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CMS Measure ID:
Version:
7
NQF Number:
712
Performance/Reporting Period
2019
Description:

The percentage of adolescent patients 12 to 17 years of age and adult patients age 18 and older with the diagnosis of major depression or dysthymia who have a completed PHQ-9 during each applicable 4 month period in which there was a qualifying depression encounter

Data Elements contained within the eCQM + Expand all

Direct Reference Code

Constrained to 'Patient Health Questionnaire 9 item (PHQ-9) total score [Reported]' LOINC code

QDM Datatype and Definition (QDM Version 5.3)

Assessment, Performed

Data elements that meet criteria using this datatype should document completion of the assessment indicated by the QDM category and its corresponding value set.

A QDM Known Issue has been identified related to this datatype. To see this QDM known Issue, please click here.

Timing: The time the assessment is completed; Author dateTime.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent diagnoses related to bipolar disorder.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Diagnosis.
Inclusion Criteria: Includes only relevant concepts associated with all relevant diagnoses associated with bipolar disorder. This is a grouping of SNOMED CT, ICD-9-CM, and ICD-10-CM codes.
Exclusion Criteria: No exclusions.

Constrained to codes in the Diagnosis: Bipolar Disorder value set (2.16.840.1.113883.3.67.1.101.1.128)

QDM Datatype and Definition (QDM Version 5.3)

Diagnosis

Data elements that meet criteria using this datatype should document the Condition/Diagnosis/Problem and its corresponding value set. The onset dateTime corresponds to the implicit start dateTime of the datatype and the abatement dateTime corresponds to the implicit stop dateTime of the datatype. If the abatement dateTime is not present, then the diagnosis is considered to still be active. When this datatype is used with timing relationships, the criterion is looking for an active diagnosis for the time frame indicated by the timing relationships.

Timing: The Prevalence Period references the time from the onset date to the abatement date.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent diagnoses related to dysthymia.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Diagnosis.
Inclusion Criteria: Includes only relevant concepts associated with diagnoses for dysthymia, including early and late onset, and primary and secondary dysthymia. This groups ICD-10-CM and SNOMED CT codes.
Exclusion Criteria: No exclusions.

Constrained to codes in the Diagnosis: Dysthymia value set (2.16.840.1.113883.3.67.1.101.1.254)

QDM Datatype and Definition (QDM Version 5.3)

Diagnosis

Data elements that meet criteria using this datatype should document the Condition/Diagnosis/Problem and its corresponding value set. The onset dateTime corresponds to the implicit start dateTime of the datatype and the abatement dateTime corresponds to the implicit stop dateTime of the datatype. If the abatement dateTime is not present, then the diagnosis is considered to still be active. When this datatype is used with timing relationships, the criterion is looking for an active diagnosis for the time frame indicated by the timing relationships.

Timing: The Prevalence Period references the time from the onset date to the abatement date.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent diagnoses related to major depression, including types of depression and depression remission.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Diagnosis.
Inclusion Criteria: Includes only relevant concepts associated with diagnoses for major depression. Chronic, recurrent, single episodes of depression are included, as are diagnoses from mild to severe. Depression remission is also included. This value set groups ICD-10-CM and SNOMED CT codes.
Exclusion Criteria: No exclusions.

Constrained to codes in the Diagnosis: Major Depression Including Remission value set (2.16.840.113883.3.67.1.101.3.2444)

QDM Datatype and Definition (QDM Version 5.3)

Diagnosis

Data elements that meet criteria using this datatype should document the Condition/Diagnosis/Problem and its corresponding value set. The onset dateTime corresponds to the implicit start dateTime of the datatype and the abatement dateTime corresponds to the implicit stop dateTime of the datatype. If the abatement dateTime is not present, then the diagnosis is considered to still be active. When this datatype is used with timing relationships, the criterion is looking for an active diagnosis for the time frame indicated by the timing relationships.

Timing: The Prevalence Period references the time from the onset date to the abatement date.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent diagnoses related to personality disorder. These specific diagnoses incorporate disorders in which the patient could not reliably complete a PHQ-9 tool due to their condition.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Diagnosis.
Inclusion Criteria: Includes only relevant concepts associated with diagnoses for personality disorder, including borderline, cyclothymic, histrionic, and factitious disorders. This is grouping SNOMED CT, ICD-9-CM and ICD-10-CM codes.
Exclusion Criteria: Excludes some personality disorders. Does not include ALL personality disorders (e.g., does not include narcissistic or obsessive compulsive personality disorders).

Constrained to codes in the Diagnosis: Personality Disorder value set (2.16.840.1.113883.3.67.1.101.1.246)

QDM Datatype and Definition (QDM Version 5.3)

Diagnosis

Data elements that meet criteria using this datatype should document the Condition/Diagnosis/Problem and its corresponding value set. The onset dateTime corresponds to the implicit start dateTime of the datatype and the abatement dateTime corresponds to the implicit stop dateTime of the datatype. If the abatement dateTime is not present, then the diagnosis is considered to still be active. When this datatype is used with timing relationships, the criterion is looking for an active diagnosis for the time frame indicated by the timing relationships.

Timing: The Prevalence Period references the time from the onset date to the abatement date.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent a diagnosis of autistic disorder, other childhood disintegrative disorder or other pervasive developmental disorder.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Diagnosis.
Inclusion Criteria: Includes only relevant concepts associated with identifying patients with a diagnosis of autistic disorder, other childhood disintegrative disorder or other pervasive developmental disorder. This is a grouping of ICD-9-CM, ICD-10-CM and SNOMED CT concepts.
Exclusion Criteria: No exclusions.

Constrained to codes in the Diagnosis: Pervasive Developmental Disorder value set (2.16.840.1.113883.3.464.1003.105.12.1152)

QDM Datatype and Definition (QDM Version 5.3)

Diagnosis

Data elements that meet criteria using this datatype should document the Condition/Diagnosis/Problem and its corresponding value set. The onset dateTime corresponds to the implicit start dateTime of the datatype and the abatement dateTime corresponds to the implicit stop dateTime of the datatype. If the abatement dateTime is not present, then the diagnosis is considered to still be active. When this datatype is used with timing relationships, the criterion is looking for an active diagnosis for the time frame indicated by the timing relationships.

Timing: The Prevalence Period references the time from the onset date to the abatement date.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent a diagnosis of all types of schizophrenia and schizoaffective disorders.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Diagnosis.
Inclusion Criteria: Includes only relevant concepts associated with identifying all types of schizophrenia and schizoaffective disorders. This is a grouping of ICD-9-CM, ICD-10-CM and SNOMED CT concepts.
Exclusion Criteria: No exclusions.

Constrained to codes in the Diagnosis: Schizophrenia or Psychotic Disorder value set (2.16.840.1.113883.3.464.1003.105.12.1104)

QDM Datatype and Definition (QDM Version 5.3)

Diagnosis

Data elements that meet criteria using this datatype should document the Condition/Diagnosis/Problem and its corresponding value set. The onset dateTime corresponds to the implicit start dateTime of the datatype and the abatement dateTime corresponds to the implicit stop dateTime of the datatype. If the abatement dateTime is not present, then the diagnosis is considered to still be active. When this datatype is used with timing relationships, the criterion is looking for an active diagnosis for the time frame indicated by the timing relationships.

Timing: The Prevalence Period references the time from the onset date to the abatement date.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent patients living in assisted living, domiciliary care or rest homes who have had an interaction with a member of their medical team.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Encounter, Performed.
Inclusion Criteria: Includes only relevant concepts associated with services provided to new and established patients living in assisted living, domiciliary care or rest home. This is a grouping value set of CPT codes.
Exclusion Criteria: Excludes visits in settings other than assisted living, domiciliary care or rest homes.

Constrained to codes in the Encounter, Performed: Care Services in Long-Term Residential Facility value set (2.16.840.1.113883.3.464.1003.101.12.1014)

QDM Datatype and Definition (QDM Version 5.3)

Encounter, Performed

Data elements that meet criteria using this datatype should document that the encounter indicated by the QDM category and its corresponding value set is in progress or has been completed.

Timing: The Relevant Period addresses:

  • startTime – the time the encounter began (admission time)
  • stopTime – the time the encounter ended (discharge time)

The Author dateTime addresses when an Encounter is documented. Documentation can occur at the beginning, during, at the end or subsequent to the end of an Encounter. The Author dateTime should be used only if the Relevant Period cannot be obtained.

The Location Period is an attribute of the attribute facility location addresses:

  • startTime - the time the patient arrived at the location;
  • stopTime - the time the patient departed from the location

 

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent contact and office visits for new and established patients, and includes in-person, telephone, online, and other visit types related to depression encounters.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Encounter, Performed.
Inclusion Criteria: Includes only relevant concepts associated with outpatient contact and office visits in which a patient may be evaluated for depression. This groups CPT and HCPCS codes.
Exclusion Criteria: Excludes inpatients for purposes of the index event. The majority of CPT codes are specified for outpatient visit types; however psychiatry and psychotherapy visits can be used in the inpatient setting.

Constrained to codes in the Encounter, Performed: Contact or Office Visit value set (2.16.840.1.113762.1.4.1080.5)

QDM Datatype and Definition (QDM Version 5.3)

Encounter, Performed

Data elements that meet criteria using this datatype should document that the encounter indicated by the QDM category and its corresponding value set is in progress or has been completed.

Timing: The Relevant Period addresses:

  • startTime – the time the encounter began (admission time)
  • stopTime – the time the encounter ended (discharge time)

The Author dateTime addresses when an Encounter is documented. Documentation can occur at the beginning, during, at the end or subsequent to the end of an Encounter. The Author dateTime should be used only if the Relevant Period cannot be obtained.

The Location Period is an attribute of the attribute facility location addresses:

  • startTime - the time the patient arrived at the location;
  • stopTime - the time the patient departed from the location

 

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent identifying patients receiving palliative, comfort or hospice care.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Encounter.
Inclusion Criteria: Includes only relevant concepts associated with identifying patients receiving palliative, comfort or hospice care.
Exclusion Criteria: No exclusions.

Constrained to codes in the Encounter, Performed: Palliative care encounter value set (2.16.840.1.113883.3.600.1.1575)

QDM Datatype and Definition (QDM Version 5.3)

Encounter, Performed

Data elements that meet criteria using this datatype should document that the encounter indicated by the QDM category and its corresponding value set is in progress or has been completed.

Timing: The Relevant Period addresses:

  • startTime – the time the encounter began (admission time)
  • stopTime – the time the encounter ended (discharge time)

The Author dateTime addresses when an Encounter is documented. Documentation can occur at the beginning, during, at the end or subsequent to the end of an Encounter. The Author dateTime should be used only if the Relevant Period cannot be obtained.

The Location Period is an attribute of the attribute facility location addresses:

  • startTime - the time the patient arrived at the location;
  • stopTime - the time the patient departed from the location

 

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent identifying patients receiving palliative, comfort or hospice care.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Intervention or Procedure.
Inclusion Criteria: Includes only relevant concepts associated with identifying patients receiving palliative, comfort or hospice care.
Exclusion Criteria: No exclusions.

Constrained to codes in the Intervention, Order: Palliative Care value set (2.16.840.1.113883.3.600.1.1579)

QDM Datatype and Definition (QDM Version 5.3)

Intervention, Order

Data elements that meet criteria using this datatype should document a request to perform the intervention indicated by the QDM category and its corresponding value set.

Timing: The time the order is signed; Author dateTime

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent whether the patient is Hispanic or not; ethnicity category defined by the Centers for Disease Control and Prevention and National Center for Health Statistics.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Patient Characteristic Ethnicity.
Inclusion Criteria: Includes only relevant concepts associated with ethnicity defined as Hispanic or Latino, or Not Hispanic or Latino.
Exclusion Criteria: No exclusions.

Constrained to codes in the Patient Characteristic Ethnicity: Ethnicity value set (2.16.840.1.114222.4.11.837)

QDM Datatype and Definition (QDM Version 5.3)

Patient Characteristic Ethnicity

Data elements that meet criteria using this datatype should document that the patient has one or more of the ethnicities indicated by the QDM category and its corresponding value set.

Timing: Ethnicity does not have a specific timing. Measures using Patient Characteristic, Ethnicity should address the most recent entry in the clinical record.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent categories of types of health care payor entities as defined by the US Public Health Data Consortium SOP code system.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Patient Characteristic Payer.
Inclusion Criteria: Includes only relevant concepts associated with payer codes in the code system.
Exclusion Criteria: No exclusions.

Constrained to codes in the Patient Characteristic Payer: Payer value set (2.16.840.1.114222.4.11.3591)

QDM Datatype and Definition (QDM Version 5.3)

Patient Characteristic Payer

Data elements that meet criteria using this datatype should document that the patient has one or more of the payers indicated by the QDM category and its corresponding value set.

Timing: The Relevant Period addresses:

  • startTime – the first day of insurance coverage with the referenced payer
  • stopTime – the last day of insurance coverage with the referenced payer

 

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent the general race category reported by the patient - subject may have more than one; defined by the Centers for Disease Control and Prevention and National Center for Health Statistics.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Patient Characteristic Race.
Inclusion Criteria: Includes only relevant concepts associated with the following race categories: American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander, Other Race, White.
Exclusion Criteria: No exclusions.

Constrained to codes in the Patient Characteristic Race: Race value set (2.16.840.1.114222.4.11.836)

QDM Datatype and Definition (QDM Version 5.3)

Patient Characteristic Race

Data elements that meet criteria using this datatype should document the patient’s race.

Timing: Race does not have a specific timing. Measures using Patient Characteristic, Race should address the most recent entry in the clinical record.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent gender identity restricted to only male and female used in administrative situations requiring a restriction to these two categories.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Patient Characteristic Sex.
Inclusion Criteria: Includes relevant concepts associated with gender concepts for male and female only.
Exclusion Criteria: Excludes any gender identity that is not male or female.

Constrained to codes in the Patient Characteristic Sex: ONC Administrative Sex value set (2.16.840.1.113762.1.4.1)

QDM Datatype and Definition (QDM Version 5.3)

Patient Characteristic Sex

Data elements that meet criteria using this datatype should document that the patient's sex matches the QDM category and its corresponding value set.

Timing: Birth (administrative) sex does not have a specific timing.