As a follow-up to our July 2023 communication regarding the Initiation and Engagement of Substance Use Disorder Treatment (IET) HEDIS measure, which assesses the follow-up care patients receive after a new episode of substance use disorder (SUD), we’d like to offer some additional tips to keep in mind:
- When a primary care provider (PCP) submits a claim with an initial diagnosis of an SUD, the PCP should schedule a follow-up visit with that patient within 2 weeks. To meet the parameters of the IET measure, the patient needs to have one visit within 14 days of the initial diagnosis and two additional visits within 34 days of the initial diagnosis and claims for a follow-up visit with the patient’s PCP or a behavioral health (BH) provider must document the same diagnosis as the initial diagnosis.
- If a patient is not interested in being referred to a BH provider, ongoing follow-up visits by the PCP office will count as appropriate engagement for the IET measure.
- Telehealth and virtual visits are acceptable as long as the SUD diagnosis is on the claim.
- For providers working in offices with an integrated care model, referral to a BH practitioner within your office may can help the patient feel more comfortable receiving the initial evaluation — just note that the diagnosis on claim must be the same as the diagnosis submitted by the PCP.
- Please be aware that an SUD diagnosis code, such as F11.20 (opioid dependence), should not be reported on claims for patients who are “dependent” on pain meds, but not considered to have an SUD. Instead, these claims should include code Z79.891 (long-term current use of opiate analgesic), which indicates that the patient is using long-term medication for pain but does not denote the presence of an SUD.
- If a patient has a history of alcohol dependence that is not currently active, please remember to use diagnosis code F10.21 to denote that the condition is in remission.
Audrey Kleinberg,
Director, Provider Relations & Communications
Annmarie Dadoly,
Senior Manager, Provider Communications
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