2016 PQRS Measure #383: Adherence to Antipsychotic Medications For Individuals with Schizophrenia

DESCRIPTION

The measure calculates the percentage of individuals aged 18 years and older as of the beginning of the measurement period with schizophrenia or schizoaffective disorder who are prescribed an antipsychotic medication, with adherence to the antipsychotic medication [defined as a Proportion of Days Covered (PDC)] of at least 0.8 during the measurement period (12 consecutive months).

INSTRUCTIONS

This measure is to be reported a minimum of once per reporting period for all patients with a diagnosis of schizophrenia or schizoaffective disorder seen during the reporting period. This measure may be reported by clinicians who perform the quality actions described in the measure for the primary management of patients with schizophrenia or schizoaffective disorder based on the services provided and the measure-specific denominator coding.

DENOMINATOR

Individuals aged 18 years and older as of the beginning of the measurement period with schizophrenia or schizoaffective disorder with at least two claims for any antipsychotic medication during the measurement period (12 consecutive months)

DENOMINATOR NOTE: The following are the oral antipsychotic medications by class for the denominator. The route of administration includes all oral formulations of the medications listed below.

TYPICAL ANTIPSYCHOTIC MEDICATIONS:
 chlorpromazine
 fluphenazine
 haloperidol
 loxapine
 molindone
 perphenazine
 perphenazine-amitriptyline
 pimozide
 prochlorperazine
 thioridazine
 thiothixene
 trifluoperazine

ATYPICAL ANTIPSYCHOTIC MEDICATIONS:
 aripiprazole
 asenapine
 clozapine
 olanzapine
 olanzapine-fluoxetine
 iloperidone
 lurasidone
 paliperidone
 quetiapine
 risperidone
 ziprasidone

The following are the long-acting (depot) injectable antipsychotic medications by class for the denominator. The route of administration includes all injectable and intramuscular formulations of the medications listed below.

TYPICAL ANTIPSYCHOTIC MEDICATIONS:
 fluphenazine decanoate (J2680)
 haloperidol decanoate (J1631)

ATYPICAL ANTIPSYCHOTIC MEDICATIONS:
 olanzapine pamoate (J2358)
 paliperidone palmitate (J2426)
 risperidone microspheres (J2794)

NOTE: Since the days’ supply variable is not reliable for long-acting injections in administrative data, the days’ supply is imputed as listed below for the long-acting (depot) injectable antipsychotic medications billed under Part D and Part B:

 fluphenazine decanoate (J2680) – 28 days’ supply
 haloperidol decanoate (J1631) – 28 days’ supply
 olanzapine pamoate (J2358) – 28 days’ supply
 paliperidone palmitate (J2426) – 28 days’ supply
 risperidone microspheres (J2794) – 14 days’ supply

Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years at the beginning of the measurement year
AND
Diagnosis for schizophrenia or schizoaffective disorder (ICD-9-CM) [for use 1/1/2015-9/30/2015]: 295.00, 295.01, 295.02, 295.03, 295.04, 295.05, 295.10, 295.11, 295.12, 295.13, 295.14, 295.15, 295.20, 295.21, 295.22, 295.23, 295.24, 295.25, 295.30, 295.31, 295.32, 295.33, 295.34, 295.35, 295.40, 295.41, 295.42, 295.43, 295.44, 295.45, 295.50, 295.51, 295.52, 259.53, 295.54, 295.55, 295.60, 295.61, 295.62, 295.63, 295.64, 295.65, 295.70, 295.71, 295.72, 295.73, 295.74, 295.75,295.80, 295.81, 295.82, 295.83, 295.84, 295.85, 295.90, 295.91, 295.92, 295.93, 295.94, 295.95, V11.0
Diagnosis for schizophrenia or schizoaffective disorder (ICD-10-CM) [for use 10/1/2015-12/31/2015]: F20.0, F20.1, F20.2, F20.3, F20.5, F20.81, F20.89, F20.9, F21 F25.0, F25.1, F25.8, F25.9
AND
Patient encounter during the reporting period (CPT or HCPCS): 90785, 90791, 90792, 90832, 90833, 90834, 90836, 90837,90838 98960, 98961,98962, 99078, 99201, 99202, 99203, 99204,99205, 99211, 99212, 99213, 99214,99215, 99217, 99218, 99219, 99220,99224, 99225, 99226, 99281, 99282, 99283, 99284, 99285, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0409

OR
90845, 90847, 90849, 90853, 90870, 90880, 99291, 99292
WITH
Place of Service (POS): 03, 05, 07, 09, 11, 12, 13, 14, 15, 20, 22, 24, 26, 33, 49, 50, 52, 53, 54, 55, 57, 62, 71, 72
OR
90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90845, 90847, 90849, 90853, 90870, 99291, 99292
WITH
Place of Service (POS): 23
OR
90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90845, 90847, 90849, 90853, 90870, 99291, 99292
WITH
Place of Service (POS): 31, 32, 55, 56, 57, 62 OR 90791, 90792, 90832, 90833, 90834, 90837, 90838, 90845, 90847, 90849, 90853, 90870, 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99291, 99292
WITH
Place of Service (POS): 21, 51, 61
AND
At least two encounters with a diagnosis of schizophrenia with different dates of service in an outpatient setting, emergency department setting, or nonacute inpatient setting during the measurement period
OR
At least one encounter with a diagnosis of schizophrenia in an acute inpatient setting during the measurement period
AND NOT
Diagnosis for dementia (ICD-9-CM) [for use 1/1/2015-9/30/2015]: 290.0, 290.10, 290.11, 290.12, 290.13, 290.20, 290.21, 290.3, 290.40, 290.41, 290.42, 290.43, 291.2, 294.10, 294.11, 294.20, 294.21, 331.0, 331.19, 331.82
Diagnosis for dementia (ICD-10-CM) [for use 10/1/2015-12/31/2015]: E75.00, E75.01, E75.02, E75.09, E75.10, E75.11, E75.19, E75.4, F01.50, F01.51, F02.80, F02.81, F03, F03.90, F03.91, F05, F10.27, F10.97, F13.27, F13.97, G30.0, G30.1, G30.8, G30.9, G31.09, G31.83

NUMERATOR

Individuals with schizophrenia or schizoaffective disorder who filled at least two prescriptions for any antipsychotic medication and have a Proportion of Days Covered (PDC) for antipsychotic medications of at least 0.8

NUMERATOR NOTE: The PDC is calculated as follows:

PDC NUMERATOR: The PDC numerator is the sum of the days covered by the days’ supply of all antipsychotic prescriptions. The period covered by the PDC starts on the day the first prescription is filled (index date) and lasts through the end of the measurement period, or death, whichever comes first. For prescriptions with a days’ supply that extends beyond the end of the measurement period, count only the days for which the drug was available to the individual during the measurement period. If there are prescriptions for the same drug (generic name or 10-digit generic product identifier [GPI]) on the same date of service, keep the prescription with the largest days’ supply. If prescriptions for the same drug (generic name or GPI) overlap, then adjust the latest prescription start date to be the day after the previous fill has ended.

PDC DENOMINATOR: The PDC denominator is the number of days from the first prescription date through the end of the measurement period, or death date, whichever comes first.

Numerator Options:
Performance Met: Individual filled at least two prescriptions for any antipsychotic medication and had a PDC of 0.8 or greater (G9369)

OR
Performance Not Met: Individual who did not fill at least two prescriptions for any antipsychotic medication or did not have a PDC of 0.8 or greater (G9370)
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Adherence to Antipsychotic Medications For Individuals with Schizophrenia

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