Measure Information | 2022 Performance Period |
---|---|
CMS eCQM ID | CMS177v10 |
NQF Number | 1365e |
MIPS Quality ID | 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 |
Initial Population |
All patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder |
Numerator |
Patient visits with an assessment for suicide risk |
Numerator Exclusions |
Not Applicable |
Denominator |
Equals Initial Population |
Denominator Exclusions |
None |
Denominator Exceptions |
None |
Steward | Mathematica |
Measure Scoring | Proportion measure |
Measure Type | Process measure |
Improvement Notation |
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. |
Telehealth Eligible | Yes |
Next Version | |
Previous Version |
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Measure Information | 2021 Performance Period | 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 | Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment |
CMS eCQM ID | CMS177v9 | CMS177v10 | CMS177v11 | CMS177v12 |
NQF Number | 1365e | 1365e | 1365e | Not Applicable |
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 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 |
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 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 |
Denominator |
Equals Initial Population |
Equals Initial Population |
Equals Initial Population |
Equals Initial Population |
Denominator Exclusions | None | None | None | None |
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 |
Patient visits with an assessment for suicide risk |
Numerator Exclusions |
Not Applicable |
Not Applicable |
Not Applicable |
Not Applicable |
Denominator Exceptions |
None |
None |
None |
None |
Measure Steward | PCPI(R) Foundation (PCPI[R]) | Mathematica | Mathematica | Mathematica |
Measure Scoring | Proportion measure | Proportion measure | Proportion measure | Proportion measure |
Measure Type | Process measure | Process measure | Process measure | Process measure |
Improvement Notation |
Higher score indicates better quality |
Higher score indicates better quality |
Higher score indicates better quality |
Higher score indicates better quality |
Guidance |
This eCQM is an episode-based measure. A suicide risk assessment should be performed at every visit for major depressive disorder 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. 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. For example, at every visit for MDD, the patient should have a suicide risk assessment. 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 5.5. 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. |
MIPS Quality ID | 382 | 382 | 382 | 382 |
Telehealth Eligible | Yes | Yes | Yes | Yes |
Next Version | CMS177v10 | CMS177v11 | CMS177v12 | No Version Available |
Previous Version | No Version Available |
Data Element Repository
Header
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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
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Updated disclaimer.
Measure Section: Disclaimer
Source of Change: Measure Lead
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Updated Rationale section in measure header to include evidence from current literature.
Measure Section: Rationale
Source of Change: Measure Lead
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Updated references.
Measure Section: Reference
Source of Change: Annual Update
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Added clarifying language to guidance section of episode-based measures to define the episode.
Measure Section: Guidance
Source of Change: Measure Lead
Logic
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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
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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.
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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
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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
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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