Product Lines:
Advantage MD, EHP, Priority Partners, and USFHP.

Measurement Period: January 1 - December 31

Description: 
The percentage of acute inpatient hospitalizations, residential treatment or withdrawal management visits for a diagnosis of substance use disorder among persons 13 years of age and older that result in a follow-up visit or service for substance use disorder. Two rates are reported:

1. The percentage of visits or discharges for which the person received follow-up for substance use disorder within the 30 days after the visit or discharge.
2. The percentage of visits or discharges for which the person received follow-up for substance use disorder within the 7 days after the visit or discharge.

Stratifications:
Age as of date of the discharge, stay or event.

• 13 -17 years.
• 18 - 64 years.
• 65 years and older.

Improvement Notation:
Increased score indicates improvement.

Data Collection:

• Administrative.
• Supplemental.

Initial Population:

• Measure Item Count: Episode. 
• Age: 13 years of age or older as of date of the discharge, stay or event.
• Benefits: Medical, chemical dependency and pharmacy.
  Note: A withdrawal management/detoxification-only chemical dependency benefit does not meet these criteria.
• Continuous Enrollment: Episode date through 30 days after episode date (31 total days).
• Allowable gap: None.

Definition:
Direct transfer: A direct transfer occurs when the discharge date from an initial stay is followed by an admission to a subsequent stay within one calendar day or less. Direct transfers can occur between different facilities and between acute inpatient and observation settings.

Episode date: The date of service for any acute inpatient discharge, residential treatment discharge or withdrawal management visit with a principal diagnosis of substance use disorder.

For an acute inpatient discharge or residential treatment discharge or for withdrawal management that occurred during an acute inpatient stay or residential treatment stay, the episode date is the date of discharge.

For direct transfers, the episode date is the discharge date from the transfer admission.

For withdrawal management (other than withdrawal management that occurred during an acute inpatient stay or residential treatment stay), the episode date is the date of service.

Denominator:
High-intensity care for substance use disorder.
Acute inpatient discharge, residential treatment or withdrawal management event for a principal diagnosis of substance use disorder on or between January 1 and December 1 of the measurement period.
Either of the following meets criteria:

• An acute inpatient discharge or a residential behavioral health stay with a principal diagnosis of substance use disorder (AOD Abuse and Dependence Value Set) on the discharge claim. 
• A withdrawal management visit (Detoxification Value Set) with a principal diagnosis of substance use disorder (AOD Abuse and Dependence Value Set).

Note: The measure is based on episodes; therefore, it is possible for the denominator to include multiple events for the same person.

Numerators:

Numerator 1: 30-Day Follow-Up.
A follow-up visit or event with any practitioner for a diagnosis of substance use disorder within the 30 days after an episode for substance use disorder. Do not include visits that occur on the date of the denominator episode.

Numerator 2: 7-Day Follow-Up.
A follow-up visit or event with any practitioner for a principal diagnosis of substance use disorder within the 7 days after an episode for substance use disorder. Do not include visits that occur on the date of the denominator episode.

For both indicators, any of the following meet criteria for a follow-up visit:

• Visits with a diagnosis of substance use disorder (AOD Abuse and Dependence Value Set):
  • An acute or nonacute inpatient admission or residential behavioral health stay.
  • An outpatient visit (Visit Setting Unspecified Value Set) with any of the following Place of services:
  • Community mental health center POS.
    • Nonresidential Substance Abuse Treatment Facility POS.
    • Outpatient POS.
    • Psychiatric Facility-Partial Hospitalization POS.
    • Telehealth POS.
  • A BH outpatient visit.
  • A partial hospitalization or intensive outpatient.
  • A substance use disorder service.
  • Substance use disorder counseling and surveillance.
  • An opioid treatment service that bills monthly or weekly.
  • Residential behavioral health treatment.
  • A telephone visit.
  • An e-visit or virtual check-in.
  • A pharmacotherapy dispensing event or medication treatment event.
  • Peer support service

Note: Follow-up does not include withdrawal management. Exclude all withdrawal management events (Detoxification Value Set) when identifying follow-up care for numerator compliance. Detoxification does not need to be excluded from pharmacotherapy dispensing events identified using pharmacy claims (Alcohol Use Disorder Treatment Medications List; Opioid Use Disorder Treatment Medications List), because detoxification codes are not used on pharmacy claims.

Summary of changes:

• Modified the numerators to allow a substance use disorder diagnosis to take any position on the claim.
• Added peer support services to the numerators.

Best Practice and Measure Tips

• Refer patient to a behavior health provider to be seen within seven days after an episode of substance use disorder.
  • The Johns Hopkins Health Plans Care Management team offers a variety of services to help members who are living with substance abuse and mental health issues may receive confidential care management support and coordination of care from a Licensed Clinical Social Worker. These behavioral health clinicians help members navigate their treatment needs for conditions such as depression, anxiety disorders, addictions, and autism spectrum disorders. For Priority Partners members, we work with Carelon Behavioral Health of Maryland to manage mental health needs.
    • Please send us your member referrals by contacting us at:
      Phone:800-557-6916
      Monday through Friday: 8 a.m. to 5 p.m.
      Voicemail messages received after normal business hours will be addressed the following business day.
      EHP Behavioral Health:410-424-4891
      EHP Behavioral Health- Secured: 410-424-4765
      USFHP Mental Health: 410-424-4839
      Advantage MD Behavioral Health, Inpatient & Outpatient:844-340-2217
      Email:[email protected]
• Ways to help patients find care they need:
  • Helping them schedule an appointment.
  • Verify if the behavior health provider is a good fit by considering location, transportation and time.
  • Identify and address any barriers that may prevent member keeping the appointment.
  • Making sure member has a good support system by engaging parents/guardian or significant others in the treatment plan, stressing the importance of treatment, and attending to their appointment.
  • Ensure member received an appointment with 7 days of an episode.
  • Share all transition of care with the member’s Primary Care Physician (PCP) and behavior health provider to ensure members follows-up with the treatment plan.
  • Ensure member has a PCP.
• Educate member on:
  • Importance of consistency and adherence to the medication regiment.
  • Medication side effect, what to do if the side effect is severe and can potentially result in lack of adherence to the medication regiment and treatment plan.
  • Crisis Intervention options.
• Even patients receiving medication from their primary care provider still need supportive therapy with a licensed behavior health clinician such as a therapist or social worker.
• Maintain appointment availability for members with recent episode of substance use disorder.
• Provider should provide reminder calls to confirm appointment within 24 hours.
• If member is unable to keep scheduled appointment, reschedule it or offer Telehealth visits.
• Telehealth visits are acceptable.
• Submit all claims with correct service coding and principal diagnosis timely.

Measure Exclusions

Denominator Exclusions:

• Persons in hospice or using hospice services any time during the measurement period.
• Persons who died any time during the measurement period.

Measure Codes

AOD Abuse and Dependence

• ICD-10-CM: F10.10, F10.120, F10.121, F10.129, F10.130, F10.131, F10.132, F10.139, F10.14, F10.150, F10.151, F10.159, F10.180, F10.181, F10.182, F10.188, F10.19, F10.20, F10.220, F10.221, F10.229, F10.230, F10.231, F10.232, F10.239, F10.24, F10.250, F10.251, F10.259, F10.26, F10.27, F10.280, F10.281, F10.282, F10.288, F10.29, F11.10, F11.120, F11.121, F11.122, F11.129, F11.13, F11.14, F11.150, F11.151, F11.159, F11.181, F11.182, F11.188, F11.19, F11.20, F11.220, F11.221, F11.222, F11.229, F11.23, F11.24, F11.250, F11.251, F11.259, F11.281, F11.282, F11.288, F11.29, F12.10, F12.120, F12.121, F12.122, F12.129, F12.13, F12.150, F12.151, F12.159, F12.180, F12.188, F12.19, F12.20, F12.220, F12.221, F12.222, F12.229, F12.23, F12.250, F12.251, F12.259, F12.280, F12.288, F12.29, F13.10, F13.120, F13.121, F13.129, F13.130, F13.131, F13.132, F13.139, F13.14, F13.150, F13.151, F13.159, F13.180, F13.181, F13.182, F13.188, F13.19, F13.20, F13.220, F13.221, F13.229, F13.230, F13.231, F13.232, F13.239, F13.24, F13.250, F13.251, F13.259, F13.26, F13.27, F13.280, F13.281, F13.282, F13.288, F13.29, F14.10, F14.120, F14.121, F14.122, F14.129, F14.13, F14.14, F14.150, F14.151, F14.159, F14.180, F14.181, F14.182, F14.188, F14.19, F14.20, F14.220, F14.221, F14.222, F14.229, F14.23, F14.24, F14.250, F14.251, F14.259, F14.280, F14.281, F14.282, F14.288, F14.29, F15.10, F15.120, F15.121, F15.122, F15.129, F15.13, F15.14, F15.150, F15.151, F15.159, F15.180, F15.181, F15.182, F15.188, F15.19, F15.20, F15.220, F15.221, F15.222, F15.229, F15.23, F15.24, F15.250, F15.251, F15.259, F15.280, F15.281, F15.282, F15.288, F15.29, F16.10, F16.120, F16.121, F16.122, F16.129, F16.14, F16.150, F16.151, F16.159, F16.180, F16.183, F16.188, F16.19, F16.20, F16.220, F16.221, F16.229, F16.24, F16.250, F16.251, F16.259, F16.280, F16.283, F16.288, F16.29, F18.10, F18.120, F18.121, F18.129, F18.14, F18.150, F18.151, F18.159, F18.17, F18.180, F18.188, F18.19, F18.20, F18.220, F18.221, F18.229, F18.24, F18.250, F18.251, F18.259, F18.27, F18.280, F18.288, F18.29, F19.10, F19.120, F19.121, F19.122, F19.129, F19.130, F19.131, F19.132, F19.139, F19.14, F19.150, F19.151, F19.159, F19.16, F19.17, F19.180, F19.181, F19.182, F19.188, F19.19, F19.20, F19.220, F19.221, F19.222, F19.229, F19.230, F19.231, F19.232, F19.239, F19.24, F19.250, F19.251, F19.259, F19.26, F19.27, F19.280, F19.281, F19.282, F19.288, F19.29
• SNOMED CT US Edition: 281004, 1383008, 1686006, 1973000, 2403008, 5002000, 5444000, 5602001, 6348008, 7052005, 7071007, 7200002, 8635005, 8837000, 10327003, 11387009, 14784000, 15167005, 15277004, 18653004, 18689007, 19445006, 20385005, 20876004, 21647008, 22574000, 25753007, 26714005, 27956007, 28864000*

*Please note that not all SNOMED CT US Edition codes are listed here. For access to the complete set of codes, contact your Provider Engagement Liaison or email [email protected].

AOD Medication Treatment

• HCPCS: G0533, G2069, G2073, H0020, H0033, J0571, J0572, J0573, J0574, J0575, J0577, J0578, J2315, Q9991, Q9992, S0109
• SNOMED CT US Edition: 310653000

BH Outpatient

• CPT: 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98960, 98961, 98962, 99078, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99242, 99243, 99244, 99245, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99381, 99382, 99383, 99384, 99385, 99386, 99387, 99391, 99392, 99393, 99394, 99395, 99396, 99397, 99401, 99402, 99403, 99404, 99411, 99412, 99483, 99492, 99493, 99494, 99510
• HCPCS: G0155, G0176, G0177, G0409, G0463, G0512, G0560, H0002, H0004, H0031, H0034, H0036, H0037, H0039, H0040, H2000, H2010, H2011, H2013, H2014, H2015, H2016, H2017, H2018, H2019, H2020, T1015**
  • NOTE: **T1015 HCPCS code which identifies an all-inclusive clinic visit for services rendered at a Federally Qualified Health Center (FQHC)
• SNOMED CT US Edition: 50357006, 77406008, 84251009, 86013001, 90526000, 185463005, 185464004, 185465003, 209099002, 281036007, 391223001, 391224007, 391225008, 391233009, 391237005, 391239008, 391242002, 391257009, 391260002, 391261003, 439740005, 866149003, 3391000175108, 444971000124105, 456201000124103
• UBREV: 0510, 0513, 0515, 0516, 0517, 0519, 0520, 0521, 0522, 0523, 0526, 0527, 0528, 0529, 0900, 0902, 0903, 0904, 0911, 0914, 0915, 0916, 0917, 0919, 0982, 0983

Inpatient Stay

• UBREV: 0100, 0101, 0110, 0111, 0112, 0113, 0114, 0116, 0117, 0118, 0119, 0120, 0121, 0122, 0123, 0124, 0126, 0127, 0128, 0129, 0130, 0131, 0132, 0133, 0134, 0136, 0137, 0138, 0139, 0140, 0141, 0142, 0143, 0144, 0146, 0147, 0148, 0149, 0150, 0151, 0152, 0153, 0154, 0156, 0157, 0158, 0159, 0160, 0164, 0167, 0169, 0170, 0171, 0172, 0173, 0174, 0179, 0190, 0191, 0192, 0193, 0194, 0199, 0200, 0201, 0202, 0203, 0204, 0206, 0207, 0208, 0209, 0210, 0211, 0212, 0213, 0214, 0219, 1000, 1001, 1002

Online Assessments

• CPT: 98016, 98970, 98971, 98972, 98980, 98981, 99421, 99422, 99423, 99457, 99458
• HCPCS: G0071, G2010, G2012, G2250, G2251, G2252

OUD Monthly Office Based Treatment

• HCPCS: G2069, G2086, G2087

OUD Weekly Drug Treatment Service

• HCPCS: G0533, G2067, G2068, G2073

OUD Weekly Non Drug Service

• HCPCS: G2074, G2075, G2076, G2077, G2080

Partial Hospitalization or Intensive Outpatient

• HCPCS: G0410, G0411, H0035, H2001, H2012, S0201, S9480, S9484, S9485
• SNOMED CT US Edition: 7133001, 305345009, 305346005, 305347001, 391038005, 391042008, 391043003, 391046006, 391047002, 391048007, 391054008, 391055009, 391056005, 391133003, 391150001, 391151002, 391152009, 391153004, 391170007, 391185001, 391186000, 391187009, 391188004, 391191004, 391192006, 391194007, 391195008, 391207001, 391208006, 391209003, 391210008, 391211007, 391228005, 391229002, 391232004, 391252003, 391254002, 391255001, 391256000
• UBREV: 0905, 0907, 0912, 0913

Residential Behavioral Health Treatment

• HCPCS: H0017, H0018, H0019, T2048

Substance Abuse Counseling and Surveillance

• ICD-10-CM: Z71.41, Z71.51

Substance Use Disorder Services

• CPT: 99408, 99409
• HCPCS: G0396, G0397, G0443, H0001, H0005, H0007, H0015,H0016, H0022, H0047, H0050, H2035, H2036, T1006, T1012
• SNOMED CT US Edition: 20093000, 23915005, 56876005, 61480009, 64297001, 67516001, 87106005, 182969009, 266707007, 310653000, 370776007, 370854007, 385989002, 386449006, 386450006, 386451005, 414054004, 414056002, 414283008, 414501008, 415662004, 445628007, 445662007, 450760003, 704182008, 707166002, 711008001, 713106006, 713107002, 713127001, 720174008, 720175009, 720176005, 720177001, 763104007, 763233002, 763302001, 772813001, 774090004, 774091000, 792901003, 792902005, 827094004, 865964007, 428211000124100
• UBREV: 0906, 0944, 0945

Telephone Visits

• CPT: 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015, 98966, 98967, 98968, 99441, 99442, 99443
• SNOMED CT US Edition: 185317003. 314849005. 386472008. 386473003. 401267002

Outpatient visit (Visit Setting Unspecified)

• CPT: 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90847, 90849, 90853, 90875, 90876, 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99252, 99253, 99254, 99255
• An Outpatient visit with any of the following Place of Service (POS)
  • 53- Community Mental Health Center
  • Nonresidential Substance Abuse Treatment Facility POS
    • 57- Non-residential Substance Abuse Treatment Facility
    • 58- Non-residential Opioid Treatment Facility
  • Outpatient POS
    • 03- School
    • 05- Indian Health Service Free-standing Facility
    • 07- Tribal 638 Free-standing Facility
    • 09- Prison/Correctional Facility
    • 11- Office
    • 12- Home
    • 13- Assisted Living Facility
    • 14- Group Home
    • 15- Mobile Unit
    • 16- Temporary Lodging
    • 17- Walk-in Retail Health Clinic
    • 18- Place of Employment-Worksite
    • 19- Off Campus-Outpatient Hospital
    • 20- Urgent Care Facility
    • 22- On Campus-Outpatient Hospital
    • 33- Custodial Care Facility
    • 49- Independent Clinic
    • 50- Federally Qualified Health Center
    • 71- Public Health Clinic
    • 72- Rural Health Clinic
  • 52- Psychiatric Facility-Partial Hospitalization
  • Telehealth POS
    • 02- Telehealth Provided Other than in Patient’s Home
    • 10- Telehealth Provided in Patient’s Home

Peer Support Services

• HCPCS: G0140, G0177, H0024, H0025, H0038, H0039, H0040, H0046, H2014, H2023, S9445, T1012, T1016, T1017

Measure Medication

Alcohol Use Disorder Treatment Medications

• Acamprosate
• Disulfiram
• Naltrexone

Opioid Use Disorder Treatment Medications

• Buprenorphine
• Buprenorphine-naloxone
• Naltrexone

Note: Methadone is not included on the medication lists for this measure. Methadone for opioid use disorder is only administered or dispensed by federally certified opioid treatment programs and does not show up in pharmacy claims data. A pharmacy claim for methadone would be more indicative of treatment for pain than for an opioid use disorder and therefore is not included on medication lists. The AOD Medication Treatment Value Set and OUD Weekly Drug Treatment Service Value Set include codes that identify methadone treatment for opioid use disorder because these codes are used on medical claims, not on pharmacy claims.