Back to top
Top
U.S. flag

An official website of the United States government

Dot gov

Official websites use .gov
A .gov website belongs to an official government organization in the United States.

Https

Secure .gov websites use HTTPS
A lock ( ) or https:// means you’ve safely connected to the .gov website. Share sensitive information only on official, secure websites.

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

Compare Versions of: "Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment"

The Compare function compares two years of the measure specifications found in the header of the measure's HTML. It does not include a comparison of any information in the body of the HTML, e.g., population criteria, Clinical Quality Language, or value sets.

Strikethrough text highlighted in red indicates information changed from the previous version. Text highlighted in green indicates information updated in the new eCQM version.

Compare version to

Measure Information 2022 Performance Period 2023 Performance Period 2024 Performance Period
Title Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment
CMS eCQM ID CMS177v10 CMS177v11 CMS177v12
CBE ID 1365e 1365e Not Applicable
MIPS Quality ID 382 382 382
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

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

Percentage of patient visits for those patients aged 6 through 16 at the start of the measurement period with a diagnosis of major depressive disorder (MDD) with an assessment for suicide risk

Definition *See CMS177v10.html *See CMS177v11.html

Numerator Definition: The specific type and magnitude of the suicide risk assessment is intended to be at the discretion of the individual clinician and should be specific to the needs of the patient. At a minimum, suicide risk assessment should evaluate:

1. Risk (e.g., age, sex, stressors, comorbid conditions, hopelessness, impulsivity) and protective factors (e.g., religious belief, concern not to hurt family) that may influence the desire to attempt suicide.

2. Current severity of suicidality.

3. Most severe point of suicidality in episode and lifetime.

 

Low burden tools to track suicidal ideation and behavior such as the Columbia-Suicidal Severity Rating Scale can also be used. Because no validated assessment tool or instrument fully meets the aforementioned requirements for the suicide risk assessment, individual tools or instruments have not been explicitly included in coding.

Initial Population

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

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

All patient visits for those patients aged 6 through 16 at the start of the measurement period with a diagnosis of major depressive disorder

Numerator

Patient visits with an assessment for suicide risk

Patient visits with an assessment for suicide risk

Patient visits with an assessment for suicide risk

Numerator Exclusions

Not Applicable

Not Applicable

Not Applicable

Denominator

Equals Initial Population

Equals Initial Population

Equals Initial Population

Denominator Exclusions

None

None

None

Denominator Exceptions

None

None

None

Measure Steward Mathematica Mathematica Mathematica
Measure Scoring Proportion measure Proportion measure Proportion measure
Measure Type Process measure Process measure Process measure
Improvement Notation

Higher score indicates better quality

Higher score indicates better quality

Higher score indicates better quality

Guidance

This eCQM is an episode-based measure. An episode is defined as each eligible encounter for major depressive disorder (MDD) during the measurement period. A suicide risk assessment should be performed at every visit for MDD during the measurement period.

In recognition of the growing use of integrated and team-based care, the diagnosis of depression and the assessment for suicide risk need not be performed by the same provider or clinician.

Suicide risk assessments completed via telehealth services can also meet numerator performance.

Use of a standardized tool(s) or instrument(s) to assess suicide risk will meet numerator performance, so long as the minimum criteria noted above is evaluated. Standardized tools can be mapped to the concept "Intervention, Performed": "Suicide risk assessment (procedure)" included in the numerator logic below, as no individual suicide risk assessment tool or instrument would satisfy the requirements alone.

This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM.

This eCQM is an episode-based measure. An episode is defined as each eligible encounter for major depressive disorder (MDD) during the measurement period. A suicide risk assessment should be performed at every visit for MDD during the measurement period.

In recognition of the growing use of integrated and team-based care, the diagnosis of depression and the assessment for suicide risk need not be performed by the same provider or clinician.

Suicide risk assessments completed via telehealth services can also meet numerator performance.

Use of a standardized tool(s) or instrument(s) to assess suicide risk will meet numerator performance, so long as the minimum criteria noted above is evaluated. Standardized tools can be mapped to the concept "Intervention, Performed": "Suicide risk assessment (procedure)" included in the numerator logic below, as no individual suicide risk assessment tool or instrument would satisfy the requirements alone.

This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM.

This eCQM is an episode-based measure. An episode is defined as each eligible encounter for major depressive disorder (MDD) during the measurement period. A suicide risk assessment should be performed at every visit for MDD during the measurement period.

In recognition of the growing use of integrated and team-based care, the diagnosis of depression and the assessment for suicide risk need not be performed by the same provider or clinician.

Suicide risk assessments completed via telehealth services can also meet numerator performance.

Use of a standardized tool(s) or instrument(s) to assess suicide risk will meet numerator performance, so long as the minimum criteria noted above is evaluated. Standardized tools can be mapped to the concept "Intervention, Performed": "Suicide risk assessment (procedure)" included in the numerator logic below, as no individual suicide risk assessment tool or instrument would satisfy the requirements alone.

To ensure all patients with major depressive disorder (MDD) are assessed for suicide risk, there are two clinical quality measures addressing suicide risk assessment; CMS177 covers children and adolescents aged 6 through 16 at the start of the measurement period, and CMS161 - Adult Major Depressive Disorder (MDD): Suicide Risk Assessment covers the adult population aged 17 years and older at the start of the measurement period.

This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM.

Telehealth Eligible Yes Yes Yes
Rationale *See CMS177v10.html *See CMS177v11.html

Research has shown that youth with major depressive disorder (MDD) are at a high risk for suicide attempts and completion - among the most significant and devastating sequelae of the disease (Fontanella et al., 2020). Suicide risk is a critical consideration in children and adolescents with MDD, and an important aspect of care that should be assessed at each visit and subsequently managed to minimize that risk. Additionally, the importance of the assessments is underscored by research (Fontanella et al., 2020; Luoma, Martin, & Pearson, 2002) that indicates that many individuals who die by suicide do make contact with primary care providers and mental health services beforehand. More specifically, approximately 15% of suicide victims aged 35 years or younger had seen a mental health professional within 1 month of suicide while approximately 23% had seen a primary care provider within 1 month of suicide (Luoma, Martin, & Pearson, 2002). A recent analysis of depression severity and suicidal ideation symptom trajectories (Witt et al., 2021) found that suicidal ideation among children and young adults (15-25 years) might not improve with depression symptom severity. This evidence suggests the potential utility of continued suicide risk screening even after improvements in depression symptoms. Better assessment and identification of suicide risk in the health care setting should lead to improved connection to treatment and reduction in suicide attempts and deaths by suicide.

Stratification *See CMS177v10.html *See CMS177v11.html

None

Risk Adjustment *See CMS177v10.html *See CMS177v11.html

None

Clinical Recommendation Statement *See CMS177v10.html *See CMS177v11.html

The evaluation must include assessment for the presence of harm to self or others (American Academy of Child and Adolescent Psychiatry, 2007).

Suicidal behavior exists along a continuum from passive thoughts of death to a clearly developed plan and intent to carry out that plan. Because depression is closely associated with suicidal thoughts and behavior, it is imperative to evaluate these symptoms at the initial and subsequent assessments. For this purpose, low burden tools to track suicidal ideation and behavior such as the Columbia-Suicidal Severity Rating Scale can be used. Also, it is crucial to evaluate the risk (e.g., age, sex, stressors, comorbid conditions, hopelessness, impulsivity) and protective factors (e.g., religious belief, concern not to hurt family) that might influence the desire to attempt suicide. The risk for suicidal behavior increases if there is a history of suicide attempts, comorbid psychiatric disorders (e.g., disruptive disorders, substance abuse), impulsivity and aggression, availability of lethal agents (e.g., firearms), exposure to negative events (e.g., physical or sexual abuse, violence), and a family history of suicidal behavior (American Academy of Child and Adolescent Psychiatry, 2007).

A careful and ongoing evaluation of suicide risk is necessary for all patients with major depressive disorder (Category I). Such an assessment includes specific inquiry about suicidal thoughts, intent, plans, means, and behaviors; identification of specific psychiatric symptoms (e.g., psychosis, severe anxiety, substance use) or general medical conditions that may increase the likelihood of acting on suicidal ideas; assessment of past and, particularly, recent suicidal behavior; delineation of current stressors and potential protective factors (e.g., positive reasons for living, strong social support); and identification of any family history of suicide or mental illness (Category I) (American Psychiatric Association, 2010, reaffirmed 2015).

Next Version No Version Available
Previous Version No Version Available

Header

  • Updated the eCQM version number.

    Measure Section: eCQM Version Number

    Source of Change: Annual Update

  • Updated Measure Steward.

    Measure Section: Measure Steward

    Source of Change: Measure Lead

  • Updated Measure Developer.

    Measure Section: Measure Developer

    Source of Change: Measure Lead

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated disclaimer.

    Measure Section: Disclaimer

    Source of Change: Measure Lead

  • Updated Rationale section in measure header to include evidence from current literature.

    Measure Section: Rationale

    Source of Change: Measure Lead

  • Updated references.

    Measure Section: Reference

    Source of Change: Annual Update

  • Added clarifying language to guidance section of episode-based measures to define the episode.

    Measure Section: Guidance

    Source of Change: Measure Lead

Logic

  • Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-6.2.000). Updated the 'Inpatient Encounter' definition to include a 'day of' timing clarification. Added the following timing functions: Normalize Interval, Has Start, Has End, Latest, Latest Of, Earliest, and Earliest Of. Please see individual measure details for application of specific timing functions.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Added new NormalizeInterval function to timing attributes to decrease implementation burden due to variable use of timing attributes for select QDM data types. The NormalizeInterval function was applied, where applicable, for the following data elements: Assessment, Performed; Device, Applied; Diagnostic Study, Performed; Intervention, Performed; Laboratory Test, Performed; Medication, Administered; Medication, Dispensed; Physical Exam, Performed; Procedure, Performed; Substance, Administered.

    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 Psych Visit - Family Psychotherapy (2.16.840.1.113883.3.526.3.1018): Added 2 SNOMED CT codes (302247005, 361229007) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Group Psychotherapy (2.16.840.1.113883.3.526.3.1187): Added 3 SNOMED CT codes (1555005, 27591006, 28868002) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Major Depressive Disorder-Active (2.16.840.1.113883.3.526.3.1491): Added 2 SNOMED CT codes (10811121000119102, 191604000) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

Last Updated: Feb 13, 2024