Skip to Main Content

Johns Hopkins Health Plans

FUH - Follow-Up After Hospitalization for Mental Illness

Product Lines:
Advantage MD, Dual Eligible Special Needs Plans (D-SNP), EHP, Priority Partners and USFHP.

Measurement Period: January 1 - December 31

Description:
The percent of discharges for persons age 6 and older who were hospitalized for a principal diagnosis of mental illness diagnoses, or any diagnosis of intentional self-harm, and had a follow-up service. Two rates are reported:

  1. The percentage of discharges for which the person received follow-up within 30 days after discharge.
  2. The percentage of discharges for which the person received follow-up within 7 days after discharge. 

Provider Specialty: Mental Health Practitioner.

Stratifications: 
Age as of the start of the date of discharge.

  • 6-17 years.
  • 18–64 years.
  • 65 and older.

Report stratification by race and ethnicity.

Improvement Notation:
Increased score indicates improvement.

Data Collection:

  • Administrative.
  • Supplemental.

Initial Population:

  • Measure Item Count: Episode.
  • Age: 6 years of age and older as of the date of discharge.
  • Benefits: Medical and mental health (inpatient and outpatient).
  • Continuous Enrollment: Date of discharge through 30 days after discharge.
  • Allowable Gap: None.

Denominator:
Hospitalization for mental illness.
An acute inpatient discharge with a principal diagnosis of mental illness (Mental Illness Value Set), or any diagnosis of intentional self-harm (Intentional Self Harm Value Set), on the discharge claim on or between January 1 and December 1 of the measurement period.

Acute readmission or direct transfer.
A readmissions and direct transfers to an acute inpatient care setting during the 30-day follow-up period.

  • If the readmission/direct transfer to the acute inpatient care setting was for a principal diagnosis of mental health disorder, or any diagnosis of intentional self-harm (Mental Health Diagnosis Value Set; Intentional Self Harm Value Set), count only the last discharge (use only the discharge claim).

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

Numerator:
Numerator 1: 30-day follow-up.
A follow-up visit with a mental health provider, or with any practitioner for any diagnosis of a mental health disorder, within 30 days after discharge. Do not include visits that occur on the date of discharge

Numerator 2: 7-day follow-up.
A follow-up visit with a mental health provider, or with any practitioner for any diagnosis of a mental health disorder, 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: 

  • A community mental health center visit.
  • A visit in a behavioral healthcare setting.
  • An intensive outpatient encounter or partial hospitalization. 
  • Electroconvulsive therapy.
  • Psychiatric collaborative care management.
  • Psychiatric residential treatment.
  • Visits with any diagnosis of mental health disorder:
    • A BH outpatient visit. 
    • An outpatient visit.
    • A telehealth visit.
    • A telephone visit.
    • Transitional care management services.
    • Peer support services.
  • Visits with a Mental Health Provider: 
    • A BH outpatient visit. 
    • An outpatient visit.
    • A telehealth visit.
    • A telephone visit.
    • Transitional care management services.

Best Practice and Measure Tips

  • The denominator for this measure is based on discharges, not on members. If members have more than one discharge, include all discharges on or between January 1 and December 1 of the measurement year.
  • Modified the denominator criteria to allow intentional self-harm diagnoses to take any position on the acute inpatient discharge claim.
  • Added phobia, anxiety and additional intentional self-harm diagnoses to the denominator in the event/ diagnosis.
  • Added visits with any diagnosis of a mental health disorder to the numerator.
  • Added peer support and residential treatment services to the numerator.
  • Visits that occur on the date of discharge will not count toward compliance.
  • This measure focuses on follow-up treatment, which must be with a mental health provider.
  • Refer patient to a mental health provider to be seen within seven days of discharge.
    • The Johns Hopkins Health Plans Care Management team offers a variety of services to help members who are living with mental health 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 referrals by contacting us at:
  • While patient is in inpatient care help them coordinate care with a mental health provider by:
    • Helping them schedule an appointment
    • Verify if the mental 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 discharge.
    • Share all transition of care with the member’s Primary Care Physician (PCP) 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 are 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 post-discharge supportive therapy with a licensed mental health clinician such as a therapist or social worker.
  • Maintain appointment availability for members with recent inpatient discharge.
  • 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 with a behavioral health provider are acceptable.
  • Behavioral Health visits count toward compliance.
  • Psychiatric collaborative care management count toward compliance. 
  • 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.
  • Exclude discharges followed by readmission or direct transfer to a nonacute inpatient care setting (except for psychiatric residential treatment) within the 30-day follow-up period, regardless of the diagnosis for the readmission.

Measure Codes

Behavioral Healthcare Setting

  • UBREV: 0513, 0900, 0901, 0902, 0903, 0904, 0905, 0907, 0911, 0912, 0913, 0914, 0915, 0916, 0917, 0919, 1001

Electroconvulsive Therapy

  • CPT: 90870
  • ICD-10-PCS: GZB0ZZZ, GZB2ZZZ, GZB4ZZZ
  • Electroconvulsive Therapy Value Set with any of the following place of service (POS):
    • Ambulatory Surgical Center POS: 24
    • Community Mental Health Center POS: 53
    • Partial Hospitalization POS: 52 
    • 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

BH Outpatient Visit with a Mental Health Provider

  • 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)
  • 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

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
  • Visit Setting Unspecified Value Set with any of the following Place of Service (POS):
    • Community Mental Health Center POS: 53
    • Partial Hospitalization POS: 52
    • Psychiatric residential treatment center POS: 56
    • Telehealth POS with a Mental Health Provider:
    • Telehealth Provided Other than in Patient’s Home: 02
    • Telehealth Provided in Patient’s Home:10
    • Outpatient POS with a Mental Health Provider (Listed above)

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

Psychiatric Collaborative Care Management

  • CPT: 99492, 99493, 99494
  • HCPCS: G0512

Telephone Visits with a Mental Health Provider

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

Transitional Care Management with a Mental Health Provider

  • CPT: 99495, 99496

Community mental health center visit with place of service (POS) 53 with any of the previously listed codes above:

  • Visit Setting Unspecified
  • BH Outpatient
  • Transitional Care Management Services

Peer Support Services

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

Residential Behavioral Health Treatment

  • HCPCS: H0017, H0018, H0019, T2048

Mental Health Diagnosis

  • Any diagnosis of mental health disorder for any follow-up service for codes previously listed above:
    • Visit Setting Unspecified
    • BH Outpatient
    • Transitional Care Management Services
    • Telehealth POS
    • Telephone visit
    • Peer support services
  • ICD-10-CM: F03.90, F03.911, F03.918, F03.92, F03.93, F03.94, F03.A0, F03.A11, F03.A18, F03.A2, F03.A3, F03.A4, F03.B0, F03.B11, F03.B18, F03.B2, F03.B3, F03.B4, F03.C0, F03.C11, F03.C18, F03.C2, F03.C3, F03.C4, F20.0, F20.1, F20.2, F20.3, F20.5, F20.81, F20.89, F20.9, F21, F22, F23, F24, F25.0, F25.1, F25.8, F25.9, F28, F29, 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, F31.9, F32.0, F32.1, F32.2, F32.3, F32.4, F32.5, F32.81, F32.89, F32.9, F32.A, F33.0, F33.1, F33.2, F33.3, F33.40, F33.41, F33.42, F33.8, F33.9, F34.0, F34.1, F34.81, F34.89, F34.9, F39, F40.00, F40.01, F40.02, F40.10, F40.11, F40.210, F40.218, F40.220, F40.228, F40.230, F40.231, F40.232, F40.233, F40.240, F40.241, F40.242, F40.243, F40.248, F40.290, F40.291, F40.298, F40.8, F40.9, F41.0, F41.1, F41.3, F41.8, F41.9, F42.2, F42.3, F42.4, F42.8, F42.9, F43.0, F43.10, F43.11, F43.12, F43.20, F43.21, F43.22, F43.23, F43.24, F43.25, F43.29, F43.81, F43.89, F43.9, F44.0, F44.1, F44.2, F44.4, F44.5, F44.6, F44.7, F44.81, F44.89, F44.9, F45.0, F45.1, F45.20, F45.21, F45.22, F45.29, F45.41, F45.42, F45.8, F45.9, F48.1, F48.2, F48.8, F48.9, F50.00, F50.010, F50.011, F50.012, F50.013, F50.014, F50.019, F50.020, F50.021, F50.022,  F50.023, F50.024, F50.029, F50.20, F50.21, F50.22, F50.23, F50.24, F50.25, F50.810, F50.811, F50.812, F50.813, F50.814, F50.819, F50.82, F50.83, F50.84, F50.89, F50.9, F51.01, F51.02, F51.03, F51.04, F51.05, F51.09, F51.11, F51.12, F51.13, F51.19, F51.3, F51.4, F51.5, F51.8, F51.9, F52.0, F52.1, F52.21, F52.22, F52.31, F52.32, F52.4, F52.5, F52.6, F52.8, F52.9, F53.0, F53.1, F59, F60.0, F60.1, F60.2, F60.3, F60.4, F60.5, F60.6, F60.7, F60.81, F60.89, F60.9, F63.0, F63.1, F63.2, F63.3, F63.81, F63.89, F63.9, F64.0, F64.1, F64.2, F64.8, F64.9, F65.0, F65.1, F65.2, F65.3, F65.4, F65.50, F65.51, F65.52, F65.81, F65.89, F65.9, F66, F68.10, F68.11, F68.12, F68.13, F68.8, F68.A, F69, F80.0, F80.1, F80.2, F80.4, F80.81, F80.82, F80.89, F80.9, F81.0, F81.2, F81.81, F81.89, F81.9, F82, F84.0, F84.2, F84.3, F84.5, F84.8, F84.9, F88, F89, F90.0, F90.1, F90.2, F90.8, F90.9, F91.0, F91.1, F91.2, F91.3, F91.8, F91.9, F93.0, F93.8, F93.9, F94.0, F94.1, F94.2, F94.8, F94.9, F95.0, F95.1, F95.2, F95.8, F95.9, F98.0, F98.1, F98.21, F98.29, F98.3, F98.4, F98.5, F98.8, F98.9, F99
  • SNOMED CT US Edition: 109006, 162004, 281004, 568005, 596004, 600009, 832007, 1145003, 1196001, 1376001, 1380006, 1383008, 1499003, 1686006, 1816003, 1855002, 1973000, 2312009, 2506003, 2618002, 2815001, 3109008, 3158007, 3530005, 3586005, 4306003, 4441000, 4817008, 4863002, 4926007, 4932002, 4949009, 4997005, 5095008, 5158005, 5464005, 5509004, 5510009*

*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].