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

Specifications

General eCQM Information

CMS Measure ID CMS177v6
NQF Number 1365
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 PCPI(R) Foundation (PCPI[R])
Domain Patient Safety
Measure Scoring Proportion measure
Measure Type Process measure
Improvement Notation

Higher score indicates better quality

Guidance

A suicide risk assessment should be performed at every visit for major depressive disorder during the measurement period.

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 or instrument to assess suicide risk will meet numerator performance. Standardized tools can be mapped to the concept "Intervention, Performed: Suicide Risk Assessment" included in the numerator logic below.

Next Version
Release Notes

Header

  • ​Incremented eMeasure Version number.

    Measure Section: eMeasure Version number

    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 Clinical Recommendation Statement.

    Measure Section: Clinical Recommendation Statement

    Source of Change: Measure Lead

Logic

  • Removed data element 'Diagnosis: Major Depressive Disorder-Active' from the Initial Population logic. Modified variable logic by adding an attribute for diagnosis of MDD to ensure the encounter(s) are MDD related.

    Measure Section: Initial Population

    Source of Change: Measure Lead

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 Major Depressive Disorder-Active (2.16.840.1.113883.3.526.3.1491): Added 1 ICD10CM code (F32.89).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

Last Updated: May 06, 2020