Follow-up Care for Children Prescribed ADHD Medication (ADD) is retired, only ADD-E measure will be reported.

Product Lines:
EHP, Priority Partners and USFHP.

Eligible Population:
Members between 6 years and 12 years of age as of December 31 of the measurement year.

Definition:

Measure evaluates the percentage of members 6-12 years of age with newly prescribed attention-deficit/hyperactivity disorder (ADHD) medication who had at least three follow up care visits within a 10-month period. One visit is required within 30 days of when the first ADHD medication was dispensed. Two rates are reported.

• Initiation Phase: percentage of members 6-12 years of age as of the IPSD (Index Prescription Start Date) with a prescription dispensed for ADHD medication, who had one follow-up visit with a practitioner with prescribing authority during the 30-day Initiation Phase.
• Continuation and Maintenance (C&M) Phase: percentage of members 6-12 years of age with a prescription dispensed for ADHD medication, who remained on the medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase.

Continuous Enrollment:

• Initiation Phase: The member was enrolled with a medical and pharmacy benefit and had no gaps in enrollment between 120 days prior to the IPSD through 30 days after the IPSD.
• C&M phase: The member was enrolled with a medical and pharmacy benefit between 120 days prior to the IPSD through 300 days after the IPSD.
  • Commercial: No more than one 45-day gap in enrollment is allowed between 31 days after the IPSD through 300 days after the IPSD.
  • Medicaid: Monthly verified enrollment with only 1 gap in coverage is allowed.

Best Practice and Measure Tips

• Timing of scheduled visits is key based on the prescription day supply to evaluate medication effectiveness, any adverse effects and to monitor the patient’s progress.
• When prescribing a new ADHD medication for a patient:
  • Schedule follow-up visits to occur before the refill is given.
  • Schedule a 30-day, 60-day and 180-day follow-up visit from the initial visit before member leaves office.
  • Consider scheduling follow-up visit within 14 to 21 days of each prescription.
  • Consider prescribing an initial two-week supply and follow-up prescriptions to a 30-day supply to ensure patient follow-up.
  • Only one of the two visits (during days 31–300) may be an e-visit or virtual check-in.
• Review treatment plan regularly and make any modifications if the patient’s symptoms do not respond.
• Treatment should continue as long as symptoms remain present and cause impairment.
• Monitor treatment-emergent side effects.
• Assess periodically to determine whether there is a continue need for treatment or if symptoms have remitted.

Measure Medications

ADHD Medications:

Measure Exclusions

Required Exclusions:

• Members in hospice or using hospice services anytime during the measurement year.
• Members who died any time during the measurement year. 
• Patients who filled an ADHD prescription 120 days (4 months) prior to the IPSD (Index Prescription Start Date). Applies to only Rate 1 – Initiation phase.
• Patients who had an acute inpatient encounter or admission for a mental, behavioral or neurodevelopmental disorder during the 30 days after the IPSD.
• Members with a diagnosis of narcolepsy any time during their history through December 31 or the measurement year.

Exclusion Codes:

Narcolepsy ICD-10-CM:

• [G47.411] Narcolepsy with cataplexy;
• [G47.419] Narcolepsy without cataplexy;
• [G47.421] Narcolepsy in conditions classified elsewhere with cataplexy;
• [G47.429] Narcolepsy in conditions classified elsewhere without cataplexy.

Measure Codes

The following code combinations identify follow-up visits:

• Outpatient Visit (Visit Setting Unspecified)  
  • CPT: 90791, 90792, 90832–90834, 90836–90840, 90845, 90847, 90849, 90853, 90875, 90876, 99222–99223, 99231–99233, 99238, 99239, 99251–99255
  • Visit Setting Unspecified Value Set with any of the following place of service (POS)
    
    • Partial Hospitalization POS: 52
    • Community Mental Health Center POS: 53
    • Telehealth POS:
      • Telehealth Provided Other than in Patient’s Home: 02
      • Telehealth Provided in Patient’s Home:10
    • Outpatient POS:

 

• BH Outpatient visit
  • CPT: 98960–98962, 99078, 99202–99205, 99211–99215, 99242–99245, 99341, 99342, 99344, 99345, 99347–99350, 99381–99387, 99391–99397, 99401–99404, 99411, 99412, 99483, 99492-99494, 99510  
  • HCPCS: G0155, G0176, G0177, G0409, G0463, G0512, H0002, H0004, H0031, H0034, H0036, H0037, H0039, H0040, H2000, H2010, H2011, H2013–H2020, T1015**.
    • NOTE: **T1015 HCPCS code which identifies an all-inclusive clinic visit for services rendered at a Federally Qualified Health Center (FQHC).
  • UBREV: 0510, 0513, 0515, 0516, 0517, 0519, 0520, 0521, 0522, 0523, 0526, 0527, 0528, 0529, 0900, 0902, 0903, 0904, 0911, 0914, 0915, 0916, 0917, 0919, 0982, 0983 
• A health and behavior assessment/intervention
  • CPT: 96156, 96158, 96159, 96164, 96165, 96167, 96168, 96170, 96171
• Intensive outpatient encounter or partial hospitalization 
  • HCPCS: G0410, G0411, H0035, H2001, H2012, S0201, S9480, S9484, S9485
  • UBREV: 0905, 0907, 0912, 0913 
• Telehealth visit
  • CPT: 98966–98968, 99441–99443.
• E-visit or virtual check-in (Online Assessments)
  • CPT : 98970, 98971, 98972, 98980, 98981, 99421- 99423, 99421, 99422, 99423, 99444, 99457, 99458 
  • HCPCS: G0071, G2010, G2012, G2250- G2252