Errata Sheet to Metrics and Quality Measures for Behavioral Health Clinics 

Technical Specifications and Resource Manual (2018 update) 

This page includes clarifications and corrections to the Metrics and Quality Measures for 

Behavioral Health Clinics Technical Specifications and Resource Manual, volumes 1 and 2, 

followed by tables A and B, which identify the linked sources of codes needed to calculate 

clinic-reported and state-reported measures, respectively. 

Volume 1 

ROUT, p. 27, section A, Guidance for Reporting: Replace NIATx link with NIATx updated link 

I-EVAL, p. 30, section A, Guidance for Reporting: Replace NIATx link with NIATx updated link 

I-EVAL, p. 33, section E, Exclusions: For “None”, substitute “Exclude from the Metric #2 

denominator all eligible new consumers who never received an initial evaluation. Indicate in 

Additional Notes in the data reporting template the number so excluded.” 

I-EVAL, p. 33, section F, paragraph 2, sent. 3: For “non-consumers”, substitute “new 

consumers” 

TX-EVAL, p. 34, section A, Guidance for Reporting: Replace NIATx link with NIATx updated link 

TX-EVAL, p. 36, section D, Exclusions: For “None”, substitute “Exclude from the denominator all 

eligible new consumers who never received a treatment planning evaluation. Indicate in 

Additional Notes in the data reporting template the number so excluded.” 

BMI-SF, p. 45, section A, Guidance for Reporting: The PQRS link for encounter and other codes 

remains current and may be used (see PQRS measure 128). CMS, however, has replaced the 

PQRS measures with the MIPS measures. The 2018 MIPS specification with the necessary codes 

also is available and is located at 2018 MIPS Measure Specifications under MIPS Quality 

Measure Specifications, Claims Registry Measures 101-150. If you wish to use this version, see 

Measure_128_Claims at the MIPS link above. 

WCC-BH, p. 51, section A, Guidance for Reporting: The current link to value sets references the 

NCQA HEDIS 2016 measure set; this link does connect to the 2016 measures in the HEDIS 

archives. You may use the more current HEDIS measure set which presently is dated 2019 

using the same link. 

WCC-BH, p. 51, section A, Measurement Period: Exclude the last sentence related to 

hypertension. 

CBP-BH, p. 56, section A, Guidance for Reporting: The current link to value sets references the 

NCQA HEDIS 2016 measure set; this link does connect to the 2016 measures in the HEDIS 

archives. You may use the more current HEDIS measure set which presently is dated 2019 

using the same link. 

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CBP-BH, p. 56, section A, Guidance for Reporting: Replace the bullet stating “Table CBP-A 

corresponds to National Drug Code (NDC) Table CDC-A that is posted to NCQA HEDIS Final NDC 

Lists” with the following “Refer to the HEDIS 2018 Medication List Directory (MLD) of NDC 

Codes, available at HEDIS 2018 MLD for the most current HEDIS list of diabetes medications, 

which are updated annually.” 

CBP-BH, p. 59, section C, Eligible Population, Diabetes flag for the numerator, step 1, 2. 

Pharmacy data: Replace “Consumers who were dispensed insulin or 

hypoglycemics/antihyperglycemics on an ambulatory basis during the measurement year or the 

year prior to the measurement year (refer to Table CBP-A in Appendix CBP-BH)” with 

“Consumers who were dispensed insulin or hypoglycemics/antihyperglycemics on an 

ambulatory basis during the measurement year or the year prior to the measurement year 

(refer to the HEDIS 2018 Medication List Directory (MLD) of NDC Codes, available at HEDIS 2018 

MLD for the most current HEDIS list of diabetes medications, which are updated annually).” 

TSC, p. 66, section A, Guidance for Reporting: The PQRS link for encounter and other codes 

remains current and may be used (see PQRS measure 226). CMS, however, has replaced the 

PQRS measures with the MIPS measures. The 2018 MIPS specification with the necessary codes 

also is available and is located at 2018 MIPS Measure Specifications under MIPS Quality 

Measure Specifications, Claims Registry Measures 201-250. If you wish to use this version, see 

Measure_226_Claims at the MIPS link above. 

ASC, p. 69, section A, Guidance for Reporting: The PQRS link for encounter and other codes 

remains current and may be used (see PQRS measure 431). CMS, however, has replaced the 

PQRS measures with the MIPS measures. The 2018 MIPS specification with the necessary codes 

also is available and is located at 2018 MIPS Measure Specifications under MIPS Quality 

Measure Specifications, Claims Registry Measures 401-467. If you wish to use this version, see 

Measure_431_Registry at the MIPS link above. 

SRA-BH-C, p. 74, section A, Guidance for Reporting: Remove the 4th bullet that says “More 

information about this measure is available in the eCQM Library (CMS177v3), available at 

eCQM Library, Annual Updates.” 

SRA-BH-C, p. 76, section D, Electronic Health Record Specification, Denominator, Denominator 

Logic, Initial Consumer Population: Replace “OR: “Encounter, Performed: Patient Provider 

Interaction”” with “ OR: “Encounter, Performed: Face-to-Face Interaction””. 

SRA-BH-C, p. 80, Data Criteria: Remove “"Encounter, Performed: Patient Provider Interaction" 

using "Patient Provider Interaction Grouping Value Set (2.16.840.1.113883.3.526.3.1012)"”. 

SRA-A, p. 82, section A, first paragraph: For “Percentage of consumers age 18 years and older 

....”, substitute “Percentage of consumer visits for those aged 18 years and older ....” 

SRA-A, p. 82, section A, Guidance for Reporting: Under the bullet stating “For those using the 

Electronic Health Records Specification” remove the 1st bullet that says “More information 

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about this measure is available in the eCQM Library (CMS161v3), available at eCQM Library, 

Annual Updates.” 

SRA-A, p. 83, section B, Definitions, include the following definition of Recurrent: “For the 

purposes of this measure, an episode of 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 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.” See eCQI information link. 

SRA-A, p. 85, section C, Event/Diagnosis for Those Using the Medical Records Specification, Step 

3: Replace the language with the following: “Identify consumers from step 2 with a new 

diagnosis or recurrent episode of MDD identified by the provider entity during the 

measurement year. Relevant codes (International Classification of Diseases, Tenth Revision, 

Clinical Modification ([CD-10-CM] and Current Procedural Terminology [CPT®]) may be found at 

the following link: VSAC link to codes. Click on the section that says “eCQM Value Sets for 

Eligible Professionals and Eligible Clinicians. Sorted by value set name.” That will require you to 

sign up for a VSAC license (it is free and your organization can be the holder of the license) if 

you have not already done so. The relevant value set name is "Major Depressive DisorderActive Grouping Value Set (2.16.840.1.113883.3.526.3.1491)". That value set will provide all 

needed ICD-10 diagnosis codes. 

”SRA-A, p. 89, section E, Denominator: For “The number of consumers in the eligible 

population (Section C)”, substitute “The number of consumer visits by those in the eligible 

population (Section C)”. 

CDF-BH, p. 91, section A, Guidance for Reporting: The PQRS link for encounter and other codes 

remains current and may be used (see PQRS measure 134). CMS, however, has replaced the 

PQRS measures with the MIPS measures. The 2018 MIPS specification with the necessary codes 

also is available and is located at 2018 MIPS Measure Specifications under MIPS Quality 

Measure Specifications, Claims Registry Measures 101-150. If you wish to use this version, see 

Measure_134_Claims at the MIPS link above. 

DEP-REM-12, p. 95, section A, Guidance for Reporting, replace the 5th (dark) bullet (referencing 

value sets) with the following: For the referenced value sets, you may access the 2016 PQRS 

measure #370 at 2016 PQRS Specifications. CMS has discontinued PQRS and now uses MIPS. 

The 2018 MIPS specification with the necessary codes is located at 2018 MIPS Measure 

Specifications under MIPS Quality Measure Specifications, Claims Registry Measures 351-400. If 

you wish to use this version, see Measure_370_Registry at the MIPS link above. 

HOU, p. 101, section A, Guidance for Reporting, replace first bullet with the following: “These 

data are reported in aggregate by the states as part of the URS and are broken into 10 

categories of living situations. As part of the URS, they are reported in Table 15 of the URS 

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Tables; for the Mental Health Block Grants, they are reported in Table 18 of the MHBG Report 

Tables (see Updated MHBG Forms and Information website). For purposes of this measure, the 

state will report by provider entity.” 

PEC, p. 109, section A, Guidance for Reporting, replace first bullet, third sub-bullet, with the 

following: “States will submit the results aggregated at the CCBHC and comparison clinic level 

as part of CCBHC data reporting using Tables 11 and 11a of the URS reporting template that is 

current at time of the survey and that may be found at Updated MHBG Forms and Information 

website (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.” 

PEC, p. 110, section B, Definitions, Adult Consumer Experience of Care Survey, replace the link 

with the following link: Updated URS & CLD Forms and Information page on NRI website 

Y/FEC, p. 111, section A, Guidance for Reporting, replace first bullet, third sub-bullet, with the 

following: “States will submit the results aggregated at the CCBHC and comparison clinic level 

as part of CCBHC data reporting using Tables 11 and 11a of the URS reporting template that is 

current at time of the survey and that may be found at Updated MHBG Forms and Information 

website (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.” 

Y/FEC, p. 112, section B, Definitions, YSS-F Experience of Care Survey, replace the link with the 

following link: Updated URS & CLD Forms and Information page on NRI website 

FUM, p. 113, section A, Guidance for Reporting: The current link to value sets references the 

NCQA HEDIS 2017 measure set; this link does connect to the 2017 measures in the HEDIS 

archives. You may use the more current HEDIS measure set which presently is dated 2019 

using the following link: NCQA HEDIS 2019. 

FUA, p. 118, section A, Guidance for Reporting: The current link to value sets references the 

NCQA HEDIS 2017 measure set; this link does connect to the 2017 measures in the HEDIS 

archives. You may use the more current HEDIS measure set which presently is dated 2019 

using the following link: NCQA HEDIS 2019. 

PCR-BH, p. 123, section A, Guidance for Reporting: The current link to value sets references the 

NCQA 2016 measure set; this link does connect to the 2016 measures in the HEDIS archives. 

You may use the more current HEDIS measure set which presently is dated 2019 using the 

following link: NCQA HEDIS 2019. 

PCR-BH, p. 129, section E, last sentence: For “Better quality = Higher score”, substitute “Better 

quality = Lower score” 

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SSD, p. 130, section A, Guidance for Reporting: The current link to value sets references the 

NCQA HEDIS 2016 measure set; this link does connect to the 2016 measures in the HEDIS 

archives. You may use the more current HEDIS measure set which presently is dated 2019 

using the following link: NCQA HEDIS 2019. 

SSD, p. 131, section C, Allowable Gap, second sentence: For “To determine continuous 

enrollment consumer for whom enrollment is verified monthly, the consumer may not have 

more than a 1-month gap in coverage (i.e., a consumer whose coverage lapses for 2 months [60 

days] is not considered continuously enrolled).”, substitute ““To determine continuous 

enrollment for a consumer for whom enrollment is verified monthly, the consumer may not 

have more than a 1-month gap in coverage (i.e., a consumer whose coverage lapses for 2 

months [60 days] is not considered continuously enrolled).” 

SMI-PC, p. 141, section C, step 4, Pharmacy data: Replace the sentence reading “For 

prescriptions that can be used to identify consumers with diabetes, refer to Table CDC-A on the 

NCQA HEDIS 2016 Final National Drug Code (NDC) Lists webpage at: HEDIS 2016 Final NDC 

Lists)” with “For prescriptions that can be used to identify consumers with diabetes, refer to the 

HEDIS 2018 Medication List Directory (MLD) of NDC Codes, available at HEDIS 2018 MLD for the 

most current HEDIS list of diabetes medications, which are updated annually).” 

APM, p. 144, section A, Guidance for Reporting: The current link to value sets references the 

NCQA HEDIS 2016 measure set; this link does connect to the 2016 measures in the HEDIS 

archives. You may use the more current HEDIS measure set which presently is dated 2019 

using the following link: NCQA HEDIS 2019. 

APM, p. 144, section B, revise the definition of Antipsychotic Medication Dispensing Events as 

follows “A dispensed antipsychotic, as identified by claim/encounter data. Antipsychotics are 

those identified on the National Committee for Quality Assurance (NCQA) HEDIS 2018 

Medication List Directory (MLD) of NDC Codes, available at HEDIS 2018 MLD, which are updated 

annually.” 

APM, p. 146, section C, step 3, replace the parenthetical with the following: “See National 

Committee for Quality Assurance (NCQA) HEDIS 2018 Medication List Directory (MLD) of NDC 

Codes, available at HEDIS 2018 MLD, which are updated annually.” 

SMC, p. 147, section A, Guidance for Reporting: The second bullet references the 2016 HEDIS 

value sets. The link does connect to the 2016 measures in the HEDIS archives. You may use the 

more current HEDIS measure set which presently is dated 2019 using the following link: NCQA 

HEDIS 2019. 

SAA-BH, p. 158, section A, Guidance for Reporting, second bullet: If you do not find the value 

set titled “Other Bipolar Disorder” in the HEDIS 2016 or more current value sets at the link, look 

in the 2016 CMS Adult Core SSD measure value set which is available on-line at the following 

link: Medicaid Adult Core Value Set 

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SAA-BH, p. 158, section A, Guidance for Reporting, replace the third bullet with the following: 

“Antipsychotics are those identified on the National Committee for Quality Assurance (NCQA) 

HEDIS 2018 Medication List Directory (MLD) of NDC Codes, available at HEDIS 2018 MLD, which 

are updated annually.” 

SAA-BH, pp. 159-163, change all references to Table SAA-A and Appendix SAA-BH to refer to the 

National Committee for Quality Assurance (NCQA) HEDIS 2018 Medication List Directory (MLD) 

of NDC Codes, available at HEDIS 2018 MLD” which are updated annually. 

FUH-BH-A, p. 165, section A, Guidance for Reporting, the 4th bullet references the 2016 HEDIS 

value sets. The link does connect to the 2016 measures in the HEDIS archives. You may use the 

more current HEDIS measure set which presently is dated 2019 using the following link: NCQA 

HEDIS 2019. 

FUH-BH-C, p. 172, section A, Guidance for Reporting, the 5th bullet references the 2016 HEDIS 

value sets. The link does connect to the 2016 measures in the HEDIS archives. You may use the 

more current HEDIS measure set which presently is dated 2019 using the following link: NCQA 

HEDIS 2019. 

ADD-BH, p. 180, 4th bullet under section A: This bullet references the 2016 HEDIS value sets. 

The link does connect to the 2016 measures in the HEDIS archives. You may use the more 

current HEDIS measure set which presently is dated 2019 using the following link: NCQA HEDIS 

2019. 

ADD-BH, p. 180, replace 5th bullet under section A with the following: “ADHD medications are 

those identified on the National Committee for Quality Assurance (NCQA) HEDIS 2018 

Medication List Directory (MLD) of NDC Codes, available at HEDIS 2018 MLD” which are 

updated annually.” 

ADD-BH, p. 182, section C, replace step 1 with the following: “Identify all children in the 

specified age range who were dispensed an ADHD medication (as identified in the NCQA 

Medication List Directory (MLD) of NDC Codes, available at HEDIS 2018 MLD) during the 12-

month Intake Period.” 

AMM-BH, p. 187, section A, Guidance for Reporting, the 2nd bullet references the 2016 HEDIS 

value sets. The link does connect to the 2016 measures in the HEDIS archives. You may use the 

more current HEDIS measure set which presently is dated 2019 using the following link: NCQA 

HEDIS 2019. 

AMM-BH, p. 187, section A, Guidance for Reporting, replace the 3rd bullet with the following: 

“Antidepressant medications are those identified on the National Committee for Quality 

Assurance (NCQA) HEDIS 2018 Medication List Directory (MLD) of NDC Codes, available at 

HEDIS 2018 MLD which are updated annually.” 

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AMM-BH, p. 190, replace step 3 with the following: “Determine the IPSD. For consumers 

identified in step 2, identify the date of the earliest dispensing event for an antidepressant 

medication (as identified in the NCQA HEDIS Medication List Directory (HEDIS 2018 MLD) during 

the Intake Period.” 

AMM-BH, p. 191, replace the first paragraph under Rate 1 with the following: “At least 84 days 

(12 weeks) of continuous treatment with antidepressant medication (as identified in the NCQA 

HEDIS Medication List Directory (HEDIS 2018 MLD) beginning on the IPSD through 114 days 

after the IPSD (115 total days). Continuous treatment allows gaps in medication treatment up 

to a total of 30 days during the 115-day period. Gaps can include either washout period gaps to 

change medication or treatment gaps to refill the same medication.” 

AMM-BH, p. 192, replace the first paragraph under Rate 2 with the following: “At least 180 days 

(6 months) of continuous treatment with antidepressant medication (as identified in the NCQA 

HEDIS Medication List Directory (HEDIS 2018 MLD) beginning on the IPSD through 231 days 

after the IPSD (232 total days). Continuous treatment allows gaps in medication treatment up 

to a total of 51 days during the 232-day period. Gaps can include either washout period gaps to 

change medication or treatment gaps to refill the same medication.” 

IET-BH, p. 193, section A, Guidance for Reporting: “The current link to value sets references the 

NCQA HEDIS 2016 measure set; this link does connect to the 2016 measures in the HEDIS 

archives. You may use the more current HEDIS measure set which presently is dated 2019 

using the same link.” 

IET-BH, p. 196, section C, Eligible Population, current Step 1 should become Step 2 (and so 

forth) and new Step 1 should read as follows: “Identify consumers flagged as having been seen 

at the provider entity at least once during the measurement year.” 

Volume 2 

Table A1, p. 9, final column for Suicide Attempts (SU-A), replace “The measurement year” with 

“N/A.” 

Remove Appendix CBP-BH, Table CBP-A, pp. 42-43. Refer instead to the relevant medications 

identified on the National Committee for Quality Assurance (NCQA) HEDIS 2018 Medication List 

Directory (HEDIS 2018 MLD), which are updated annually. 

Appendix SRA-BH-C, p. 50, 3.e and 3.f, replace references to “CONSUMER PROVIDER 

INTERACTION” with “FACE-TO-FACE INTERACTION”. 

Appendix SRA-A.B, p. 62, first paragraph: For “Percentage of consumers age 18 years and older 

....”, substitute “Percentage of consumer visits for those aged 18 years and older ....” 

Remove Appendix SAA-BH, Table SAA-A, pp. 130-131. Refer instead to the relevant 

medications identified on the National Committee for Quality Assurance (NCQA) HEDIS 2018 

Medication List Directory (HEDIS 2018 MLD), which are updated annually. 

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Remove Appendix ADD-BH, Table ADD.A, p. 132. Refer instead to the relevant medications 

identified on the National Committee for Quality Assurance (NCQA) HEDIS 2018 Medication List 

Directory (HEDIS 2018 MLD), which are updated annually. 

Remove Appendix AMM-BH, Table AMM-C, p. 133-134. Refer instead to the relevant 

medications identified on the National Committee for Quality Assurance (NCQA) HEDIS 2018 

Medication List Directory (HEDIS 2018 MLD), which are updated annually. 

Tables with Links to Required Programming Codes and Drug Information 

Table A. Links to Required Programming Codes and Drug Information by Clinic-Reported 

Measure 

Measure Link Information 

ROUT N/A 

I-EVAL N/A 

TX-EVAL N/A 

SUIC N/A 

DOCa PQRS version (130): 2016 PQRS Specifications 

MIPS version (130): 2018 MIPS Measure Specifications 

BMI-SFa PQRS version (128): 2016 PQRS Specifications 

MIPS version (128): 2018 MIPS Measure Specifications 

WCC-BHb HEDIS value sets: NCQA HEDIS 2019 

CBP-BHb,c HEDIS value sets: NCQA HEDIS 2019 

HEDIS 2018 Medication List Directory: HEDIS 2018 MLD 

TSCa PQRS version (226): 2016 PQRS Specifications 

MIPS version (226): 2018 MIPS Measure Specifications 

ASCa PQRS version (431): 2016 PQRS Specifications 

MIPS version (431): 2018 MIPS Measure Specifications 

SRA-BH-C CMS eCQM (177): U.S. National Library of Medicine Value Set Authority Center 

(VSAC) 

SRA-A For Electronic Health Record specification version: CMS eCQM (161): U.S. 

National Library of Medicine Value Set Authority Center (VSAC) 

For Medical Record specification version: VSAC link to codes 

CDF-BHa PQRS version (134): 2016 PQRS Specifications 

MIPS version (134): 2018 MIPS Measure Specifications 

DEP-REM12a PQRS version (370): 2016 PQRS Specifications 

MIPS version(370): 2018 MIPS Measure Specifications a The PQRS link for encounter and other codes needed to calculate the numbered PQRS measure remains current 

and may be used. CMS, however, has replaced the PQRS measures with the MIPS measures. The 2018 MIPS 

specification with the necessary codes also is available and is located at 2018 MIPS Measure Specifications under 

MIPS Quality Measure Specifications, Claims Registry Measures. If you wish to use this version, see the folder at 

the link which contains the relevant measure number (unchanged from PQRS number). b HEDIS measures and codes are updated annually and the current link is provided. HEDIS measure value sets 

require purchase from NCQA. c The HEDIS Medication List Directory (MLD) of NDC Codes is updated annually. 

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Table B. Links to Required Programming Codes and Drug Information by State-Reported 

Measure 

Measure Link Information 

HOU N/A 

SU-A Volume 2 Appendix SU-A 

PEC N/A 

Y/FEC N/A 

FUMa HEDIS value sets: NCQA HEDIS 2019 

FUAa HEDIS value sets: NCQA HEDIS 2019 

PCR-BHa HEDIS value sets: NCQA HEDIS 2019 

SSDa HEDIS value sets: NCQA HEDIS 2019 

SMI-PCb HEDIS 2018 Medication List Directory: HEDIS 2018 MLD 

APMa,b HEDIS value sets: NCQA HEDIS 2019 

HEDIS 2018 Medication List Directory: HEDIS 2018 MLD 

SMCa HEDIS value sets: NCQA HEDIS 2019 

AMS-BD NQF 1880 value sets: CMS Quality Measures 

SAA-BHa,b HEDIS value sets: NCQA HEDIS 2019 

HEDIS 2018 Medication List Directory: HEDIS 2018 MLD 

FUH-BH-Aa HEDIS value sets: NCQA HEDIS 2019 

FUH-BH-Ca HEDIS value sets: NCQA HEDIS 2019 

ADD-BHa,b HEDIS value sets: NCQA HEDIS 2019 

HEDIS 2018 Medication List Directory: HEDIS 2018 MLD 

AMM-BHa,b HEDIS value sets: NCQA HEDIS 2019 

HEDIS 2018 Medication List Directory: HEDIS 2018 MLD 

IET-BHa HEDIS value sets: NCQA HEDIS 2019 a HEDIS measures and codes are updated annually and the current link is provided. HEDIS measure value sets 

require purchase from NCQA. 

b The HEDIS Medication List Directory (MLD) of NDC Codes is updated annually. 

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