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Depression Utilization of the PHQ-9 Tool

CMS Measure ID
CMS160v8
Version
8
NQF Number
0712e
Measure Description

The percentage of adolescent patients 12 to 17 years of age and adult patients age 18 and older with the diagnosis of major depression or dysthymia who have a completed PHQ-9 during each applicable 4 month period in which there was a qualifying depression encounter

Initial Population

Adolescent patients 12 to 17 years of age and adult patients 18 years of age and older with an office visit and the diagnosis of major depression or dysthymia during the four month period

Denominator Statement
Denominator Exclusions

1: Patients who died

2: Patients who received hospice or palliative care services

3: Patients who were permanent nursing home residents

4: Patients with a diagnosis of bipolar disorder

5: Patients with a diagnosis of personality disorder

6: Patients with a diagnosis of schizophrenia or psychotic disorder

7: Patients with a diagnosis of pervasive developmental disorder

Numerator Statement

Adolescent patients 12 to 17 years of age and adult patients 18 years of age and older who have a PHQ-9 or PHQ-9M tool administered at least once during the four-month period

Numerator Exclusions

Not applicable

Denominator Exceptions

None

Measure Steward
Previous Version
Measure Scoring
Measure Type
Improvement Notation

Higher scores indicate better quality

Guidance

If a patient has a qualifying diagnosis and encounter in more than one of the 4 month periods within the measurement year, the patient must be counted (denominator and numerator) in each qualifying 4 month period. For example, a patient could be counted in the first and third 4 month periods.

Quality ID
371

Specifications

Attachment Size
CMS160v8.html 117.75 KB
CMS160v8.zip 87.86 KB
CMS160v8-TRN.xlsx 22.06 KB

Release Notes

 

Header

  • Updated eCQM version number.

    Measure Section: eCQM Version number

    Source of Change: Measure Lead

  • Added 'e' to NQF number.

    Measure Section: NQF Number

    Source of Change: Standards Update

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated disclaimer.

    Measure Section: Disclaimer

    Source of Change: Measure Lead

  • Updated rationale statement to align with most recent literature and revised text to include the acronym MDE for major depressive episode.

    Measure Section: Rationale

    Source of Change: Measure Lead

  • Updated clinical recommendation statement by deleting definitions for Response, Remission, Recovery, Relapse, and Recurrence to improve clarity.

    Measure Section: Clinical Recommendation Statement

    Source of Change: Measure Lead

  • Updated references to align with American Psychological Association (APA) style.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Updated references.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Updated parenthetical citations to align with American Psychological Association (APA) style.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

 

Logic

  • Revised logic to replace the direct reference code with the 'PHQ 9 and PHQ 9M Tools' value set to improve alignment with measure intent.

    Measure Section: Numerator

    Source of Change: Measure Lead

  • Updated the names of Clinical Quality Language (CQL) definitions, functions, and/or aliases for clarification and to align with CQL Style Guide.

    Measure Section: Definitions and Functions

    Source of Change: Standards Update

  • Updated Clinical Quality Language (CQL) expression to conform with the HL7 Standard: Clinical Quality Language Specification, Release 1 STU 3 (CQL 1.3).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated definitions and functions in the Measure Authoring Tool (MAT) Global Common Functions Library to align with standards changes, Clinical Quality Language (CQL) Style Guide, and to include two new functions related to calculating hospital stays.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-4.0.000).

    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.

  • Value set Bipolar Disorder (2.16.840.1.113883.3.67.1.101.1.128): Added 8 SNOMED CT codes (133091000119105, 261000119107, 723903001, 723905008, 765176007, 767631007, 767635003, 767636002).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set (2.16.840.1.113883.3.600.1.1579): Renamed to Palliative or Hospice Care.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Personality Disorder (2.16.840.1.113883.3.67.1.101.1.246): Added 6 SNOMED CT codes (21586000, 24315006, 33693007, 430744005, 430751001, 76105009).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Schizophrenia or Psychotic Disorder (2.16.840.1.113883.3.464.1003.105.12.1104): Added 4 SNOMED CT codes (31027006, 36158005, 55736003, 88975006).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Major Depression Including Remission (2.16.840.113883.3.67.1.101.3.2444): Added 2 SNOMED CT codes (16264901000119109, 104851000119103).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set PHQ 9 and PHQ 9M Tools (2.16.840.1.113883.3.67.1.101.1.263): Added PHQ 9 and PHQ 9M Tools.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Replaced direct reference code 'Patient Health Questionnaire 9 item (PHQ-9) total score [Reported]' using 'LOINC Code (44261-6)' with value set 'PHQ 9 and PHQ 9M Tools' (2.16.840.1.113883.3.67.1.101.1.263).

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Direct reference code for Birth date (LOINC Code (21112-8)) is now displayed in Human Readable.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Direct reference code for Dead (finding) (SNOMED CT Code (419099009)) is now displayed in Human Readable.

    Measure Section: Terminology

    Source of Change: Annual Update

  • ​Removed code system versions from direct reference codes. Please refer to Appendix A of the Electronic Clinical Quality Measure Logic and Implementation Guidance document for a list of code system versions used in the eCQM specifications for 2020 reporting/performance.

    Measure Section: Terminology

    Source of Change: Standards Update

  • Standardized purpose statement language in value sets across eCQMs. Value set purpose statements are visible in the Value Set Authority Center (VSAC) as well as the downloadable eCQM value set files.

    Measure Section: Terminology

    Source of Change: Measure Lead

Last Updated: Jul 22, 2019