Developing Quality Measures for Medicaid Beneficiaries with Schizophrenia: Final Report. Appendix F. Schizophrenia Quality Measures: Numerator, Denominator and Exclusion Criteria

01/30/2012

TABLE F.1. Measure Criteria: Numerators, Denominators and Exclusions
Measure Title Numerator Denominator Exclusions
Use of Antipsychotic Medications Individuals with schizophrenia prescribed any antipsychotic medication during the year. Adults age 25-64 with a diagnosis of schizophrenia during the measurement year. None.
Antipsychotic Medication Possession Ratio Individuals who achieved a PDCa of at least 80% for their antipsychotic medications during the measurement year. Adults age 25-64 with a diagnosis of schizophrenia with a claim for any antipsychotic medication during the measurement year. Individuals with fewer than 90 days in observation period.
Diabetes Screening Individuals with a CPT code for glucose screening: 82947, 82950, 82951, or ICD9 DX code V77.1. Adults age 25-64 with a diagnosis of schizophrenia or bipolar disorder during the measurement year who received at least 2 months of an antipsychotic medication. Individuals with diabetesb.
Diabetes Monitoring Individuals with a CPT code for HbA1c testing: 83036, 83037, 3044F, 3045F, 3046F, and any CPT code for LDL-C screening: 80061, 83700, 83701, 83704, 83721, 3048F, 3049F, 3050F. Adults age 25-64 with a diagnosis of schizophrenia and diabetesb during the measurement year. None.
Cardiovascular Health Screening Individuals with a CPT code for LDL-C screening: 80061, 83700, 83701, 83704, 83721, 3048F, 3049F, 3050F. Adults age 25-64 with a diagnosis of schizophrenia or bipolar disorder during the measurement year who received at least 2 months of an antipsychotic medication. Individuals who had diagnoses or CPT, HCPCS codes indicating CABG, PCI, CHF, IVD or MI during the measurement year.
Cardiovascular Health Monitoring Individuals with a CPT code for LDL-C testing: 80061, 83700, 83701, 83704, 83721, 3048F, 3049F, 3050F. Adults age 25-64 with a diagnosis of schizophrenia and any codes indicating CABG, CHF, PCI, IVD or MI during the measurement year. None.
Cervical Cancer Screening Individuals with a CPT code for cervical cancer screen. Female adults age 25-64 with a diagnosis of schizophrenia. Hysterectomy.
ED Utilization for Mental Health Conditions ED visit with a visit related diagnosis of 290, 293, 295-302, 306-316. Adults age 25-64 with a diagnosis of schizophrenia during the measurement year. None.
Follow-up after Mental Health Discharge (7 days) Any CPT, HCPCs or POS codes to identify follow-up visit within 7 days of discharge date.

CPT=90804-90815, 98960-98962, 99078, 99201-99205, 99211-99215, 99217-99220, 99241-99245, 99341-99345, 99347-99350, 99383-99387, 99393-99397, 99401-99404, 99411, 99412, 99510. [90801, 90802, 90816-90819, 90821-90824, 90826-90829, 90845, 90847, 90849, 90853, 90857, 90862, 90870, 90875, 90876 (required POS=03, 05, 07, 09, 11, 12, 13, 14, 15, 20, 22, 24, 33, 49, 50, 52, 53, 71, 72)] [99221-99223, 99231-99233, 99238, 99239, 99251-99255 (require POS=52, 53)]

HCPS=G0155, G0176, G0177, G0409-G0411, H0002, H0004, H0031, H0034-H0037, H0039, H0040, H2000, H2001, H2010-H2020, M0064, S0201, S9480, S9484, S9485.

Inpatient mental health discharges (ICD-9 diagnosis=290, 293, 295-302, 306-316) among adults age 25-64 with a diagnosis of schizophrenia. None.
Follow-up after Mental Health Discharge (30 days) Any CPT, HCPCs or POS codes to identify follow-up visit within 30 days of discharge date. (See 7-day measure for listing of codes to identify outpatient follow-up visit). Inpatient mental health discharges (ICD-9 diagnosis=290, 293, 295-302, 306-316) among adults age 25-64 with a diagnosis of schizophrenia. None.
NOTE: Schizophrenia identified by any inpatient primary diagnosis ICD-9 code of 295 or 2 primary outpatient ICD-9 codes of 295 observed on different days.
  1. Proportion of days covered (PDC) = number of days filled divided by days in observation period.
  2. Diabetes identified by the following ICD-9 diagnoses: 250, 357.2, 362.0, 366.41, 648.0.

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