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

Measure Information 2022 Performance Period
CMS Measure ID CMS177v10
NQF Number 1365e
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 Population

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

Denominator Statement

Equals Initial Population

Denominator Exclusions

None

Numerator Statement

Patient visits with an assessment for suicide risk

Numerator Exclusions

Not Applicable

Denominator Exceptions

None

Measure Steward Mathematica
Quality Domain Patient Safety
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 (https://ecqi.healthit.gov/qdm) for more information on the QDM.

MIPS Quality ID 382
Meaningful Measure Prevention, Treatment, and Management of Mental Health
Telehealth Eligible Yes
Next Version
Previous Version

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Measure Information 2021 Performance Period 2022 Performance Period 2023 Performance Period
CMS Measure ID CMS177v9 CMS177v10 CMS177v11
NQF Number 1365e 1365e 1365e
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

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

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

Denominator Statement

Equals Initial Population

Equals Initial Population

Equals Initial Population

Denominator Exclusions None None None
Numerator Statement

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 Exceptions

None

None

None

Measure Steward PCPI(R) Foundation (PCPI[R]) Mathematica Mathematica
Quality Domain Patient Safety Patient Safety Patient Safety
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. 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 (https://ecqi.healthit.gov/qdm) 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.

MIPS Quality ID 382 382 382
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 CMS177v10 CMS177v11 No Version Available
Previous Version No Version Available

Release Notes

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: May 04, 2022