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Depression Remission at Twelve Months

Measure Information 2023 Performance Period
CMS Measure ID CMS159v11
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 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

Denominator Exclusions

1: Patients who died any time prior to the end of the measure assessment period

2: Patients who received hospice or palliative care services between the start of the denominator period and the end of the measurement assessment period

3: 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 period

5: Patients with a diagnosis of personality disorder emotionally labile any time prior to the end of the measure assessment period

6: Patients with a diagnosis of schizophrenia or psychotic disorder any time prior to the end of the measure assessment period

7: 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 the most recent 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 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
Meaningful Measure Prevention, Treatment, and Management of Mental Health
Telehealth Eligible Yes
Next Version No Version Available
Previous Version

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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

Release Notes

Header

  • Revised formatting and grammar to improve readability.

    Measure Section: Description

    Source of Change: Measure Lead

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated references.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Updated version number of the Quality Data Model (QDM) used in the measure specification to v5.6.

    Measure Section: Guidance

    Source of Change: Standards/Technical Update

  • Replaced reference to 'baseline assessment' with 'index assessment' to align with the phrase used elsewhere in the header and logic.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Added denominator exclusion timeframes to reflect the measure logic.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Added clarifying text of 'most recent' depression assessment to align with the logic.

    Measure Section: Numerator

    Source of Change: Measure Lead

  • Revised formatting and grammar for improved clarity and readability.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

Logic

  • Updated the version of the Quality Data Model (QDM) to 5.6 and Clinical Quality Language (CQL) to 1.5.

    Measure Section: Multiple Sections

    Source of Change: Standards/Technical Update

  • Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library to v7.0.000.

    Measure Section: Multiple Sections

    Source of Change: Standards/Technical Update

  • Replaced the Global.CalendarAgeInYearsAt function with the native CQL function AgeInYearsAt to take advantage of existing CQL features and increase human readability.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Updated logic to use 'let' statement and updated the timing precision in the definitions from datetime to date by adding 'day of', 'date from', and/or function 'ToDate' to align with the measure intent.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Updated denominator exclusion logic related to patients who receive hospice or palliative care to better harmonize with other measures, and restricted the lookback period to begin during the denominator identification period.

    Measure Section: Multiple Sections

    Source of Change: ONC Project Tracking System (JIRA): CQM-4194

  • 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/Technical 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.

  • Added direct reference code SNOMED CT code (428361000124107) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Removed two value sets (Palliative Care Encounter 2.16.840.1.113883.3.600.1.1575 and Palliative or Hospice Care 2.16.840.1.113883.3.600.1.1579) and added five value sets (Hospice Care Ambulatory 2.16.840.1.113883.3.526.3.1584, Hospice Encounter 2.16.840.1.113883.3.464.1003.1003, Palliative Care Encounter 2.16.840.1.113883.3.464.1003.101.12.1090, Palliative Care Intervention 2.16.840.1.113883.3.464.1003.198.12.1135, and Encounter Inpatient 2.16.840.1.113883.3.666.5.307) to harmonize with other measures and better identify patients receiving hospice or palliative care for denominator exclusion.

    Measure Section: Terminology

    Source of Change: ONC Project Tracking System (JIRA): CQM-4194

  • Value set Contact or Office Visit (2.16.840.1.113762.1.4.1080.5): Added 8 CPT codes (99384, 99394, 99385, 99386, 99387, 99395, 99396, 99397) based on review by technical experts, SMEs, and/or public feedback. Deleted 1 CPT code (99201) based on terminology update.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Added direct reference code SNOMED CT code (428371000124100) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Added direct reference code ICD-10-CM code (Z51.5) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Added direct reference code LOINC code (71007-9) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Added direct reference code LOINC code (45755-6) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Added direct reference code SNOMED CT code (373066001) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

Last Updated: May 04, 2022