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Depression Remission at Twelve Months

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Measure Information 2020 Performance Period
CMS Measure ID CMS159v8
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
Measure Scoring Proportion measure
Measure Type Outcome measure
Improvement Notation

Higher score indicates better quality
Guidance

None
MIPS Quality ID 370
Meaningful Measure Prevention, Treatment, and Management of Mental Health
Telehealth Eligible Yes
Next Version
CMS159v9
Specifications
Attachment Size
CMS159v8.html 83.4 KB
CMS159v8.zip 76.55 KB
CMS159v8-TRN.xlsx 22.63 KB

Data Element Repository

Release Notes

CMS159v8-TRN.xlsx

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

Last Updated: Dec 13, 2021