Adult Major Depressive Disorder (MDD): Suicide Risk Assessment

Last updated: May 4, 2017

CMS Measure ID: CMS161v4
Version: 4
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 Patient 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: American Medical Association-convened Physician Consortium for Performance Improvement(R) (AMA-PCPI)
Domain: Effective Clinical Care
Next Version: Adult Major Depressive Disorder (MDD): Suicide Risk Assessment
Previous Version: Adult Major Depressive Disorder (MDD): Suicide Risk Assessment
Measure Score: Proportion
Improvement Notation:

Higher score indicates better quality

Guidance:

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). This measure is an episode-of-care measure and should be reported for each instance of a new or recurrent episode of MDD; every new or recurrent episode will count separately in the Initial Population.

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.

The measure description outlined in the header for this measure states, 'patients aged 18 years and older' while the logic statement states, '>= 17 year(s) at: Measurement Period'. The logic statement, 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.

Specifications

Release Notes

Header

  • Added Item Count field. The Item Count identifies the unit of measure for the eCQM. For this episode-of-care measure, the unit of measure is each visit or encounter that meets the additional measure criteria as detailed in the initial population.
  • Copyright updated.
  • Disclaimer updated.
  • eMeasure version number incremented.
  • Guidance updated.
  • Reference updated.

Logic

  • Introduced occurrencing on variables to enforce that the same instance of a clinical event is used throughout the measure when the logic within the variable does not limit the event to a single instance, e.g., FIRST or MOST RECENT.
  • Introduced variable $MDDEncounters161 to allow re-use of logical expressions and reduce redundancy/complexity.
  • Replaced 'ORs' with 'Union of' operator to provide a mechanism for specifying that qualifying event(s) must be a member of at least one of the data elements being unioned (if appropriate for measure intent).
  • Replaced 'Patient Characteristic Birthdate' with 'Age at' operator.

Value Sets

No changes

External Resources