Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment

Last updated: May 4, 2017

CMS Measure ID: CMS177v3
Version: 3
NQF Number: 1365
Measure Description:

Percentage of patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder with an assessment for suicide risk

Initial Patient Population:

All patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder

Denominator Statement:

Equals Initial Patient Population

Denominator Exclusions:

None

Numerator Statement:

Patient visits with an assessment for suicide risk

Numerator Exclusions:

Not Applicable

Denominator Exceptions:

None

Measure Steward: American Medical Association-convened Physician Consortium for Performance Improvement(R) (AMA-PCPI)
Domain: Patient Safety
Next Version: Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment
Measure Score: Proportion
Score Type: Process
Improvement Notation:

Higher score indicates better quality

Guidance:

A suicide risk assessment should be performed at every visit for major depressive disorder during the measurement period.

This measure is an episode-of-care measure; the level of analysis for this measure is every visit for major depressive disorder during the measurement period. A minimum of two encounters are required during the measurement period for a patient to be included in this measure to establish that the eligible professional has an existing relationship with the patient; if the patient is only seen once by the eligible professional, the patient is not included in the measure. Once it has been established that the patient has been seen at least twice by the eligible professional, every visit for major depressive disorder should be counted as a measurable episode for the measure calculation. For example, at every visit for MDD, the patient should have a suicide risk assessment.

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 included in the numerator logic below.

Specifications

External Resources