Product Lines:
EHP, Priority Partners and USFHP.

Measurement Period: January 1 - December 31

Description:
The percentage of persons newly prescribed attention-deficit/hyperactivity disorder (ADHD) medication who had at least three follow-up care visits within a 300-day (10 month) period, one of which was within 30 days of when the first ADHD medication was dispensed. Two rates are reported:

• Initiation Phase. The percentage of persons 6–12 years of age 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. The percentage of persons 6–12 years of age 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.

Improvement Notation:
Increased score indicates improvement.

Data Collection:

• ECDS. 

Initial Population:

• Measure Item Count: Person.
• Age: 6 years of age as of March 1 of the year prior to the measurement period to 12 years as of the last calendar day of February of the measurement period.
• Benefits: Medical and pharmacy.
• Continuous Enrollment: 
  
  • Initial population 1: 120 days prior to the IPSD through 30 days after the IPSD. 
  • Initial population 2: 120 days prior to the IPSD through 300 days after the IPSD.
• Allowable Gap: 
  
  • Initial population 1: None.
  • Initial population 2: No more than one gap of ≤45 days between 31 days after the IPSD through 300 days after the IPSD.

Definition: 
C&M phase: The 300 days following the IPSD. 

Continuous medication treatment: There must be ≥210 treatment days during the 301-day period, with allowed gaps in medication of up to a total of 91 days. 
Gaps may include either washout period gaps to change medication or treatment gaps to refill the same medication. 
Regardless of the number of gaps, there may not be more than 91 total gap days.
 
Identifying same or different drugs: Dispensing events from different medication value sets are considered different drugs; dispensing events from the same medication value set are considered the same drug. Use all of the medication lists below to identify ADHD dispensing events.

• Dexmethylphenidate Medications List.
• Dextroamphetamine Medications List.
• Lisdexamfetamine Medications List.
• Methylphenidate Medications List.
• Methamphetamine Medications List.
• Clonidine Medications List.
• Guanfacine Medications List.
• Atomoxetine Medications List.
• Viloxazine Medications List.

Initiation phase: The 30 days following the IPSD. 

Intake period: March 1 of the year prior to the measurement period through the last calendar day of February of the measurement period. 

IPSD- Index prescription start date: 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: A period of 120 days prior to the IPSD when the person had no ADHD medications dispensed for either new or refill prescriptions. 

Treatment days (covered days): The actual number of calendar days covered by prescriptions during the 301-day period.

Denominator:
Persons newly prescribed ADHD medication.
Denominator 1: Initiation Phase. 
Persons in the specified age range who were dispensed an ADHD medication during the 12-month intake period.

Denominator 2: C&M Phase.
Persons from initial population 1 who were dispensed a sufficient number of prescriptions to provide continuous medication treatment beginning on the IPSD through 300 days after the IPSD.

Numerator:
Numerator 1: Initiation phase. 
Persons who had a follow-up visit with a practitioner with prescribing authority within 30 days after the IPSD.
Any of the following code combinations meet criteria for a visit; the visit must be with a provider with prescribing authority.

• An outpatient visit (Visit Setting Unspecified Value Set with Outpatient POS Value Set).
• An outpatient visit (BH Outpatient 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 POS code 52).
• 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 POS Code 53).
• A telehealth visit (Visit Setting Unspecified Value Set with Telehealth POS Value Set).
• A telephone visit (Telephone Visits Value Set).

Numerator 2: C&M phase. 
Persons numerator who meet the following:

• Numerator compliant for Rate 1—Initiation Phase, and 
• At least two follow-up visits on different dates of service with any provider, from 31-300 days after the IPSD. 

Any of the following code combinations meet criteria for follow-up visits:

• An outpatient visit (Visit Setting Unspecified Value Set with Outpatient POS Value Set).
• An outpatient visit (BH Outpatient 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 POS code 52).
• 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 POS Code 53).
• 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 the 31–300 days after the IPSD) may be an e-visit or virtual check-in (Online Assessments Value Set).

Best Practice and Measure Tips

• Timing of scheduled visits is key based on the prescription day supply to evaluate medication effectiveness, any adverse effects and to monitor the patient’s progress.
• When prescribing a new ADHD medication for a patient:
  • Schedule follow-up visits to occur before the refill is given.
  • Schedule a 30-day, 60-day and 180-day follow-up visit from the initial visit before member leaves office.
  • Consider scheduling follow-up visit within 14 to 21 days of each prescription.
  • Consider prescribing an initial two-week supply and follow-up prescriptions to a 30-day supply to ensure patient follow-up.
  • Only one of the two visits (during days 31–300) may be an e-visit or virtual check-in.
• Review treatment plan regularly and make any modifications if the patient’s symptoms do not respond.
• Treatment should continue as long as symptoms remain present and cause impairment.
• Monitor treatment-emergent side effects.
• Assess periodically to determine whether there is a continue need for treatment or if symptoms have remitted. 

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.
• Persons who filled an ADHD prescription 120 days (4 months) prior to the IPSD (Index Prescription Start Date). Applies to only Rate 1 – Initiation phase.
• Persons who had an acute inpatient encounter or admission for a mental, behavioral or neurodevelopmental disorder during the 30 days after the IPSD.
• Persons with a diagnosis of narcolepsy any time during their history through December 31 or the measurement period.

Exclusion Codes:

Narcolepsy

• ICD-10-CM: G47.411, G47.419, G47.421, G47.429
• SNOMED CT US Edition: 60380001, 193042000, 427426006, 735676003, 91521000119104, 434241000124107, 434251000124109, 434261000124106

Measure Codes

The following code combinations identify follow-up visits:

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)
  • Partial Hospitalization POS: 52
  • Community Mental Health Center POS: 53
  • Telehealth POS:
    • Telehealth Provided Other than in Patient’s Home: 02
    • Telehealth Provided in Patient’s Home:10
  • 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

• 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

A health and behavior assessment/intervention

• CPT: 96156, 96158, 96159, 96164, 96165, 96167, 96168, 96170, 96171

Intensive outpatient encounter or partial hospitalization

• 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

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

Telehealth Visit (E-visit or virtual check-in)

• CPT : 98016, 98970, 98971, 98972, 98980, 98981, 99421, 99422, 99423, 99457, 99458
• HCPCS: G0071, G2010, G2012, G2250, G2251, G2252
• Telehealth visit (E-visit or virtual check-in) codes only apply to Continuation and Maintenance (C&M) Phase numerator.
• Only one of the two visits (during the 31–300 days after the IPSD) may be a telehealth visit (e-visit or virtual check-in).

 

Measure Medications

ADHD Medications:

• Amphetamine aspartate-amphetamine sulfate-dextroamphetamine saccharate-dextroamphetamine sulfate
• Atomoxetine
• Clonidine
• Dexmethylphenidate
• Dextroamphetamine
• Guanfacine
• Lisdexamfetamine
• Methamphetamine
• Methylphenidate 
• Viloxazine