CMS 137 Numerator satisfactions Inquiry

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    • Type: EC eCQMs - Eligible Clinicians
    • Resolution: Answered
    • Priority: Moderate
    • Component/s: None
    • None
    • Mayo Clinic
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      Thank you for your inquiry about CMS137v13 (performance period 2025). Please see the responses to the scenarios mentioned below.

      For situation #1a and 2a, these patients will meet numerator 1 criteria and denominator criteria for population 2.

      For situation #1b, this patient will not meet numerator criteria because SNOMED CT code 386445006 is not an appropriate code used in this measure. Clinically equivalent services can be mapped to the measure's value set. If mapping is done, please maintain documentation in case of a CMS audit.

      For situation 2b, please reference the response for 2a, review the codes in the value sets, and ensure they are within the required timeframes.

      For 3, 4, 5a and 5b, please clarify the dates for each service documented in the EHR for us to evaluate whether these scenarios would meet numerator criteria.

      If you have questions regarding implementing the measure, you may refer to the "Implementation Checklist for eCQM Annual Update" for additional guidance. If you have questions about reading the measure specification or understanding data requirements, you may refer to the "Guide for Reading eCQMs" for additional guidance. These resources can be found in the eCQI Resource Center: https://ecqi.healthit.gov/ep-ec?qt-tabs_ep=ecqm-resources&global_measure_group=eCQMs
      Show
      Thank you for your inquiry about CMS137v13 (performance period 2025). Please see the responses to the scenarios mentioned below. For situation #1a and 2a, these patients will meet numerator 1 criteria and denominator criteria for population 2. For situation #1b, this patient will not meet numerator criteria because SNOMED CT code 386445006 is not an appropriate code used in this measure. Clinically equivalent services can be mapped to the measure's value set. If mapping is done, please maintain documentation in case of a CMS audit. For situation 2b, please reference the response for 2a, review the codes in the value sets, and ensure they are within the required timeframes. For 3, 4, 5a and 5b, please clarify the dates for each service documented in the EHR for us to evaluate whether these scenarios would meet numerator criteria. If you have questions regarding implementing the measure, you may refer to the "Implementation Checklist for eCQM Annual Update" for additional guidance. If you have questions about reading the measure specification or understanding data requirements, you may refer to the "Guide for Reading eCQMs" for additional guidance. These resources can be found in the eCQI Resource Center: https://ecqi.healthit.gov/ep-ec?qt-tabs_ep=ecqm-resources&global_measure_group=eCQMs
    • CMS0137v13
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      We are hoping to understand situations that will satisfy the numerator for CMS 137 Initiation and Engagement of Substance Use Disorder Treatment as we assess our current Substance Use Disorder workflows in various practices. Will you please provide anticipated measure outcomes for Initiation and Engagement for these situations?
      Show
      We are hoping to understand situations that will satisfy the numerator for CMS 137 Initiation and Engagement of Substance Use Disorder Treatment as we assess our current Substance Use Disorder workflows in various practices. Will you please provide anticipated measure outcomes for Initiation and Engagement for these situations?

      Situation #1a--Patient admitted to the hospital from the ER with CPT Code 99285 Emergency Department Evaluation and Management Visit on 3/1/2025 to 3/4/2025. Previous SUD event 8/1/2024. On progress note from nurse care manager on 3/4/2025, ICD 10 Code F10.129 Alcohol Abuse with Intoxication, Unspecified documented with SNOMED CT code 408935001 Substance abuse prevention education (procedure) documented. Unable to perform interventions earlier due to acute condition. Patient did not follow up with OP referrals and recommendations.

      Situation #1b-Patient admitted to the hospital from the ER with CPT Code 99285 Emergency Department Evaluation and Management Visit on 3/1/2025 to 3/4/2025. SNOMED CT 386445006 Substance Use Treatment: drug withdrawal (regime/therapy) and ICD 10 Code F10.129 Alcohol Abuse with Intoxication, Unspecified documented on 3/1/2025. Previous SUD event 8/1/2024. 3/2/2025- during hospitalization SNOMED CT 386445006 Substance Use Treatment: drug withdrawal (regime/therapy) and ICD 10 Code F10.129 Alcohol Abuse with Intoxication, Unspecified documented on progress note. On progress note from nurse care manager on 3/4/2025, ICD 10 Code F10.129 Alcohol Abuse with Intoxication, Unspecified documented with SNOMED CT code 408935001 Substance abuse prevention education (procedure) documented. Unable to perform interventions earlier due to acute condition. Patient did not follow up with OP referrals and recommendations. (This is the same situation as above, except additional SNOMED CT codes in hospitalization).

      Situation #2a-Patient in the ER with CPT Code 99285 Emergency Department Evaluation and Management Visit on 3/1/2025. Primary Diagnosis ICD 10 Code F10.129 Alcohol Abuse with Intoxication, Unspecified. Previous SUD Episode 12/23/2024. Transferred to XYX Inpatient Behavioral Health Center on 3/1/2025 and discharged from XYZ Behavioral Health Center on 3/2/2025. Limited availability of HIE record from XYZ due to psychiatric condition. 3/9/2025-hospital follow-up with psych 99215 PR VIST EST PATIENT LEVEL 5 CPT code and Alcohol Moderate Or Severe Use Disorder (Dependence) With Alcohol Induced Mood Disorder (HCC) F10.24. 3/16/2025—hospital follow-up with nurse case manager telephone visit with SNOMED Code 424407005 Substance use cessation education, guidance, and counseling (procedure) and SNOMED CT Code 386473003 Telephone follow-up (procedure) and Diagnosis Code F10.129 Alcohol Abuse with Intoxication, Unspecified, not billed.

      Situation #2b-Patient in the ER with CPT Code 99285 Emergency Department Evaluation and Management Visit on 3/1/2025. Primary Diagnosis ICD 10 Code F10.129 Alcohol Abuse with Intoxication, Unspecified. SNOMED CT 386449006 Substance Use Treatment: alcohol withdrawal (regime/therapy) documented on 3/1/2025 . Previous SUD Episode 12/23/2024. Transferred to XYX Inpatient Behavioral Health Center on 3/1/2025 and discharged from XYZ Behavioral Health Center on 3/2/2025. Limited availability of HIE record from XYZ due to psychiatric condition. 3/9/2025-hospital follow-up with psych 99215 PR VIST EST PATIENT LEVEL 5 CPT code and Alcohol Moderate Or Severe Use Disorder (Dependence) With Alcohol Induced Mood Disorder (HCC) F10.24. 3/16/2025—hospital follow-up with nurse case manager telephone visit with SNOMED Code 424407005 Substance use cessation education, guidance, and counseling (procedure) and SNOMED CT Code 386473003 Telephone follow-up (procedure) and Diagnosis Code F10.129 Alcohol Abuse with Intoxication, Unspecified, not billed. (This is the same situation as above, except additional SNOMED CT code in ED visit).

      Situation #3--Patient evaluated in Sleep Medicine 3/1/2025 with ICD 10 F10.182 Alcohol abuse with alcohol-induced sleep disorder and 99245 PR OFFICE CONSULT LEVEL 5. SNOMED CT Code Counseling about alcohol consumption (procedure) 413473000. Documented in text notes that patient follows up externally for depression and alcohol abuse. Nurse Care Manager documents in telephone visit SNOMED CT Codes 386473003 Telephone follow-up (procedure), 424148004 Substance use cessation surveillance (regime/therapy), 15167005 Alcohol abuse (disorder) ( not billed externally) on 3/7/2025 and again on 3/14/2025 to check to ensure patient is following alcohol abuse treatment plan.

      Situation #4--Patient evaluated in Family Medicine 3/1/2024 with ICD 10 Alcohol Moderate Or Severe Use Disorder (Dependence) Uncomplicated (HCC) F10.20, CPT 99214 PR VISIT EST PATIENT LEVEL 4 and SNOMED CT Code Counseling about alcohol consumption (procedure) 413473000 on that day. Patient declined naltrexone. Nurse Care Manager documents in telephone visit SNOMED CT Codes 386473003 Telephone follow-up (procedure), 424148004 Substance use cessation surveillance (regime/therapy), 15167005 Alcohol abuse (disorder) ( not billed externally) on 3/7/2025. Patient says she is struggling and nurse arranges for a prescription for naltrexone hcl 50 mg tablet from primary care provider for the patient on 3/7/2025.

      Situation #5a—Patient evaluated in ER with CPT Code 99285 Emergency Department Evaluation and Management Visit on 3/1/2025. Primary Diagnosis ICD 10 Code F10.129 Alcohol Abuse with Intoxication, Unspecified. SNOMED CT 386449006 Substance Use Treatment: alcohol withdrawal (regime/therapy) documented on 3/1/2025. Left against medical advice that day. Telemedicine visit with 99213 PR VISIT EST PATIENT LEVEL 3 1) F10.24 - Alcohol dependence with alcohol-induced mood disorder on 3/12/2025 with primary care provider. Nurse Care Manager documents in telephone visit SNOMED CT Codes 386473003 Telephone follow-up (procedure) and 15167005 Alcohol abuse (disorder) ( not billed externally) on 4/2/2025.

      Situation #5b—Patient evaluated in ER with CPT Code 99285 Emergency Department Evaluation and Management Visit on 3/1/2025. Primary Diagnosis ICD 10 Code F10.129 Alcohol Abuse with Intoxication, Unspecified. SNOMED CT 386449006 Substance Use Treatment: alcohol withdrawal (regime/therapy) documented on 3/1/2025. Left against medical advice that day. Telemedicine visit with 99213 PR VISIT EST PATIENT LEVEL 3 1) F10.24 - Alcohol dependence with alcohol-induced mood disorder on 3/12/2025 with primary care provider. Nurse Care Manager documents in telephone visit SNOMED CT Codes 386473003 Telephone follow-up (procedure), 424148004 Substance use cessation surveillance (regime/therapy), 15167005 Alcohol abuse (disorder) ( not billed externally) on 4/2/2025. (Added SNOMED CT code to nurse visit)

      Thank you for helping us understand measure outcomes for this measure better

            Assignee:
            AIR EC eCQM Team
            Reporter:
            Amanda Fredricksen
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