eCQMs for 2020 Performance Period CMS2v9 CMS22v8 CMS50v8 CMS52v8 CMS56v8 CMS66v8 CMS68v9 CMS69v8 CMS74v9 CMS75v8 CMS82v7 CMS90v9 CMS117v8 CMS122v8 CMS124v8 CMS125v8 CMS127v8 CMS128v8 CMS129v9 CMS130v8 CMS131v8 CMS132v8 CMS133v8 CMS134v8 CMS135v8 CMS136v9 CMS137v8 CMS138v8 CMS139v8 CMS142v8 CMS143v8 CMS144v8 CMS145v8 CMS146v8 CMS147v9 CMS149v8 CMS153v8 CMS154v8 CMS155v8 CMS156v8 CMS157v8 CMS159v8 CMS160v8 CMS161v8 CMS165v8 CMS177v8 CMS249v2 CMS347v3 CMS349v2 CMS645v3 CMS771v1 CMS Measure ID CMS159v8 Version 8 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 screened using PHQ-9 and PHQ-9M up to 7 days prior to the office visit (including the day of the office visit). Denominator Statement 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 6: Patients with a diagnosis of schizophrenia or psychotic disorder 7: Patients with a diagnosis of pervasive developmental disorder 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 Numerator Exclusions Not Applicable Denominator Exceptions None Measure Steward MN Community Measurement Domain Effective Clinical Care Previous Version CMS159v7 Measure Scoring Proportion Measure Type Outcome Improvement Notation Higher score indicates better quality Guidance None Quality ID 370 Meaningful Measure Prevention, Treatment, and Management of Mental Health Specifications Attachment Size CMS159v8.html 83.4 KB CMS159v8.zip 76.55 KB CMS159v8-TRN.xlsx 22.63 KB Release Notes Header Updated eCQM version number. Measure Section: eCQM Version number Source of Change: Measure Lead Added 'e' to NQF number. Measure Section: NQF Number Source of Change: Standards Update Updated copyright. Measure Section: Copyright Source of Change: Annual Update Updated disclaimer. Measure Section: Disclaimer Source of Change: Measure Lead Updated rationale statement to align with most recent literature and revised text to include the acronym MDE for major depressive episode. Measure Section: Rationale Source of Change: Measure Lead Updated clinical recommendation statement by deleting definitions for Response, Remission, Recovery, Relapse, and Recurrence to improve clarity. Measure Section: Clinical Recommendation Statement Source of Change: Measure Lead Updated references to align with American Psychological Association (APA) style. Measure Section: Reference Source of Change: Measure Lead Updated references. Measure Section: Reference Source of Change: Measure Lead Updated definition statement with addition of text for Index Event Date to align with measure intent: '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).' Measure Section: Definition Source of Change: ONC Project Tracking System (JIRA): CQM-3045 Updated initial population statement with addition of text to align with measure intent: 'or up to 7 days prior to.' Measure Section: Initial Population Source of Change: ONC Project Tracking System (JIRA): CQM-3045 Updated parenthetical citations to align with American Psychological Association (APA) style. Measure Section: Multiple Sections Source of Change: Measure Lead Logic Revised logic to allow the PHQ-9/PHQ-9M depression assessment to be administered during the index encounter or up to 7 days prior to the encounter. Measure Section: Initial Population Source of Change: ONC Project Tracking System (JIRA): CQM-3045 Revised logic to replace the direct reference code with the 'PHQ 9 and PHQ 9M Tools' value set to improve alignment with measure intent. Measure Section: Numerator Source of Change: Measure Lead Updated the names of Clinical Quality Language (CQL) definitions, functions, and/or aliases for clarification and to align with CQL Style Guide. Measure Section: Definitions and Functions Source of Change: Standards Update Updated Clinical Quality Language (CQL) expression to conform with the HL7 Standard: Clinical Quality Language Specification, Release 1 STU 3 (CQL 1.3). Measure Section: Multiple Sections Source of Change: Standards Update Updated definitions and functions in the Measure Authoring Tool (MAT) Global Common Functions Library to align with standards changes, Clinical Quality Language (CQL) Style Guide, and to include two new functions related to calculating hospital stays. Measure Section: Multiple Sections Source of Change: Standards Update Updated version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-4.0.000). Measure Section: Multiple Sections Source of Change: Standards 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 (2.16.840.1.113883.3.600.1.1579): Renamed to Palliative or Hospice Care. Measure Section: Terminology Source of Change: Annual Update Value set PHQ 9 and PHQ 9M Tools (2.16.840.1.113883.3.67.1.101.1.263): Added PHQ 9 and PHQ 9M Tools. Measure Section: Terminology Source of Change: Annual Update Value set Bipolar Disorder (2.16.840.1.113883.3.67.1.101.1.128): Added 8 SNOMED CT codes (133091000119105, 261000119107, 723903001, 723905008, 765176007, 767631007, 767635003, 767636002). Measure Section: Terminology Source of Change: Annual Update Value set Personality Disorder (2.16.840.1.113883.3.67.1.101.1.246): Added 6 SNOMED CT codes (21586000, 24315006, 33693007, 430744005, 430751001, 76105009). Measure Section: Terminology Source of Change: Annual Update Value set Schizophrenia or Psychotic Disorder (2.16.840.1.113883.3.464.1003.105.12.1104): Added 4 SNOMED CT codes (31027006, 36158005, 55736003, 88975006). Measure Section: Terminology Source of Change: Annual Update Value set Major Depression Including Remission (2.16.840.113883.3.67.1.101.3.2444): Added 2 SNOMED CT codes (16264901000119109, 104851000119103). Measure Section: Terminology Source of Change: Annual Update Replaced direct reference code 'Patient Health Questionnaire 9 item (PHQ-9) total score [Reported]' using 'LOINC Code (44261-6)' with value set 'PHQ 9 and PHQ 9M Tools' (2.16.840.1.113883.3.67.1.101.1.263). Measure Section: Terminology Source of Change: Measure Lead Direct reference code for Birth date (LOINC Code (21112-8)) now displayed in Human Readable. Measure Section: Terminology Source of Change: Annual Update Direct reference code for Dead (finding) (SNOMED CT Code (419099009)) now displayed in Human Readable. Measure Section: Terminology Source of Change: Annual Update Removed code system versions from direct reference codes. Please refer to Appendix A of the Electronic Clinical Quality Measure Logic and Implementation Guidance document for a list of code system versions used in the eCQM specifications for 2020 reporting/performance. Measure Section: Terminology Source of Change: Standards Update Standardized purpose statement language in value sets across eCQMs. Value set purpose statements are visible in the Value Set Authority Center (VSAC) as well as the downloadable eCQM value set files. Measure Section: Terminology Source of Change: Measure Lead Data Elements contained within CMS159v8 External Resources United States Health Information Knowledgebase NLM Value Set Authority Center (VSAC)