We are implementing the CMS 137 Initiation & Engagement of Substance Used Disorder (SUD) Treatment (IET) measure using the eCQM collection method.

In reviewing CMS 137, we noticed that many of the services included in the numerator rely heavily on billing codes and associated diagnoses. At our organization, we provide a number of no-charge visits—such as nurse-only, pharmacy, social work, peer-to-peer interventions, and integrative therapies. This is a strategic decision: the reimbursement for these services often does not exceed the administrative effort required to generate and process a claim. Given that these encounters often do not generate claims or diagnosis codes, how does the measure account for this type of care delivery? Is there a path for documentation-based inclusion (e.g., flowsheet data or clinical events) in the absence of billing artifacts, especially in EHR-based submissions? If there currently is not a path for this, could this be considered for a near future specification change for the EHR submission method?

We would like to raise a consideration regarding patients who are offered but decline medication-assisted treatment (MAT) for substance use disorder (SUD). In our clinical experience, pharmacists and providers frequently offer naloxone nasal spray kits as a harm reduction strategy to patients who are not ready or willing to begin MAT. This practice reflects both clinical judgment and patient autonomy—patients have the right to refuse treatment, and the provision of naloxone demonstrates due diligence in promoting patient safety and reducing overdose risk. We encourage the measure steward to consider whether the documented dispensing of naloxone in such cases could be recognized as a meaningful clinical action, particularly in quality measures evaluating appropriate care for patients with opioid use disorder. Including harm reduction efforts like naloxone provision may better reflect the full spectrum of evidence-based, patient-centered care.

Our opioid stewardship group would like to raise a concern regarding the inclusion of substance "dependence" diagnoses in the value set for CMS 137: Initiation and Engagement of Substance Use Disorder (SUD) Treatment. The term dependence reflects outdated diagnostic language from earlier versions of the DSM and has since been replaced by the unified diagnosis of Substance Use Disorder in the DSM-5. The continued inclusion of "dependence" codes (e.g., F11.20, F10.20) in the measure value set may not align with current clinical understanding or documentation practices. We respectfully recommend that CMS consider reviewing and potentially removing "dependence" codes from the value set to better reflect contemporary diagnostic standards. This change could improve the clinical relevance of the denominator population and support more accurate identification of individuals in need of engagement and treatment for SUD.

We would like to inquire whether CMS would consider excluding patients who are residing in skilled nursing facilities (SNFs) from CMS 137: Initiation and Engagement of Substance Use Disorder (SUD) Treatment. While SNF patients may have a qualifying SUD diagnosis, their access to traditional outpatient behavioral health services or follow-up visits may be limited due to care setting constraints. As a result, including these patients in the denominator could unintentionally reflect structural limitations rather than true gaps in care delivery or engagement. Has CMS considered adding SNF residency as an exclusion criterion for this measure, similar to how hospice or inpatient stays are sometimes treated in other quality measures?

We would appreciate any guidance on whether such scenarios are currently accounted for or may be considered in future measure updates.