Depression Remission at Twelve Months

Measure Information	2021 Performance Period
CMS Measure ID	CMS159v9
NQF Number	0710e
Measure Description	The percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event.
Initial Population	Adolescent patients 12 to 17 years of age and adult patients 18 years of age and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 or PHQ-9M score greater than nine during the index event. Patients may be screened using PHQ-9 and PHQ-9M up to 7 days prior to the office visit (including the day of the office visit).
Denominator Statement	Equals Initial Population
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 emotionally labile 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 achieved remission at twelve months as demonstrated by a twelve month (+/- 60 days) PHQ-9 or PHQ-9M score of less than five
Numerator Exclusions	Not Applicable
Denominator Exceptions	None
Measure Steward	MN Community Measurement
Quality Domain	Effective Clinical Care
Measure Scoring	Proportion measure
Measure Type	Outcome measure
Improvement Notation	Higher score indicates better quality
Guidance	When a baseline assessment is conducted with PHQ 9M, the follow-up assessment can use either a PHQ 9M or PHQ 9. This eCQM is a patient-based measure. This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM.
MIPS Quality ID	370
Meaningful Measure	Prevention, Treatment, and Management of Mental Health
Telehealth Eligible	Yes
Next Version	CMS159v10
Previous Version	No Version Available

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Measure Information	2021 Performance Period	2022 Performance Period	2023 Performance Period
CMS Measure ID	CMS159v9	CMS159v10	CMS159v11
NQF Number	0710e	0710e	0710e
Measure Description	The percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event.	The percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event.	The percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event
Initial Population	Adolescent patients 12 to 17 years of age and adult patients 18 years of age and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 or PHQ-9M score greater than nine during the index event. Patients may be screened using PHQ-9 and PHQ-9M up to 7 days prior to the office visit (including the day of the office visit).	Adolescent patients 12 to 17 years of age and adult patients 18 years of age and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 or PHQ-9M score greater than nine during the index event. Patients may be assessed using PHQ-9 or PHQ-9M on the same date or up to 7 days prior to the encounter (index event).	Adolescent patients 12 to 17 years of age and adult patients 18 years of age and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 or PHQ-9M score greater than nine during the index event. Patients may be assessed using PHQ-9 or PHQ-9M on the same date or up to 7 days prior to the encounter (index event).
Denominator Statement	Equals Initial Population	Equals Initial Population	Equals Initial Population
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 emotionally labile 6: Patients with a diagnosis of schizophrenia or psychotic disorder 7: Patients with a diagnosis of pervasive developmental disorder	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 emotionally labile 6: Patients with a diagnosis of schizophrenia or psychotic disorder 7: Patients with a diagnosis of pervasive developmental disorder	1: Patients who died any time prior to the end of the measure assessment period2: Patients who received hospice or palliative care services between the start of the denominator period and the end of the measurement assessment period3: Patients who were permanent nursing home residents between the start of the denominator period and the end of the measurement assessment period 4: Patients with a diagnosis of bipolar disorder any time prior to the end of the measure assessment period5: Patients with a diagnosis of personality disorder emotionally labile any time prior to the end of the measure assessment period6: Patients with a diagnosis of schizophrenia or psychotic disorder any time prior to the end of the measure assessment period7: Patients with a diagnosis of pervasive developmental disorder any time prior to the end of the measure assessment period
Numerator Statement	Adolescent patients 12 to 17 years of age and adult patients 18 years of age and older who achieved remission at twelve months as demonstrated by a twelve month (+/- 60 days) PHQ-9 or PHQ-9M score of less than five	Adolescent patients 12 to 17 years of age and adult patients 18 years of age and older who achieved remission at twelve months as demonstrated by a twelve month (+/- 60 days) PHQ-9 or PHQ-9M score of less than five	Adolescent patients 12 to 17 years of age and adult patients 18 years of age and older who achieved remission at twelve months as demonstrated by the most recent twelve month (+/- 60 days) PHQ-9 or PHQ-9M score of less than five
Numerator Exclusions	Not Applicable	Not Applicable	Not Applicable
Denominator Exceptions	None	None	None
Measure Steward	MN Community Measurement	MN Community Measurement	MN Community Measurement
Quality Domain	Effective Clinical Care	Effective Clinical Care	Effective Clinical Care
Measure Scoring	Proportion measure	Proportion measure	Proportion measure
Measure Type	Outcome measure	Outcome measure	Outcome measure
Improvement Notation	Higher score indicates better quality	Higher score indicates better quality	Higher score indicates better quality
Guidance	When a baseline assessment is conducted with PHQ 9M, the follow-up assessment can use either a PHQ 9M or PHQ 9. This eCQM is a patient-based measure. This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM.	When a baseline assessment is conducted with PHQ 9M, the follow-up assessment can use either a PHQ 9M or PHQ 9. This eCQM is a patient-based measure. This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.	When an index assessment is conducted with PHQ-9M, the follow-up assessment can use either a PHQ-9M or PHQ-9. This eCQM is a patient-based measure. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM.
MIPS Quality ID	370	370	370
Meaningful Measure	Prevention, Treatment, and Management of Mental Health	Prevention, Treatment, and Management of Mental Health	Prevention, Treatment, and Management of Mental Health
Telehealth Eligible	Yes	Yes	Yes
Next Version	CMS159v10	CMS159v11	No Version Available
Previous Version	No Version Available	CMS159v9	CMS159v10

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CMS159v9.html	73.29 KB
CMS159v9.zip	73.84 KB
CMS159v9-TRN.xlsx	22.55 KB

Data Element Repository

Data Elements contained within CMS159v9

Value Sets

Value Sets to be used with CMS159v9

Release Notes

CMS159v9-TRN.xlsx

Header

Updated eCQM Version Number.

Measure Section: eCQM Version Number

Source of Change: Standards Update
Updated copyright.

Measure Section: Copyright

Source of Change: Annual Update
Added text to clarify stratification takes place at the time of the index assessment.

Measure Section: Stratification

Source of Change: Measure Lead
Updated the rationale with newer studies and data.

Measure Section: Rationale

Source of Change: Measure Lead
Updated the clinical recommendations to include the latest relevant studies and guidelines.

Measure Section: Clinical Recommendation Statement

Source of Change: Measure Lead
Added text to identify the Quality Data Model (QDM) version used in the measure specification.

Measure Section: Guidance

Source of Change: Standards Update
Added text to indicate whether the measure is patient-based or episode-based.

Measure Section: Guidance

Source of Change: Standards Update
Added text to indicate clarify which assessment can be used for the follow-up assessment.

Measure Section: Guidance

Source of Change: Measure Lead
Updated text to clarify patients diagnosed with a personality disorder emotionally labile should be excluded, and align with updated value sets.

Measure Section: Denominator Exclusions

Source of Change: Measure Lead

Logic

Updated logic to reflect accurate name of the value set Palliative or Hospice Care (2.16.840.1.113883.3.600.1.1579).

Measure Section: Denominator Exclusions

Source of Change: ONC Project Tracking System (Jira): CQM-3637
Updated the alias 'PalliativeCareOrder' in the 'Palliative Care Order' definition to better differentiate from the 'Encounter Palliative Care' definition's alias.

Measure Section: Denominator Exclusions

Source of Change: Measure Lead
Updated the 'Palliative Care Order' definition logic to be consistent with the alias name and assessment period name changes.

Measure Section: Denominator Exclusions

Source of Change: Measure Lead
Removed null text to streamline stratification logic.

Measure Section: Stratification

Source of Change: Measure Lead
QDM v5.5 standards update: Added 'relevantDatetime' attribute to QDM datatypes. 'RelevantDatetime' indicates when the action occurred whereas 'authorDatetime' indicates when the action was recorded.

Measure Section: Multiple Sections

Source of Change: Standards Update
Updated Clinical Quality Language (CQL) expression to conform with the HL7 Standard: Clinical Quality Language Specification, Release 1 STU 4 (CQL 1.4).

Measure Section: Multiple Sections

Source of Change: Standards Update
Updated the names of CQL definitions, functions, and/or aliases for clarification and to align with the CQL Style Guide.

Measure Section: Multiple Sections

Source of Change: Standards Update
Updated the term follow-up assessment period to measure assessment period to increase consistency between the header and the logic.

Measure Section: Multiple Sections

Source of Change: Measure Lead
Updated version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-5.0.000). Updated definitions and functions in the MAT Global Common Functions Library to align with standards changes, CQL Style Guide, and to include one new function related to calculating length of hospital stays with observation stays.

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 5 SNOMEDCT codes (231444002, 767632000, 767633005, 271000119101, 23741000119105) based on review by technical experts to better capture relevant exclusions.

Measure Section: Terminology

Source of Change: Measure Lead
Value set Personality Disorder Emotionally Labile (2.16.840.1.113883.3.67.1.101.1.246): Added 1 SNOMEDCT code (191765005) based on review by technical experts to better capture relevant exclusions.

Measure Section: Terminology

Source of Change: Measure Lead
Value set Contact or Office Visit (2.16.840.1.113762.1.4.1080.5): Added 3 CPT codes (99421, 99422, 99423) based on terminology update. Added 3 HCPCS codes (G2061, G2062, G2063) based on terminology update.

Measure Section: Terminology

Source of Change: Measure Lead
Value set (2.16.840.1.113883.3.67.1.101.1.246): Renamed grouping value set to Personality Disorder Emotionally Labile to more accurately reflect the codes included in the value set. Renamed extensional value sets (2.16.840.1.113883.3.67.1.101.1.247, 2.16.840.1.113883.3.67.1.101.1.248, 2.16.840.1.113883.3.67.1.101.1.249) within the grouping value set to more accurately reflect the codes included in the value set.

Measure Section: Terminology

Source of Change: Measure Lead