ADHERENCE TO ANTIPSYCHOTIC MEDICATIONS FOR INDIVIDUALS WITH SCHIZOPHRENIA (SAA)
APPLICATIONS
HEDIS® (Administrative) NCQA Rating
OBJECTIVE Purpose of Measure: ELIGIBLE POPULATION Which members are included? STANDARD OF CARE
To identify adult members with Schizophrenia who were dispensed and remained on an antipsychotic medication for at least 80% of the treatment period Schizophrenic members age nineteen to sixty-four as of December 31st of the measurement year.
Members that also have a diagnosis of dementia are excluded. An appropriate medication should be prescribed as soon as feasible, and the patient should be maintained on the medication. Should intolerable side effects, persistent symptoms, or non-adherence occur, a different, clinically appropriate medication and/or adjunctive medication should be initiated. NCQA ACCEPTED Please see code table. CODES Table SAA-A: Antipsychotic Medications** Description Miscellaneous antipsychotic agents
Phenothiazine antipsychotics
Psychotherapeutic combinations Thioxanthenes Long-acting injections
Prescription Aripiprazole Olanzapine Asenapine Paliperidone Clozapine Pimozide Haloperidol Quetiapine Iloperidone Quetiapine fumarate Loxapine Risperidone Lurisadone Ziprasidone Molindone Cariprazine Chlorpromazine Prochlorperazine Fluphenazine Thioridazine Perphenazine Trifluoperazine
Days Supply
Perphenazine
amitriptyline Fluoxetineolanzapine Thiothixene Aripiprazole Fluphenazine decanoate Haloperidol decanoate
Olanzapine Paliperidone
palmitate
28 days supply
Risperidone
DOCUMENTATION REQUIREMENTS What documentation should be submitted?
REFERENCES
14 days supply
Documentation should include date of service and clear evidence that antipsychotic medication was prescribed (medication list containing antipsychotic and the date it was prescribed, note indicating the name of the antipsychotic and the date it was prescribed, or a copy of the prescription that was given to the member). Adherence to (compliance with) to the medication regimen should also be assessed and documented at each visit. For more information, please refer to Beacon’s Schizophrenia Clinical Practice Guideline and Provider Toolkit.
The criteria above are based on standards established under NCQA’s HEDIS 2017 Technical Specifications. HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).
Behavioral health case management is available for Passport members. To make a referral, call the Behavioral Health Hotline at 1-855-834-5651. Our behavioral health case managers work with our medical case managers to coordinate care and communication between providers.
** If you have questions about medications or our formulary, please visit our website http://passporthealthplan.com/pharmacy/#drugformulary or contact: o Paula Straub, Outreach Pharmacist Consultant (contracted) – Email:
[email protected] or Ph#: 502-814-3156 o Cheryl Stevens, Outreach Pharmacisit Consultant (contracted)-Covers regions 1,2,4,7 & 8. Email
[email protected] or phone 502-212-6723
ADHERENCE TO ANTIPSYCHOTIC MEDICATIONS FOR INDIVIDUALS WITH SCHIZOPHRENIA Meet Screening Criteria Schizophrenia Code System
Code
Definition
ICD10CM ICD10CM ICD10CM ICD10CM ICD10CM ICD10CM ICD10CM ICD10CM ICD10CM ICD10CM ICD10CM ICD10CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM
F20.0 F20.1 F20.2 F20.3 F20.5 F20.81 F20.89 F20.9 F25.0 F25.1 F25.8 F25.9 295.00 295.01 295.02 295.03 295.04 295.05 295.10 295.11 295.12 295.13 295.14 295.15 295.20 295.21 295.22 295.23 295.24 295.25 295.30 295.31 295.32 295.33 295.34 295.35 295.40
[F20.0] Paranoid schizophrenia [F20.1] Disorganized schizophrenia [F20.2] Catatonic schizophrenia [F20.3] Undifferentiated schizophrenia [F20.5] Residual schizophrenia [F20.81] Schizophreniform disorder [F20.89] Other schizophrenia [F20.9] Schizophrenia, unspecified [F25.0] Schizoaffective disorder, bipolar type [F25.1] Schizoaffective disorder, depressive type [F25.8] Other schizoaffective disorders [F25.9] Schizoaffective disorder, unspecified Simpl schizophren-unspec Simpl schizophren-subchr Simple schizophren-chr Simp schiz-subchr/exacer Simpl schizo-chr/exacerb Simpl schizophren-remiss Hebephrenia-unspec Hebephrenia-subchronic Hebephrenia-chronic Hebephren-subchr/exacerb Hebephrenia-chr/exacerb Hebephrenia-remission Catatonia-unspec Catatonia-subchronic Catatonia-chronic Catatonia-subchr/exacerb Catatonia-chr/exacerb Catatonia-remission Paranoid schizo-unspec Paranoid schizo-subchr Paranoid schizo-chronic Paran schizo-subchr/exac Paran schizo-chr/exacerb Paranoid schizo-remiss Schizophreniform dis NOS
ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM
295.41 295.42 295.43 295.44 295.45 295.50 295.51 295.52 295.53 295.54 295.55 295.60 295.61 295.62 295.63 295.64 295.65 295.70 295.71 295.72 295.73 295.74 295.75 295.80 295.81 295.82 295.83 295.84 295.85 295.90 295.91 295.92 295.93 295.94 295.95
Schizophrenic dis-subchr Schizophren dis-chronic Schizo dis-subchr/exacer Schizophr dis-chr/exacer Schizophrenic dis-remiss Latent schizophren-unsp Lat schizophren-subchr Latent schizophren-chr Lat schizo-subchr/exacer Latent schizo-chr/exacer Lat schizophren-remiss Schizophr dis resid NOS Schizoph dis resid-subch Schizophr dis resid-chr Schizo resid subchr/exac Schizoph resid-chro/exac Schizoph dis resid-remis Schizoaffective dis NOS Schizoaffectv dis-subchr Schizoaffective dis-chr Schizoaff dis-subch/exac Schizoafftv dis-chr/exac Schizoaffectve dis-remis Schizophrenia NEC-unspec Schizophrenia NEC-subchr Schizophrenia NEC-chr Schizo NEC-subchr/exacer Schizo NEC-chr/exacerb Schizophrenia NEC-remiss Schizophrenia NOS-unspec Schizophrenia NOS-subchr Schizophrenia NOS-chr Schizo NOS-subchr/exacer Schizo NOS-chr/exacerb Schizophrenia NOS-remiss
Long-Acting Injections 14 Day Supply Code System Code Definition HCPCS
J2794
Injection, risperidone, long acting, 0.5 mg (J2794)
Long-Acting Injections 28 Day Supply Code System Code Definition HCPCS HCPCS HCPCS
J0401 J1631 J2358
Injection, aripiprazole, extended release, 1 mg (J0401) Injection, haloperidol decanoate, per 50 mg (J1631) Injection, olanzapine, long-acting, 1 mg (J2358)
HCPCS HCPCS
J2426 J2680
Injection, paliperidone palmitate extended release, 1 mg (J2426) Injection, fluphenazine decanoate, up to 25 mg (J2680)
Exclusions Dementia Code System
Code
Definition
ICD10CM ICD10CM ICD10CM
F01.50 F01.51 F02.80
ICD10CM
F02.81
ICD10CM ICD10CM ICD10CM ICD10CM ICD10CM ICD10CM
F03.90 F03.91 F04 F10.27 F10.97 F13.27
ICD10CM
F13.97
ICD10CM ICD10CM ICD10CM ICD10CM
F18.17 F18.27 F18.97 F19.17
ICD10CM
F19.27
ICD10CM
F19.97
ICD10CM ICD10CM ICD10CM ICD10CM ICD10CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM
G30.0 G30.1 G30.8 G30.9 G31.83 290.0 290.10 290.11 290.12 290.13 290.20 290.21 290.3 290.40 290.41 290.42
[F01.50] Vascular dementia without behavioral disturbance [F01.51] Vascular dementia with behavioral disturbance [F02.80] Dementia in other diseases classified elsewhere without behavioral disturbance [F02.81] Dementia in other diseases classified elsewhere with behavioral disturbance [F03.90] Unspecified dementia without behavioral disturbance [F03.91] Unspecified dementia with behavioral disturbance [F04] Amnestic disorder due to known physiological condition [F10.27] Alcohol dependence with alcohol-induced persisting dementia [F10.97] Alcohol use, unspecified with alcohol-induced persisting dementia [F13.27] Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced persisting dementia [F13.97] Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or anxiolytic-induced persisting dementia [F18.17] Inhalant abuse with inhalant-induced dementia [F18.27] Inhalant dependence with inhalant-induced dementia [F18.97] Inhalant use, unspecified with inhalant-induced persisting dementia [F19.17] Other psychoactive substance abuse with psychoactive substanceinduced persisting dementia [F19.27] Other psychoactive substance dependence with psychoactive substance-induced persisting dementia [F19.97] Other psychoactive substance use, unspecified with psychoactive substance-induced persisting dementia [G30.0] Alzheimer's disease with early onset [G30.1] Alzheimer's disease with late onset [G30.8] Other Alzheimer's disease [G30.9] Alzheimer's disease, unspecified [G31.83] Dementia with Lewy bodies Senile dementia uncomp Presenile dementia Presenile delirium Presenile delusion Presenile depression Senile delusion Senile depressive Senile delirium Vascular dementia,uncomp Vasc dementia w delirium Vasc dementia w delusion
ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM ICD9CM
290.43 290.8 290.9 291.2 292.82 294.0 294.10 294.11 294.20 294.21 331.0 331.82
Vasc dementia w depressn Senile psychosis NEC Senile psychot cond NOS Alcohol persist dementia Drug persisting dementia Amnestic disord oth dis Dementia w/o behav dist Dementia w behavior dist Demen NOS w/o behv dstrb Demen NOS w behav distrb Alzheimer's disease Dementia w Lewy bodies
