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Bipolar Disorder: Level-of-function evaluation

1.4 Project
Endorsement Status
1.1 New or Maintenance
E&M Cycle
Is Under Review
1.3 Measure Description

Percentage of patients treated for bipolar disorder with evidence of level-of-function evaluation at the time of the initial assessment and again within 12 weeks of initiating treatment

        • 1.14 Numerator

          Documentation of monitoring the patient’s level-of-functioning in one of the following ways:
          • Patient self-report documented by clinician in record OR
          • Clinician documented review of patient-completed monitoring form/diary/tool OR
          • Documentation in patient chart of the use of ONE level-of-functioning monitoring tool, examples are as follows:
          o SOFAS: Social and Occupational Functioning Assessment Scale
          o GARF: Global Assessment of Relationship Functioning
          o GAF: Global Assessment of Functioning
          o WASA: Workload and Social Adjustment Assessment
          o PDS: Progressive Deterioration Scale (functional impairment; activities of daily living)
          o PHQ-9: Question 2 (How difficult has it been for you….)
          o SF 12 or SF 36
          Timeframe for numerator chart documentation
          Documentation of assessment of level-of-functions at time of initial assessment and within 12 weeks of initiating treatment for bipolar disorder
          (Note: While the acute phase of treatment varies per individual, it is during this period that the clinician attempts to closely monitor the patient progress and has the opportunity to interact with the patient to assess level-of-functioning. This acute phase has been defined by the Project’s content experts as having the possibility of lasting through the first 3 months of treatment/therapy; thus the 12 week period)

        • 1.15 Denominator

          Patients 18 years of age or older with an initial or new episode of bipolar disorder
          Documentation of a diagnosis of bipolar disorder; to include at least one of the following:
          • Codes 296.0x; 296.1x; 296.4x; 296.5x; 296.6x; 296.7; 296.80; 296.81; 296.82; 296.89; 301.13 documented in body of chart, such as a pre-printed form completed by a clinician and/or codes documented in chart notes/forms
          • Diagnosis or Impression or “working diagnosis” documented in chart indicating bipolar disorder
          • Use of a screening/assessment tool for bipolar disorder with a score or conclusion that patient has bipolar disorder and documentation that this information is used to establish or substantiate the diagnosis
          Documentation of treatment for bipolar disorder with pharmacotherapy; mood stabilizing agent and/or an antipsychotic agent.

          New diagnosis” or a “new episode,” is defined as cases where the patient has not been involved in active treatment for 6 months. Active treatment includes being hospitalized or under the out-patient care of a physician.

        • Most Recent Endorsement Activity
          Measure Retired and Endorsement Removed Behavioral Health Project 2013-2015
          Initial Endorsement
          Last Updated
          Removal Date