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Measures

Measures

The APA Mental and Behavioral Health Registry (MBHR) was again approved by the Centers for Medicare and Medicaid Services (CMS) to participate in the Merit-Based Incentive Payment System (MIPS) for 2026 as a Qualified Clinical Data Registry (QCDR). Through our partnership with Healthmonix, an outside CMS-approved software vendor, the MBHR will allow practitioners to track quality outcomes on their clients and patients utilizing measures identified by the discipline as being the most meaningful to both practitioners and those we serve.

Measure identification and development is being steered by the Advisory Committee for Measurement-Based Care and the Mental and Behavioral Health Registry, made up of experts in the fields of outcome measurement, psychotherapy, clinical research, and quality improvement. There are 14 identified MIPS measures available in the registry and 5 specialty measures, exclusive to the MBHR, that can be submitted directly to the CMS. These include measures on anxiety, posttraumatic stress disorder, trauma screen and cognitive assessment. In addition to the specialty measures, below are behavioral health related MIPS measures available. 

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Code Description Follow-up Time Frame

MBHR1 Use of anxiety severity measureopens in new window

The percentage of adult patients (18 years and older) with an anxiety disorder diagnosis (e.g. generalized anxiety disorder, social anxiety disorder, or panic disorder) who have completed a standardized tool (e.g., GAD-7 or BAI; PDF, 365KBopens in new window) during measurement period.

N/A

MBHR2 Anxiety response at six monthsopens in new window

The percentage of adult patients (18 years of age or older) with an anxiety disorder (e.g., generalized anxiety disorder, social anxiety disorder, or panic disorder) who demonstrated a response to treatment (GAD-7 score at least 25% less than score at index event PDF, 365KBopens in new window) at six months (+/- 60 days) after an index visit.

4–8 months

MBHR07 Posttraumatic stress disorder (PTSD) outcome assessment for adults and childrenopens in new window

The percentage of patients with a history of a traumatic event (i.e., an experience that was unusually or especially frightening, horrible, or traumatic) who report symptoms consistent with PTSD for at least one month following the traumatic event and with documentation of a standardized symptom monitor (PCL-5 for adults [PDF, 806KB]opens in new window, CATS for child/adolescent [PDF, 390KB]opens in new window) and demonstrated a response to treatment at six months (+/- 120 days) after the index visit.

This measure is a multistrata measure, which addresses symptom monitoring for both child and adult patients being treated for posttraumatic stress symptoms. Assessment instruments monitoring severity of symptoms for PTSD are validated either for adult or child populations. Thus, while the measurement structure will be similar for both populations, the specified instruments for symptom monitoring will be different.

2–10 months
MBHR19 Trauma Screening and Re-Traumatization Preventionopens in new window Adult patients (18 years of age or older) included in the denominator have been screened for a history of life-time trauma exposure using a systematic screening method during a 12-month measurement period AND if positive (e.g., patient endorses being exposed to trauma) the patient is screened for current symptoms of PTSD. N/A
MBHR20 Cognitive Assessment with Counseling on Safety and Potential Riskopens in new window  Percentage of patients, regardless of age, referred for evaluation due to concerns for cognitive impairment for whom 1) a standardized valid assessment of cognition was performed and 2) results of assessment informed determination of diagnosis or further clarified etiological factors of cognitive impairment or complaints, and 3) reporting of results included counseling on safety and potential risks for patents who displayed cognitive impairment that could negatively impact safety. N/A
Code

Description

09 Anti-depressant Medication Management

Percentage of patients 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression, and who remained on an antidepressant medication treatment. Two rates are reported.

a. Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks).

b. Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months).

130 Documentation of Current Medications in the Medical Record

Percentage of visits for patients aged 18 years and older for which the eligible professional or eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include all known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements and must contain the medications’ name, dosage, frequency, and route of administration.

134 Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan

Percentage of patients aged 12 years and older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool and if positive, a follow-up plan is documented on the date of the positive screen.

182 Functional Outcome Assessment

Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter and documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies.

281 Dementia: Cognitive Assessment

Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12-month period.

282 Dementia: Functional Status Assessment

Percentage of patients with dementia for whom an assessment of functional status was performed at least once in the last 12 months.

286 Dementia: Counseling Regarding Safety Concerns

Percentage of patients with dementia or their caregiver(s) for whom there was a documented safety concerns screening in two domains of risk: 1) dangerousness to self or others and 2) environmental risks; and if safety concerns screening was positive in the last 12 months, there was documentation of mitigation recommendations, including but not limited to referral to other resources or orders for home safety evaluation.

288 Dementia: Caregiver Education and Support

Percentage of patients with dementia whose caregiver(s)* were provided with education on dementia disease management and health behavior changes and were referred to additional resources for support in the last 12 months.

291 Parkinson’s Disease: Cognitive Impairment or Dysfunction Assessment for Patients with Parkinson’s Disease

Percentage of all patients with a diagnosis of Parkinson’s Disease who were assessed for cognitive impairment or dysfunction once during the measurement period.

370 Depression Remission at Twelve Months (PDF, 40KB)opens in new window

The percentage of patients 18 years of age and or older with major depression or dysthymia who reached remission 12 months (+/- 30 days) after an index visit.

374 Closing the Referral Loop: Receipt of Specialist Report

Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred.

382 Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment

Percentage of patient visits for those patients aged 6 through 16 at the start of the measurement period with a diagnosis of major depressive disorder (MDD) with an assessment for suicide risk.

431 Preventative Care and Screening: Unhealthy Alcohol Use: Screening and Brief Counseling

Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months and who received brief counseling if identified as an unhealthy alcohol user.

502 Improvement or Maintenance of Functioning for Individuals with a Mental and/or Substance Use Disorder

The percentage of patients aged 18 and older with a mental and/or substance use disorder who demonstrated improvement or maintenance of functioning based on results from the 12-item World Health Organization Disability Assessment Schedule (WHODAS 2.0) or Sheehan Disability Scale (SDS) 30 to 180 days after an index assessment.

Last updated: April 2026Date created: 2018