Transcription

Inpatient PsychiatricFacility Quality ReportingProgram Claims-BasedMeasure SpecificationsThis document is a resource for the Inpatient Psychiatric FacilityQuality Reporting (IPFQR) Program for the Centers for Medicare &Medicaid Services (CMS).June 2021

Inpatient Psychiatric Facility Quality Reporting Program Claims-Based Measure SpecificationsNotices and DisclaimersCurrent Procedural Terminology (CPT )CPT only copyright 2004-2020 American Medical Association. All rights reserved.International Classification of Disease, Tenth EditionICD-10 copyright 2020 World Health Organization. All Rights Reserved.Uniform Bill CodesUniform Bill Codes copyright 2020 American Hospital Association. All rights reserved.Applicable FARS/DFARS Restrictions Apply to Government Use.

Inpatient Psychiatric Facility Quality Reporting Program Claims-Based Measure SpecificationsTable of ContentsSection 1: Follow-Up After Hospitalization for Mental Illness (FUH) Measure Specifications –Version 5.0 . 4Description of Measure . 4Numerator Statement . 4Denominator Statement . 6Denominator Exclusions . 6Section 2: 30-Day All-Cause Unplanned Readmission Following Psychiatric Hospitalizationin an Inpatient Psychiatric Facility (IPF Readmission) Measure Specifications – Version 4.0 . 8Description of Measure . 8Numerator Statement . 8Denominator Statement . 9Statistical Risk Model and Variables . 9Risk Factor Variables . 9Section 3: Medication Continuation Following Inpatient Psychiatric Discharge (MedCont) –Version 2.0 . 12Description of Measure . 12Numerator Statement . 12Denominator Statement . 15Denominator Exclusion . 15Appendices: Summary of Measure Updates . 17Appendix A. Follow-Up After Hospitalization for Mental Illness (FUH) Measure Updates . 17Appendix B. 30-Day All-Cause Unplanned Readmission Following Psychiatric Hospitalizationin an IPF Measure Updates . 18Appendix B. Medication Continuation Following Inpatient Psychiatric Discharge Measure Updates . 193

Inpatient Psychiatric Facility Quality Reporting Program Claims-Based Measure SpecificationsSection 1: Follow-Up After Hospitalization for Mental Illness(FUH) Measure Specifications – Version 5.0Description of MeasureThis measure assesses the percentage of inpatient psychiatric facility (IPF) hospitalizations fortreatment of select mental health disorders that were followed by an outpatient mental health careencounter. Two rates are reported: The percentage of discharges for which the patient received follow-up within 7 days ofdischargeThe percentage of discharges for which the patient received follow-up within 30 days ofdischargeThe measurement period used to identify cases in the denominator is typically 12 months, starting inJuly. Due to the impacts of COVID-19 on IPFs, CMS will not count data from January 1, 2020,through June 30, 2020, for performance or payment programs. For FY2022 reporting, the FUHmeasure will use a measurement period of July 1, 2019, through December 1, 2019, allowing datafrom the start of the measurement period through 30 days after the close of the measurement periodto be used to identify follow-up visits in the numerator. 1As this is a claims-based measure, there is no action required by facilities to collect and submit datafor this measure. CMS will calculate the measure rates using Part A and Part B claims data that arereceived by Medicare for payment purposes. CMS will calculate this measure by linking Medicarefee-for-service (FFS) claims submitted by IPFs and subsequent outpatient providers for MedicareFFS IPF discharges. This approach requires no additional data collection or reporting by IPFs.Completion of this measure does not affect an IPF’s payment determination.For a full list of codes used in measure calculation, refer to the FUH codebook, posted on QualityNetat Qualitynet.cms.gov Inpatient Psychiatric Facilities Resources Program Resources/ View Measure Resources.Numerator StatementThis measure estimates the number of discharges from a psychiatric facility that are followed by anoutpatient mental health care encounter within 7 and 30 days after discharge. Outpatient mentalhealth care encounters are defined as outpatient visits, intensive outpatient encounters, or partialhospitalizations provided by a mental health provider. All codes used to identify providers are foundin Medicare outpatient/carrier files. Either a Medicare specialty code OR taxonomy code qualifies asa numerator hit. For a full list of codes, refer to the “Numerator practitioner” tab of the FUHcodebook.Outpatient visits, intensive outpatient encounters, and partial hospitalizations are defined by theCurrent Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS),and Uniform Billing (UB) Revenue codes listed in Table A1. A claim meeting any of therequirements in the table constitutes an outpatient visit.1 Refer to CMS’s March 27, 2020, memo on exceptions and extensions for quality reporting requirements for healthcare entitiesaffected by COVID-19 for more information: e-based-purchasing-programs.pdf.4

Inpatient Psychiatric Facility Quality Reporting Program Claims-Based Measure SpecificationsTable A1. Codes to identify outpatient visits, intensive outpatient encounters, and partialhospitalizationsCPTTELEHEALTH MODIFIER90839-90840, 98960-98962, 99078, 99201-99205,with or GT99211-99215, 99217-99220, 99241-99245, 99341without99345, 99347-99350, 99381-99387, 99393-99397,99401-99404, 99411, 99412, 99483, 99495, 99496,99510HCPCSG0155, G0176, G0177, G0409-G0411, G0463, H0002,with or GTH0004, H0031, H0034-H0037, H0039, H0040, H2000,withoutH2001, H2010-H2020, M0064, S0201, S9480, S9484,S9485, T1015CPTPlace of ServiceTELEHEALTH MODIFIER90832-90834, 90836with 03, 05, 07, 09, 11, 12,with or GT90838, 90845, 90847,13, 14, 15, 16, 17, 18,without90849, 90853, 90870,19, 20, 22, 24, 33, 49,90875, 90876, 9932450, 52, 53, 71, 7299328, 99383-9938799221-99223, 99231with 52, 53with or GT99233, 99238, 99239,without99251-99255CPTType ofTELEHEALTH MODIFIERService/Facility TypeClassification(TYPSVC/FACTYP)90791, 90792, 90832with TYPSVC 2 or 3 ifwith or GT90834, 90836-90838,FACTYP 1–6 or 9without90845, 90847, 90849,OR90853, 90870, 90875,FACTYP 7 or 890876, 99221-99223,99231-99233, 99238,99239, 99251-99255,99324-99328, 9938399387ICD-10-PCSGZB0ZZZ, GZB1ZZZ,with TYPSVC 2 or 3 ifwith or GTGZB2ZZZ, GZB3ZZZ,FACTYP 1–6 or 9withoutGZB4ZZZORFACTYP 7 or 8UB Revenue0513, 0900-0905, 0907, 0911-0917, 0919 – encounter does not have to have NPI taxonomy orMedicare specialty code for a mental health provider0510, 0515-0517, 0519-0523, 0526-0529, 0982, 0983 – if encounter does not have NPI taxonomy orMedicare specialty code for a mental health provider, encounter must be for a principal mental illnessdiagnosisClaims with codes for emergency room visits do not count toward the numerator and should beremoved. Emergency room visits are defined by the following UB revenue, CPT, Place of Service,and Berenson-Eggers type of service (BETOS) codes in Table A2.Table A2. Codes to identify emergency room visitsUB Revenue0450-0459, 0981CPT99281, 99282, 99283, 99284, 99285Place of Service235

Inpatient Psychiatric Facility Quality Reporting Program Claims-Based Measure SpecificationsBETOSM3Denominator StatementThe denominator includes discharges paid under the IPF prospective payment system (PPS) duringthe measurement period for Medicare FFS patients with a principal diagnosis of mental illness.Specifically, the measure includes IPF discharges (Table A3) for which the patient was: Discharged with a principal diagnosis of mental illness that would necessitate follow-up carewith a mental health professional.o Defined using the ICD-10-CM codes in the “Denominator” tab of the FUH codebook.Discharged alive to ensure they are eligible for follow-up care.o Defined as any Discharge Status Code other than “20” (expired). Enrolled in Medicare Parts A and B during the month of the discharge date and at least onemonth after the discharge date to ensure data are available to capture the index admission andfollow-up visits.o Defined as having continuous (no gaps) Medicare Part A and Part B coverage with noHealth Maintenance Organization (HMO). Therefore, the Entitlement Buy-in Indicatormust be “3” or “C” and the HMO indicator must be “0” for both the month of dischargeand the month following the discharge month for the IPF stay to qualify as continuousFFS. Six years of age or older on the date of discharge because follow-up with a mental healthprofessional may not always be recommended for younger children.o Defined using date of birth from the CMS Enrollment Data Base (EDB) beneficiary table.Table A3. Codes to identify eligible IPF dischargesCriteria for eligible IPF dischargesClaim Type 60CMS Certification Number (CCN) meets at least one of the following criteria: Last 4 digits of the CMS Certification Number (CCN) is 4000–4499 (Psychiatric Hospitalexcluded from inpatient prospective payment system) 3rd digit of CCN is ‘S’ (distinct part Psychiatric Unit in an acute care hospital) 3rd digit of CCN is ‘M’ (Psychiatric Unit in a Critical Access Hospital [CAH])Denominator ExclusionsMedicare files are used to identify all exclusions. The denominator excludes IPF discharges forpatients: Admitted or transferred to acute and non-acute inpatient facilities within the 30-day followup period because admission or transfer to other institutions may prevent an outpatientfollow-up visit from taking place.o Defined using the claim type and codes in the “Excl – admit, transfer” tab of the FUHcodebook. Each facility type must have both a claim type and one of the correspondingCCN, HCPCS, UB, or place of service (POS) codes if they are listed in the row for thatfacility type (Table A4).6

Inpatient Psychiatric Facility Quality Reporting Program Claims-Based Measure Specifications Discharged or transferred to other institutions, including direct transfer to a prison, within the30-day follow-up period because those patients may not have the opportunity for anoutpatient follow-up visit.o Defined using the discharge codes in the “Excl – transfer, disch” tabs of the FUHcodebook. Who died during the 30-day follow-up period because patients who expire may not have theopportunity for an outpatient follow-up visit.o Defined using the Medicare Enrollment File. Who use hospice services or elect to use a hospice benefit any time during the measurementyear, regardless of when the services began because patients in hospice may require differentfollow-up services.o Defined using the hospice codes listed in the “Excl - hospice” tab of the FUH codebook.Table A4. Codes to identify admission or transfer to acute and non-acute inpatient facilityDescriptionFileClaimCodesTypeAcute care admissions (IPF orMedicare Inpatient 60CCN:acute care hospitals)3rd through 6th digit 0001-0899 or4000-4449 or3rd digit S, MSNF, Hospice, Outpatient andMedicare SNF,10, 20, 30, UB Revenue:HHAHospice,40, 500115, 0125, 0135, 0145, 0155,Outpatient or HHA0650, 0656, 0658, 0659, 019x,0118, 0128, 0138, 0148, 0158,0655, 1002, 1001SNF, Hospice, Outpatient andMedicare SNF,10, 20, 30, UB Type of Bill:HHAHospice,40, 5081x, 82x, 21x, 22x, 28x, 18xOutpatient or HHAPsychiatric residential treatmentMedicare Carrier71HCPCS:centerT2048, H0017-H0019SNF, Hospice, inpatient rehab,Medicare Carrier71Place of Service (POS): 31, 32, 34,respite, intermediate care facility,54, 55, 56, 61residential substance abuse andpsychiatric treatment facilities7

Inpatient Psychiatric Facility Quality Reporting Program Claims-Based Measure SpecificationsSection 2: 30-Day All-Cause Unplanned ReadmissionFollowing Psychiatric Hospitalization in an InpatientPsychiatric Facility (IPF Readmission) MeasureSpecifications – Version 4.0Description of MeasureThis facility-level measure estimates an unplanned, 30-day, risk-standardized readmission rate foradult Medicare FFS patient discharges from an IPF with a principal discharge diagnosis of apsychiatric disorder or dementia/Alzheimer’s disease. The measurement period used to identify casesin the measure population is typically 24 months, starting in July. Due to the impacts of COVID-19on IPFs, CMS will not count data from January 1, 2020, through June 30, 2020, for performance orpayment programs. For FY2022 reporting, the IPF Readmission measure will use a measurementperiod of July 1, 2018, through December 1, 2019, allowing data from the start of the measurementperiod through 30 days after the close of the measurement period to be used to identifyreadmissions. 2 Data from 12 months prior to the start of the measurement period through themeasurement period are used to identify risk factors.For a full list of codes used in measure calculation, refer to the IPF Readmission codebook, posted onQualityNet at Qualitynet.cms.gov Inpatient Psychiatric Facilities Resources ProgramResources/ View Measure Resources.Numerator StatementThe risk-adjusted outcome measure does not have a traditional numerator and denominator. Thenumerator statement describes the outcome being measured. A readmission is defined as anyadmission, for any reason, to an IPF or a short-stay acute care hospital (including CAHs) that occurswithin 30 days after the discharge date from an eligible index admission to an IPF, except thoseconsidered planned. The measure uses the CMS 30-day Hospital-Wide Readmission (HWR)Measure Planned Readmission Algorithm, Version 4.0, to identify planned readmissions. 3 Thealgorithm follows two principles to identify planned readmissions: Select procedures and diagnoses, such as transplant surgery, maintenancechemotherapy/radiotherapy, or rehabilitation care are considered always planned. For a fulllist of planned procedures and diagnoses, refer to the “PR1” and “PR2” tabs of the IPFReadmission codebook.Some procedures, such as colorectal resection or aortic resection, are considered eitherplanned or unplanned depending on the accompanying principal discharge diagnosis. For afull list of such procedures, refer to the “PR3” and “PR3b-ICD-10 procedure codes” tabs ofthe IPF Readmission codebook. Specifically, a procedure is considered planned if it does notcoincide with a principal discharge diagnosis of an acute illness or complication. For a fulllist of such principal discharge diagnoses, refer to the “PR4” and “Pr4DiagnosisICD10” tabsof the IPF Readmission codebook.2 Refer to CMS’s March 27, 2020, memo on exceptions and extensions for quality reporting requirements for healthcare entitiesaffected by COVID-19 for more information: e-based-purchasing-programs.pdf.3 Refer to QualityNet’s Readmission Measures Methodology page for more easures/readmission/methodology.8

Inpatient Psychiatric Facility Quality Reporting Program Claims-Based Measure SpecificationsDenominator StatementThe risk-adjusted outcome measure does not have a traditional numerator and denominator. Thedenominator statement describes the measure population. The measure population consists of eligibleindex admissions to IPFs. A readmission within 30-days will also be eligible as an index admission,if it meets all other eligibility criteria. Patients may have more than one index admission within themeasurement period.Index admissions are defined as admissions to IPFs for patients with the following characteristics: Age 18 or older at admissionDischarged aliveEnrolled in Medicare FFS Parts A and B during the 12 months prior to, the month of, and atleast one month after the index admissionDischarged with a psychiatric principal diagnosis included in the “PsychCCS” tab of the IPFReadmission codebook. The list of diagnoses uses the Agency for Healthcare Research andQuality (AHRQ) Clinical Classification Software (CCS) ICD groupings. Information onsorting ICD codes into clinically coherent groups is available on the AHRQ CCS webpage ccsr archive.jsp#ccsr.The measure population excludes admissions for patients with the following characteristics: Discharged against medical advice (AMA) because the IPF may have limited opportunity tocomplete treatment and prepare for discharge.Unreliable demographic and vital status data defined as the following:o Age greater than 115 yearso Missing gendero Discharge status of “dead” but with subsequent admissionso Death date prior to admission dateo Death date within the admission and discharge dates but the discharge status was not“dead.”Readmissions on the day of discharge or day following discharge because those readmissionsare likely transfers to another inpatient facility. The hospital that discharges the patient tohome or a non-acute care setting is accountable for subsequent readmissions.Readmissions two days following discharge because readmissions to the same IPF within twodays of discharge are combined into the same claim as the index admission and do not appearas readmissions due to the interrupted stay billing policy. Therefore, complete data onreadmissions within two days of discharge are not available.Statistical Risk Model and VariablesHierarchical logistic regression is used to estimate a risk standardized readmission rate.Risk Factor VariablesFour types of risk factors are included in the risk adjustment model:1. Demographics (Table B1)o Gender and age9

Inpatient Psychiatric Facility Quality Reporting Program Claims-Based Measure Specifications2. Principal discharge diagnosis of the IPF index admission. Discharge diagnoses aresummarized into 13 distinct principal discharge risk factors using a modified version of theAHRQ CCS groupings