General eCQM Information
| CMS Measure ID | CMS161v7 |
|---|---|
| NQF Number | 0104 |
| Measure Description |
Percentage of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified |
| Initial Population | All patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) |
| Denominator Statement |
Equals Initial Population |
| Denominator Exclusions |
None |
| Numerator Statement |
Patients with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified |
| Numerator Exclusions |
Not Applicable |
| Denominator Exceptions |
None |
| Measure Steward | PCPI(R) Foundation (PCPI[R]) |
| Domain | Effective Clinical Care |
| Measure Scoring | Proportion measure |
| Measure Type | Process measure |
| Improvement Notation |
Higher score indicates better quality |
| Guidance |
This measure is an episode-of-care measure and should be reported for each instance of a new or recurrent episode of major depressive disorder (MDD); every new or recurrent episode will count separately in the Initial Population. It is expected that a suicide risk assessment will be completed at the visit during which a new diagnosis is made or at the visit during which a recurrent episode is first identified (ie, at the initial evaluation). For the purposes of this measure, an episode of major depressive disorder (MDD) would be considered to be recurrent if a patient has not had an MDD-related encounter in the past 105 days. If there is a gap of 105 or more days between visits for major depressive disorder (MDD), that would imply a recurrent episode. The 105-day look-back period is an operational provision and not a clinical recommendation, or definition of relapse, remission, or recurrence. Use of a standardized tool or instrument to assess suicide risk will meet numerator performance. Standardized tools can be mapped to the concept "Intervention, Performed": "Suicide risk assessment (procedure)" included in the numerator logic below. The logic statement for the age requirement, as written, captures patients who turn 18 years old during the measurement period so that these patients are included in the measure. To ensure all patients with major depressive disorder (MDD) are assessed for suicide risk, there are two clinical quality measures addressing suicide risk assessment; CMS 177 covers children and adolescents aged 6 through 17, and CMS 161 covers the adult population aged 18 years and older. |
| Quality ID | 107 |
| Meaningful Measure | Prevention, Treatment, and Management of Mental Health |
| Next Version |
Data Element Repository
Header
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Updated Version Number.
Measure Section: eMeasure Version number
Source of Change: Measure Lead
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Updated Copyright.
Measure Section: Copyright
Source of Change: Annual Update
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Updated Disclaimer.
Measure Section: Disclaimer
Source of Change: Measure Lead
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Updated Clinical Recommendation Statement.
Measure Section: Clinical Recommendation Statement
Source of Change: Measure Lead
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Updated References.
Measure Section: Reference
Source of Change: Measure Lead
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Updated Guidance related to age requirement to remove reference to QDM expression logic.
Measure Section: Guidance
Source of Change: Measure Lead
Logic
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Replaced SNOMEDCT single code value sets with direct referenced codes. A direct referenced code is a single concept code that is used to describe a clinical element directly within the logic. The use of direct referenced codes replaces the need for single code value sets. Measures using other code systems in single value sets may optionally transition to direct referenced codes.
Measure Section: Numerator
Source of Change: Standards Update
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Added supplemental timing attributes to most datatypes in QDM 5.3 to facilitate accurate retrieval of time related information within CQL logic. Timing attributes now include a time interval, such as prevalence period or relevant period, and/or actual time of documentation with Author Datetime. Relevant period is the general method to describe start and stop times for datatypes. Prevalence period is used for some datatypes to more accurately define onset and abatement times.
Measure Section: Multiple Sections
Source of Change: Standards Update
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Assigned cardinality to each attribute to be more explicit in guiding specification and implementation of QDM data elements. Cardinality refers to the number of instances of the attribute that can be included in the measure description. Cardinality for most attributes is 0.. 1 (i.e., can occur up to 1 time), but some attributes have a cardinality of 0.. * (i.e., can occur multiple times).
Measure Section: Multiple Sections
Source of Change: Standards Update
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CQL libraries contain sets of CQL definitions, or CQL expression statements. A context statement, patient or population, can now be used in a CQL library to clearly establish how the subsequent list of CQL expressions will be interpreted. A 'Population' context will interpret the CQL expression with reference to the entire population of the item being counted, patients or encounters. A 'Patient' context will interpret the CQL expression with reference to a single patient. Context statements are not required, but one or more context statements may be used within a library to help clarify how the CQL expressions will be interpreted. Patient context is the default if none is specified.
Measure Section: Multiple Sections
Source of Change: Standards Update
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Removed the 'Face-To-Face Interaction' data element and added relevant SNOMED codes to the Encounter Grouping value sets to better align between the SNOMED and CPT encounter codes.
Measure Section: Multiple Sections
Source of Change: Measure Lead
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Replaced measure-defined definitions with similar definitions and functions from CQL shared libraries for consistency across measures.
Measure Section: Multiple Sections
Source of Change: Standards Update
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Updated measure logic from Quality Data Model (QDM)-based logic to Clinical Quality Language (CQL)-based logic. Information on CQL can be found at the eCQI Resource center (https://ecqi.healthit.gov/cql). Information about specific versions of the new standards in use for CMS reporting periods can be found at the eCQI Resource Center (https://ecqi.healthit.gov/ecqm-tools-key-resources). Switching from QDM to CQL brings with it many changes, as well as enhanced expression capability, but only those changes with significant impact will be outlined in technical release notes. For example, in the case of timing operators, changes may only be summarized if those changes impact the measure calculation.
Measure Section: Multiple Sections
Source of Change: Standards Update
Value Set
The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.
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Replaced SNOMEDCT single code value sets with direct referenced codes. A direct referenced code is a single concept code that is used to describe a clinical element directly within the logic. The use of direct referenced codes replaces the need for single code value sets. Measures using other code systems in single value sets may optionally transition to direct referenced codes.
Measure Section: QDM Data Elements
Source of Change: Standards Update
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Value set Payer (2.16.840.1.114222.4.11.3591): Added 11 SOP codes (299, 32127, 32128, 391, 517, 524, 614, 621, 622, 623, 629) and deleted 3 SOP codes (63, 64, 69).
Measure Section: QDM Data Elements
Source of Change: Annual Update
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Value set Face-to-Face Interaction (2.16.840.1.113883.3.464.1003.101.12.1048): Removed Face-to-Face Interaction.
Measure Section: QDM Data Elements
Source of Change: Annual Update
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Value set Outpatient Consultation (2.16.840.1.113883.3.464.1003.101.12.1008): Added SNOMEDCT extensional value set (2.16.840.1.113883.3.464.1003.101.11.1266) including 3 codes.
Measure Section: QDM Data Elements
Source of Change: Annual Update
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Value set Emergency Department Visit (2.16.840.1.113883.3.464.1003.101.12.1010): Added SNOMEDCT extensional value set (2.16.840.1.113883.3.464.1003.101.11.1263) including 1 code.
Measure Section: QDM Data Elements
Source of Change: Annual Update
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Value set Office Visit (2.16.840.1.113883.3.464.1003.101.12.1001): Added SNOMEDCT extensional value set (2.16.840.1.113883.3.464.1003.101.11.1264) including 7 codes.
Measure Section: QDM Data Elements
Source of Change: Annual Update
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Value set Payer (2.16.840.1.114222.4.11.3591): Deleted 1 SOP code (24).
Measure Section: QDM Data Elements
Source of Change: 2019 Addendum