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

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eCQMs for 2020 Performance Period

CMS2v9
CMS22v8
CMS50v8
CMS56v8
CMS66v8
CMS68v9
CMS69v8
CMS74v9
CMS75v8
CMS90v9
CMS117v8
CMS122v8
CMS124v8
CMS125v8
CMS127v8
CMS128v8
CMS129v9
CMS130v8
CMS131v8
CMS133v8
CMS134v8
CMS135v8
CMS136v9
CMS137v8
CMS138v8
CMS139v8
CMS142v8
CMS143v8
CMS144v8
CMS145v8
CMS146v8
CMS147v9
CMS149v8
CMS153v8
CMS154v8
CMS155v8
CMS156v8
CMS157v8
CMS159v8
CMS161v8
CMS165v8
CMS177v8
CMS249v2
CMS347v3
CMS349v2
CMS645v3
CMS771v1

General eCQM Information

CMS Measure ID CMS177v8
NQF Number 1365e
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.

Suicide risk assessments completed via telehealth services can also meet numerator performance.

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(s) or instrument(s) to assess suicide risk will meet numerator performance, so long as the minimum criteria noted above is evaluated. 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.
Quality ID 382
Meaningful Measure Prevention, Treatment, and Management of Mental Health
Telehealth Eligible Yes
Next Version
CMS177v9
Previous Version
CMS177v7
Specifications
Attachment Size
CMS177v8.html 45.6 KB
CMS177v8.zip 52.36 KB
CMS177v8-TRN.xlsx 21.86 KB

Data Element Repository

Release Notes

CMS177v8-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 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 to align with clinical expert recommendations.

    Measure Section: Definition

    Source of Change: Expert Work Group Review

  • Updated guidance statement related to telehealth encounters based on clinical expert recommendations.

    Measure Section: Guidance

    Source of Change: Expert Work Group Review

  • Updated guidance statement to align with clinical expert recommendations.

    Measure Section: Guidance

    Source of Change: Expert Work Group Review

  • Updated parenthetical citations to align with American Psychological Association (APA) style.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

Logic

  • 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 ‘Major Depressive Disorder Encounter’ definition to allow for Telehealth Services encounters to meet visit requirements based upon clinical expert recommendations.

    Measure Section: Multiple Sections

    Source of Change: Expert Work Group Review

  • 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 Psych Visit - Family Psychotherapy (2.16.840.1.113883.3.526.3.1018): Added SNOMED CT extensional value set (2.16.840.1.113883.3.526.2.1780) including 1 code.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Group Psychotherapy (2.16.840.1.113883.3.526.3.1187): Added SNOMED CT extensional value set (2.16.840.1.113883.3.526.2.1779) including 1 code.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Major Depressive Disorder-Active (2.16.840.1.113883.3.526.3.1491): Added 17 SNOMED CT codes.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Psychoanalysis (2.16.840.1.113883.3.526.3.1141): Added SNOMED CT extensional value set (2.16.840.1.113883.3.526.2.1778) including 2 codes.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Psych Visit - Diagnostic Evaluation (2.16.840.1.113883.3.526.3.1492): Added SNOMED CT extensional value set (2.16.840.1.113883.3.526.2.1776) including 5 codes.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Psych Visit - Psychotherapy (2.16.840.1.113883.3.526.3.1496): Added SNOMED CT extensional value set (2.16.840.1.113883.3.526.2.1777) including 13 codes.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Telehealth Services (2.16.840.1.113883.3.464.1003.101.12.1031): Added Telehealth Services.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Direct reference code for Birth date (LOINC Code (21112-8)) 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 18, 2020