Measure Information | 2023 Performance Period |
---|---|
CMS eCQM ID | CMS177v11 |
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 (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 |
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 5.6. Please refer to the QDM page 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 measure description to add the acronym MDD for clarity.
Measure Section: Description
Source of Change: Measure Lead
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Updated copyright.
Measure Section: Copyright
Source of Change: Annual Update
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Updated disclaimer.
Measure Section: Disclaimer
Source of Change: Standards/Technical Update
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Updated the rationale section to further support measure intent.
Measure Section: Rationale
Source of Change: Measure Lead
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Updated references.
Measure Section: Reference
Source of Change: Measure Lead
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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
Logic
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Replaced the Global.CalendarAgeInYearsAt function with the native CQL function AgeInYearsAt to take advantage of existing CQL features and increase human readability. As a result of this change, the LOINC code 21112-8 is no longer required and has been removed from the Terminology section of the human readable specification.
Measure Section: Multiple Sections
Source of Change: Measure Lead
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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
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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
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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Removed direct reference code LOINC code (21112-8) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead