CMS 137 Initiation and Engagement of Substance Use Disorder Treatment

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    • Type: EC eCQMs - Eligible Clinicians
    • Resolution: Answered
    • Priority: Moderate
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      Thank you for your inquiry regarding CMS137v13 (2025 Performance Period). To answer your first question, Numerator 2 requires that the engagement treatment occur within 34 days after the day of the initiation treatment. A patient must first meet the criteria for Numerator 1 (Initiation) to be considered for Engagement; therefore, if the patient does not meet initiation criteria, they are not eligible for Numerator 2.

      To answer your second and fourth question, the continuation of the short-acting medication does not qualify as a medication treatment event for the engagement phase if the short-acting medication is used as the initiation. According to the measure specification, a new medication would need to be ordered to meet numerator 2 criteria.

      To answer your third question, if the follow-up telemedicine visit is documented in the medical record during a non-billed nurse/medical assistant visit without a diagnosis code, it will not count towards the measure. The encounter must be documented using a code from the "Telephone Visits" (2.16.840.1.113883.3.464.1003.101.12.1080) and a diagnosis code from the "Substance Use Disorder" (2.16.840.1.113883.3.464.1003.106.12.1001). This information must be present in the EHR. This requirement is expressed in the CQL below.

      Psychosocial Visit
      ["Intervention, Performed": "Substance Use Disorder Treatment"]
      union ["Intervention, Performed": "Psych Visit Psychotherapy"]
      union ( ( ["Encounter, Performed": "Telephone Visits"]
      union ["Encounter, Performed": "Virtual Encounter"] ) TelehealthEncounter
      where exists TelehealthEncounter.diagnoses Diagnosis
      where Diagnosis.code in "Substance Use Disorder"
      )

      To answer your fifth question, patient refusals are not currently a criteria for this measure. In the scenario mentioned in your inquiry, the patient will meet initial population criteria but not the initiation phase since the short-acting medication is not within 14 days of the SUD episode.

      To answer your sixth question, patient refusals are not currently a criteria for this measure. In the scenario mentioned in your inquiry, the patient will only meet numerator 1 criteria.

      Please refer to the measure specification to review the measure requirements: https://ecqi.healthit.gov/sites/default/files/ecqm/measures/CMS137v13.html.
      Show
      Thank you for your inquiry regarding CMS137v13 (2025 Performance Period). To answer your first question, Numerator 2 requires that the engagement treatment occur within 34 days after the day of the initiation treatment. A patient must first meet the criteria for Numerator 1 (Initiation) to be considered for Engagement; therefore, if the patient does not meet initiation criteria, they are not eligible for Numerator 2. To answer your second and fourth question, the continuation of the short-acting medication does not qualify as a medication treatment event for the engagement phase if the short-acting medication is used as the initiation. According to the measure specification, a new medication would need to be ordered to meet numerator 2 criteria. To answer your third question, if the follow-up telemedicine visit is documented in the medical record during a non-billed nurse/medical assistant visit without a diagnosis code, it will not count towards the measure. The encounter must be documented using a code from the "Telephone Visits" (2.16.840.1.113883.3.464.1003.101.12.1080) and a diagnosis code from the "Substance Use Disorder" (2.16.840.1.113883.3.464.1003.106.12.1001). This information must be present in the EHR. This requirement is expressed in the CQL below. Psychosocial Visit ["Intervention, Performed": "Substance Use Disorder Treatment"] union ["Intervention, Performed": "Psych Visit Psychotherapy"] union ( ( ["Encounter, Performed": "Telephone Visits"] union ["Encounter, Performed": "Virtual Encounter"] ) TelehealthEncounter where exists TelehealthEncounter.diagnoses Diagnosis where Diagnosis.code in "Substance Use Disorder" ) To answer your fifth question, patient refusals are not currently a criteria for this measure. In the scenario mentioned in your inquiry, the patient will meet initial population criteria but not the initiation phase since the short-acting medication is not within 14 days of the SUD episode. To answer your sixth question, patient refusals are not currently a criteria for this measure. In the scenario mentioned in your inquiry, the patient will only meet numerator 1 criteria. Please refer to the measure specification to review the measure requirements: https://ecqi.healthit.gov/sites/default/files/ecqm/measures/CMS137v13.html .
    • CMS0137v13

      Clarification requested on the following questions related to CMS137:

      Question 1: The denominators for Population 1 and Population 2 appear to be the same.  We would like clarification: if a patient does not meet the numerator criteria for Numerator 1 (Initiation), they are still eligible to meet the numerator criteria for Numerator 2 (Engagement).  If so, would the engagement period start on Day 15 after the new SUD Diagnosis?  

      Question 2: In the scenario below, does the continuation of the short-acting med qualify as a medication treatment event for engagement?   What would their measure outcome be?  

      SCENARIO 1

      • First Dependence Diagnosis at Office Visit:  1/1/XXXX at 12:00 PM 
      • Short-acting med (Suboxone) ordered on 1/1/XXXX at 12:15 PM
      • Follow-up Telemedicine Visit with appropriate ICD 10 code for SUD & SNOMED CT    code for intervention on 1/7/XXXX at 12:00 PM
      • Short-acting med (Suboxone) not ordered (same med as used for Initiation), but continued at 12:15 on 1/7/XXXX

      Question 3: In regard to SCENARIO 1:  What if the follow-up telemedicine visit is a Nurse Only telephone follow-up billed as a No Charge Visit?  Therefore, no diagnosis code is assigned. 

      Question 4: In regard to SCENARIO 1: Does the oral naltrexone (non-injectable) count when documented via medication reconciliation or continuing med rather than a new pharmacy medication order? Provider is not changing the patient's medication for the engagement population but continuing the medication as already ordered.

      Question 5: How are patient refusals of care considered by the measure, if at all?  What would be the measure outcome for the following scenario?

      SCENARIO 2: 

      First Dependence Diagnosis at Office Visit 1/1/XXXX at 12:00 PM

      Patient refuses medication or psychosocial visit in Initiation phase

      Accepts a short-acting medication and psychosocial visit (with appropriate ICD 10 code for SUD) and CPT code on 1/20/XXXX.

      Question 6: How are refusals of care considered by the measure, if at all? What would the patient outcome be for the SCENARIO 3.

      SCENARIO 3:

      First Dependence Diagnosis at Office Visit 1/1/XXXX at 12:00 PM

      Short-acting med (Suboxone) ordered on 1/1/XXXX at 12:15 PM

      Psychosocial visit with appropriate ICD10 SUD diagnosis code and intervention code (CPT or SNOMED) on 1/7/XXXXX

      Patient was a no-show for appointment and lost to follow-up for subsequent visit scheduled on 1/14/XXXX.

      Thank you for the additional guidance.

            Assignee:
            AIR EC eCQM Team
            Reporter:
            Shari Black
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