MY MY and the prior 

105 days

Child and Adolescent Major Depressive Disorder

(MDD): Suicide Risk Assessment (SRA-C) 

(optional for clinics)

MY MY

State-Collected Measures

Patient Experience of Care Survey (PEC) MY MY

Youth/Family Experience of Care Survey (Y/FEC) MY MY

Key: MY, Measurement Year

237
Appendix C. Guidance for Selecting Sample Sizes for Hybrid 

Measures

Appendix C. Guidance for Selecting Sample Sizes for Hybrid Measures

Three of the BHC measures include options to collect data and calculate using a hybrid 

approach, along with other options. The three measures are all sourced from the CMS Medicaid 

Adult Core Set Measures (as of 2023). They are identified in Table C1.

Table C1. BHC Measures with Option to Use a Hybrid Approach

Measure

Weight Assessment and Counseling for Nutrition and Physical Activity for 

Children/Adolescents (WCC-CH) (measure optional for clinics)

Controlling High Blood Pressure (CBP-AD) (measure optional for clinics)

Hemoglobin A1c Control for Patients with Diabetes (HBD-AD) (measure required for states)

For these three BHC measures that are sourced from the CMS Medicaid Adult Core Set 

Measures, please see the most current information from CMS on Selecting Sample Sizes for 

HEDIS® Hybrid Measures on the CMS website at Link to CMS Adult and Child Health Care 

Quality Measures. 

As of 2023, the current information is in Appendix B of the Core Set of Adult Health Care 

Quality Measures for Medicaid (Adult Core Set), Technical Specifications and Resource Manual 

for Federal Fiscal Year 2023 Reporting.

Additional guidance on sampling for hybrid measures is available in the following CMS 

technical assistance brief designed to assist reporters of the CMS Child or Adult Core Sets

for Medicaid/CHIP measures: “Approaches to Using the Hybrid Method to Calculate 

Measures from the Child and Adult Core Sets” (October 2014).4

4Medicaid Core Measure Technical Assistance briefs can be found at the Adult and Child Health Care Quality Measures 

website.

238
Appendix D. Definitions of Medicaid/CHIP Core Set Practitioner 

Types

Appendix D. Definitions of Medicaid/CHIP Core Set Practitioner Types

In many of the BHC measure specifications that are sourced from the CMS Medicaid Adult 

and/or Child Core Set Measures references are made to definitions of Medicaid/CHIP Core Set 

practitioner types. 

For those, please see the most current information from CMS on Definitions of 

Medicaid/CHIP Core Set Practitioner Types on the CMS website at Link to CMS Adult and 

Child Health Care Quality Measures.

As of 2023, the current information is in:

Appendix E of the Core Set of Adult Health Care Quality Measures for Medicaid (Adult Core 

Set), Technical Specifications and Resource Manual for Federal Fiscal Year 2023 Reporting 

and in 

Appendix C of the Core Set of Children’s Health Care Quality Measures for Medicaid and CHIP 

(Child Core Set), Technical Specifications and Resource Manual for Federal Fiscal Year 2023 

Reporting.

239
Appendix E. Core Set Value Set Directory User Manual

Appendix E. Core Set Value Set Directory User Manual

Many of the BHC measure specifications that are sourced from the CMS Medicaid Adult and/or 

Child Core Set Measures reference value sets that are identified in the specification, for example, 

as follows: Schizophrenia Value Set.

For assistance with use of value sets in BHC measure specifications that are sourced from the 

CMS Medicaid Adult and/or Child Core Sets, please see the most current information from 

CMS in the Core Set HEDIS® Value Set Directory User Manual on the CMS website at 

Link to CMS Adult and Child Health Care Quality Measures.

As of 2023, the current information is in 

Appendix A of the Core Set of Adult Health Care Quality Measures for Medicaid (Adult Core 

Set), Technical Specifications and Resource Manual for Federal Fiscal Year 2023 Reporting 

and in 

Appendix A of the Core Set of Children’s Health Care Quality Measures for Medicaid and CHIP 

(Child Core Set), Technical Specifications and Resource Manual for Federal Fiscal Year 2023 

Reporting.

240
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