Adult Major Depressive Disorder (MDD): Suicide Risk Assessment

Measure Information	2024 Performance Period
CMS eCQM ID	CMS161v12
NQF Number	Not Applicable
MIPS Quality ID	107
Description	Percentage of all patient visits for those patients that are 17 years of age or older at the start of the measurement period in which a new or recurrent diagnosis of major depressive disorder (MDD) was identified and a suicide risk assessment was completed during the visit
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) Suicidal ideation 2) Patient's intent of initiating a suicide attempt AND, if either is present, 3) Patient plans for a suicide attempt 4) Whether the patient has means for completing suicide Low burden tools to track suicidal ideation and behavior such as the Columbia-Suicide Severity Rating Scale (C-SSRS) and the Suicide Assessment Five-Step Evaluation and Triage (SAFE-T) 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	Patient visits for patients that are 17 years of age or older at the start of the measurement period during which a new diagnosis of MDD, single or recurrent episode, was identified
Numerator	Patient visits during which a new diagnosis of MDD, single or recurrent episode, was identified and a suicide risk assessment was completed during the visit
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 and should be reported for each instance of a new or recurrent episode of major depressive disorder (MDD) during the measurement period. This measure should be reported for each eligible encounter during which a new or recurrent episode of MDD is identified in adults that turn 18 or older during the measurement period. As the guidelines state, it is important to assess for additional factors which may increase or decrease suicide risk, such as presence of additional symptoms (e.g., psychosis, severe anxiety, hopelessness, severe chronic pain); presence of substance abuse; history and seriousness of previous attempts, particularly, recent suicidal behavior; current stressors and potential protective factors (e.g., positive reasons for living, strong social support); family history of suicide or mental illness or recent exposure to suicide; impulsivity and potential for risk to others, including history of violence or violent or homicidal ideas, plans, or intentions; and putting one's affairs in order (e.g., giving away possessions, writing a will). In addition, although the measure focuses on the initial visit, it is critical that suicide risk be monitored especially for the 90 days following the initial visit and throughout MDD treatment. It is expected that a suicide risk assessment will be completed at the visit during which a new diagnosis is made or at the visit during which a recurrent episode is first identified (i.e., at the initial evaluation). For the purposes of this measure, an episode of MDD would be considered to be recurrent if a patient has not had an MDD-related encounter in the past 105 days. If there is a gap of 105 or more days between visits for MDD, that would imply a recurrent episode. The 105-day look-back period is an operational provision and not a clinical recommendation, or definition of relapse, remission, or recurrence. 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. 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 MDD are assessed for suicide risk, there are two clinical quality measures addressing suicide risk assessment; CMS177-Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment covers children and adolescents aged 6 through 16 at the start of the measurement period, and CMS161 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
Rationale	This measure aims to improve rates of clinician assessment of suicide risk during an encounter where a new or recurrent episode of major depressive disorder (MDD) is identified. In an epidemiologic study of mental illness in the United States with a large, representative sample, 69% of respondents with lifetime suicide attempts had also met diagnostic criteria for MDD. When considering other mood disorders related to depression, such as dysthymia and bipolar disorders, this rate increases to 74% (Bolton & Robinson, 2010). In a study of individuals who had died by suicide and were enrolled in one of eight major health systems in the United States, individuals with a depressive disorder diagnosis had 7.20 increased odds of dying by suicide within one year, after adjusting for age and sociodemographic factors (Yeh et al., 2019). A recent meta-analysis (Moitra et al., 2021) presented similar findings in which depressive disorder conferred a predictive relative risk for suicide of 7.64 after adjusting for relevant factors. Suicide is associated with increased use of healthcare services, which provides an opportunity for intervention through assessment and intervention. Individuals who die by suicide are more likely to have any healthcare utilization (Ahmedani et al., 2019) and a higher frequency of healthcare visits than the general population (Chock, Bommersbach, Geske, & Bostwick, 2015). A study of individuals who died by suicide and were enrolled within one of eight health systems in the Mental Health Research Network in the United States found that 50% of these individuals had been seen in a healthcare setting within four weeks prior to death (Ahmedani et al., 2014). Better assessment and identification of suicide risk in the healthcare setting should lead to improved connection to treatment and reduction in suicide attempts and deaths by suicide. 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 after improvements in depression symptoms.
Stratification	None
Risk Adjustment	None
Clinical Recommendation	A careful and ongoing evaluation of suicide risk is necessary for all patients with major depressive disorder (American Psychiatric Association, 2010a). 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, hopelessness, insomnia, agitation) 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 (American Psychiatric Association, 2010a; Department of Veterans Affairs and Department of Defense, 2019). As part of the assessment process, impulsivity and potential for risk to others should also be evaluated, including any history of violence or violent or homicidal ideas, plans, or intentions, or the availability of firearms (American Psychiatric Association, 2010a; Department of Veterans Affairs and Department of Defense, 2019). The patient's risk of harm to him- or herself and to others should also be monitored as treatment proceeds (American Psychiatric Association, 2010a). Guidelines for Selecting a Treatment Setting for Patients at Risk for Suicide or Suicidal Behaviors (from American Psychiatric Association’s Practice Guideline for Assessment and Treatment of Patients With Suicidal Behaviors, 2010b): ADMISSION GENERALLY INDICATED After a suicide attempt or aborted suicide attempt if: - Patient is psychotic - Attempt was violent, near-lethal, or premeditated - Precautions were taken to avoid rescue or discovery - Persistent plan and/or intent is present - Distress is increased or patient regrets surviving - Patient is male, older than age 45 years, especially with new onset of psychiatric illness or suicidal thinking - Patient has limited family and/or social support, including lack of stable living situation - Current impulsive behavior, severe agitation, poor judgment, or refusal of help is evident - Patient has change in mental status with a metabolic, toxic, infectious, or other etiology requiring further workup in a structured setting In the presence of suicidal ideation with: - Specific plan with high lethality - High suicidal intent ADMISSION MAY BE NECESSARY After a suicide attempt or aborted suicide attempt, except in circumstances for which admission is generally indicated In the presence of suicidal ideation with: - Psychosis - Major psychiatric disorder - Past attempts, particularly if medically serious - Possibly contributing medical condition (e.g., acute neurological disorder, cancer, infection) - Lack of response to or inability to cooperate with partial hospital or outpatient treatment - Need for supervised setting for medication trial or electroconvulsive therapy (ECT) - Need for skilled observation, clinical tests, or diagnostic assessments that require a structured setting - Limited family and/or social support, including lack of stable living situation - Lack of an ongoing clinician-patient relationship or lack of access to timely outpatient follow-up - Evidence of putting one's affairs in order (e.g., giving away possessions, writing a will) In the absence of suicide attempts or reported suicidal ideation/plan/intent but evidence from the psychiatric evaluation and/or history from others suggests a high level of suicide risk and a recent acute increase in risk RELEASE FROM EMERGENCY DEPARTMENT WITH FOLLOW-UP RECOMMENDATIONS MAY BE POSSIBLE After a suicide attempt or in the presence of suicidal ideation/plan when: - Suicidality is a reaction to precipitating events (e.g., exam failure, relationship difficulties), particularly if the patient's view of situation has changed since coming to emergency department - Plan/method and intent have low lethality - Patient has stable and supportive living situation - Patient is able to cooperate with recommendations for follow-up, with treater contacted, if possible, if patient is currently in treatment OUTPATIENT TREATMENT MAY BE MORE BENEFICIAL THAN HOSPITALIZATION Patient has chronic suicidal ideation and/or self-injury without prior medically serious attempts, if a safe and supportive living situation is available and outpatient psychiatric care is ongoing
Next Version	No Version Available
Previous Version	CMS161v11

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Measure Information	2021 Performance Period	2022 Performance Period	2023 Performance Period	2024 Performance Period
Title	Adult Major Depressive Disorder (MDD): Suicide Risk Assessment	Adult Major Depressive Disorder (MDD): Suicide Risk Assessment	Adult Major Depressive Disorder (MDD): Suicide Risk Assessment	Adult Major Depressive Disorder (MDD): Suicide Risk Assessment
CMS eCQM ID	CMS161v9	CMS161v10	CMS161v11	CMS161v12
NQF Number	0104e	0104e	0104e	Not Applicable
Description	All patient visits during which a new diagnosis of MDD or a new diagnosis of recurrent MDD was identified for patients aged 18 years and older with a suicide risk assessment completed during the visit	All patient visits during which a new diagnosis of MDD or a new diagnosis of recurrent MDD was identified for patients aged 18 years and older with a suicide risk assessment completed during the visit	Percentage of all patient visits for those patients that turn 18 or older during the measurement period in which a new or recurrent diagnosis of major depressive disorder (MDD) was identified and a suicide risk assessment was completed during the visit	Percentage of all patient visits for those patients that are 17 years of age or older at the start of the measurement period in which a new or recurrent diagnosis of major depressive disorder (MDD) was identified and a suicide risk assessment was completed during the visit
Initial Population	Patient visits during which a new diagnosis of MDD, single or recurrent episode, was identified	Patient visits during which a new diagnosis of MDD, single or recurrent episode, was identified	Patient visits for patients that turn 18 or older during the measurement period during which a new diagnosis of MDD, single or recurrent episode, was identified	Patient visits for patients that are 17 years of age or older at the start of the measurement period during which a new diagnosis of MDD, single or recurrent episode, was identified
Denominator	Equals Initial Population	Equals Initial Population	Equals Initial Population	Equals Initial Population
Denominator Exclusions	None	None	None	None
Numerator	Patient visits during which a new diagnosis of MDD, single or recurrent episode, was identified and a suicide risk assessment was completed during the visit	Patient visits during which a new diagnosis of MDD, single or recurrent episode, was identified and a suicide risk assessment was completed during the visit	Patient visits during which a new diagnosis of MDD, single or recurrent episode, was identified and a suicide risk assessment was completed during the visit	Patient visits during which a new diagnosis of MDD, single or recurrent episode, was identified and a suicide risk assessment was completed during the visit
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-of-care measure and should be reported for each instance of a new or recurrent episode of major depressive disorder (MDD); every new or recurrent episode will count separately in the Initial Population. As the guidelines state, it is important to assess for additional factors which may increase or decrease suicide risk, such as presence of additional symptoms (e.g., psychosis, severe anxiety, hopelessness, severe chronic pain); presence of substance abuse, history and seriousness of previous attempts, particularly, recent suicidal behavior, current stressors and potential protective factors (e.g., positive reasons for living, strong social support), family history of suicide or mental illness or recent exposure to suicide, impulsivity and potential for risk to others, including history of violence or violent or homicidal ideas, plans, or intentions, and putting one's affairs in order (e.g., giving away possessions, writing a will). In addition, although the measure focuses on the initial visit, it is critical that suicide risk be monitored especially for the 90 days following the initial visit and throughout MDD treatment. It is expected that a suicide risk assessment will be completed at the visit during which a new diagnosis is made or at the visit during which a recurrent episode is first identified (i.e., at the initial evaluation). For the purposes of this measure, an episode of major depressive disorder (MDD) would be considered to be recurrent if a patient has not had an MDD-related encounter in the past 105 days. If there is a gap of 105 or more days between visits for major depressive disorder (MDD), that would imply a recurrent episode. The 105-day look-back period is an operational provision and not a clinical recommendation, or definition of relapse, remission, or recurrence. 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. Standardized tools can be mapped to the concept "Intervention, Performed": "Suicide risk assessment (procedure)" included in the numerator logic below. The logic statement for the age requirement, as written, captures patients who turn 18 years old during the measurement period so that these patients are included in the measure, so long as the minimum criteria noted above is evaluated. To ensure all patients with major depressive disorder (MDD) are assessed for suicide risk, there are two clinical quality measures addressing suicide risk assessment; CMS 177 covers children and adolescents aged 6 through 17, and CMS 161 covers the adult population aged 18 years and older, 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 and should be reported for each instance of a new or recurrent episode of major depressive disorder (MDD) during the measurement period. This measure should be reported for each eligible encounter during which a new or recurrent episode of MDD is identified. As the guidelines state, it is important to assess for additional factors which may increase or decrease suicide risk, such as presence of additional symptoms (e.g., psychosis, severe anxiety, hopelessness, severe chronic pain); presence of substance abuse, history and seriousness of previous attempts, particularly, recent suicidal behavior, current stressors and potential protective factors (e.g., positive reasons for living, strong social support), family history of suicide or mental illness or recent exposure to suicide, impulsivity and potential for risk to others, including history of violence or violent or homicidal ideas, plans, or intentions, and putting one's affairs in order (e.g., giving away possessions, writing a will). In addition, although the measure focuses on the initial visit, it is critical that suicide risk be monitored especially for the 90 days following the initial visit and throughout MDD treatment. It is expected that a suicide risk assessment will be completed at the visit during which a new diagnosis is made or at the visit during which a recurrent episode is first identified (i.e., at the initial evaluation). For the purposes of this measure, an episode of major depressive disorder (MDD) would be considered to be recurrent if a patient has not had an MDD-related encounter in the past 105 days. If there is a gap of 105 or more days between visits for major depressive disorder (MDD), that would imply a recurrent episode. The 105-day look-back period is an operational provision and not a clinical recommendation, or definition of relapse, remission, or recurrence. 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. Standardized tools can be mapped to the concept "Intervention, Performed": "Suicide risk assessment (procedure)" included in the numerator logic below. The logic statement for the age requirement, as written, captures patients who turn 18 years old during the measurement period so that these patients are included in the measure, so long as the minimum criteria noted above is evaluated. To ensure all patients with major depressive disorder (MDD) are assessed for suicide risk, there are two clinical quality measures addressing suicide risk assessment; CMS 177 covers children and adolescents aged 6 through 17, and CMS 161 covers the adult population aged 18 years and older, 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 and should be reported for each instance of a new or recurrent episode of major depressive disorder (MDD) during the measurement period. This measure should be reported for each eligible encounter during which a new or recurrent episode of MDD is identified in adults that turn 18 or older during the measurement period. As the guidelines state, it is important to assess for additional factors which may increase or decrease suicide risk, such as presence of additional symptoms (e.g., psychosis, severe anxiety, hopelessness, severe chronic pain); presence of substance abuse, history and seriousness of previous attempts, particularly, recent suicidal behavior, current stressors and potential protective factors (e.g., positive reasons for living, strong social support), family history of suicide or mental illness or recent exposure to suicide, impulsivity and potential for risk to others, including history of violence or violent or homicidal ideas, plans, or intentions, and putting one's affairs in order (e.g., giving away possessions, writing a will). In addition, although the measure focuses on the initial visit, it is critical that suicide risk be monitored especially for the 90 days following the initial visit and throughout MDD treatment. It is expected that a suicide risk assessment will be completed at the visit during which a new diagnosis is made or at the visit during which a recurrent episode is first identified (i.e., at the initial evaluation). For the purposes of this measure, an episode of major depressive disorder (MDD) would be considered to be recurrent if a patient has not had an MDD-related encounter in the past 105 days. If there is a gap of 105 or more days between visits for major depressive disorder (MDD), that would imply a recurrent episode. The 105-day look-back period is an operational provision and not a clinical recommendation, or definition of relapse, remission, or recurrence. 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. Standardized tools can be mapped to the concept "Intervention, Performed": "Suicide risk assessment (procedure)" included in the numerator logic below. The logic statement for the age requirement, as written, captures patients who turn 18 years old during the measurement period so that these patients are included in the measure, so long as the minimum criteria noted above is evaluated. 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- Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment covers children and adolescents aged 6 through 17, and CMS161 covers the adult population aged 18 years and older, 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 and should be reported for each instance of a new or recurrent episode of major depressive disorder (MDD) during the measurement period. This measure should be reported for each eligible encounter during which a new or recurrent episode of MDD is identified in adults that turn 18 or older during the measurement period. As the guidelines state, it is important to assess for additional factors which may increase or decrease suicide risk, such as presence of additional symptoms (e.g., psychosis, severe anxiety, hopelessness, severe chronic pain); presence of substance abuse; history and seriousness of previous attempts, particularly, recent suicidal behavior; current stressors and potential protective factors (e.g., positive reasons for living, strong social support); family history of suicide or mental illness or recent exposure to suicide; impulsivity and potential for risk to others, including history of violence or violent or homicidal ideas, plans, or intentions; and putting one's affairs in order (e.g., giving away possessions, writing a will). In addition, although the measure focuses on the initial visit, it is critical that suicide risk be monitored especially for the 90 days following the initial visit and throughout MDD treatment. It is expected that a suicide risk assessment will be completed at the visit during which a new diagnosis is made or at the visit during which a recurrent episode is first identified (i.e., at the initial evaluation). For the purposes of this measure, an episode of MDD would be considered to be recurrent if a patient has not had an MDD-related encounter in the past 105 days. If there is a gap of 105 or more days between visits for MDD, that would imply a recurrent episode. The 105-day look-back period is an operational provision and not a clinical recommendation, or definition of relapse, remission, or recurrence. 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. 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 MDD are assessed for suicide risk, there are two clinical quality measures addressing suicide risk assessment; CMS177-Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment covers children and adolescents aged 6 through 16 at the start of the measurement period, and CMS161 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	107	107	107	107
Telehealth Eligible	Yes	Yes	Yes	Yes
Next Version	CMS161v10	CMS161v11	CMS161v12	No Version Available
Previous Version	No Version Available	CMS161v9	CMS161v10	CMS161v11

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Header

Removed NQF Number, measure endorsement removed.

Measure Section: NQF Number

Source of Change: Measure Lead
Updated to reflect this measure is no longer NQF endorsed.

Measure Section: Endorsed By

Source of Change: Measure Lead
Updated copyright.

Measure Section: Copyright

Source of Change: Annual Update
Updated disclaimer.

Measure Section: Disclaimer

Source of Change: Annual Update
Updated references.

Measure Section: Reference

Source of Change: Measure Lead
Added guidance to assure that all patients with major depressive disorder are assessed for suicide risk.

Measure Section: Guidance

Source of Change: Measure Lead
Updated grammar, wording, and/or formatting to improve readability and consistency.

Measure Section: Multiple Sections

Source of Change: Annual Update
Revised the age description to better align with measure logic.

Measure Section: Multiple Sections

Source of Change: Measure Lead

Logic

Updated the names of CQL definitions, functions, and/or aliases for clarification and to align with the CQL Style Guide.

Measure Section: Definitions

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.

Value set (2.16.840.1.113883.3.464.1003.101.12.1010): Renamed to Emergency Department Evaluation and Management Visit based on recommended value set naming conventions.

Measure Section: Terminology

Source of Change: Annual Update
Value set Major Depressive Disorder Active (2.16.840.1.113883.3.526.3.1491): Added 2 ICD-10-CM codes (F32.4, F33.41) based on review by technical experts, SMEs, and/or public feedback. Added 5 SNOMED CT codes (30605009, 33135002, 67002003, 70747007, 16265301000119106) based on review by technical experts, SMEs, and/or public feedback.

Measure Section: Terminology

Source of Change: Measure Lead
Value set Payer (2.16.840.1.114222.4.11.3591): Added 5 SOP codes (1111, 1112, 142, 344, 141) based on review by technical experts, SMEs, and/or public feedback.

Measure Section: Terminology

Source of Change: Measure Lead