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Depression Remission at Twelve Months

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Measure Information 2021 Performance Period
CMS Measure ID CMS159v9
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 emotionally labile

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

When a baseline assessment is conducted with PHQ 9M, the follow-up assessment can use either a PHQ 9M or PHQ 9.

This eCQM is a patient-based measure.

This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM.
MIPS Quality ID 370
Meaningful Measure Prevention, Treatment, and Management of Mental Health
Telehealth Eligible Yes
Next Version
CMS159v10
Previous Version
CMS159v8
Specifications
Attachment Size
CMS159v9.html 73.29 KB
CMS159v9.zip 73.84 KB
CMS159v9-TRN.xlsx 22.55 KB

Data Element Repository

Release Notes

CMS159v9-TRN.xlsx

Header

  • Updated eCQM Version Number.

    Measure Section: eCQM Version Number

    Source of Change: Standards Update

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Added text to clarify stratification takes place at the time of the index assessment.

    Measure Section: Stratification

    Source of Change: Measure Lead

  • Updated the rationale with newer studies and data.

    Measure Section: Rationale

    Source of Change: Measure Lead

  • Updated the clinical recommendations to include the latest relevant studies and guidelines.

    Measure Section: Clinical Recommendation Statement

    Source of Change: Measure Lead

  • Added text to identify the Quality Data Model (QDM) version used in the measure specification.

    Measure Section: Guidance

    Source of Change: Standards Update

  • Added text to indicate whether the measure is patient-based or episode-based.

    Measure Section: Guidance

    Source of Change: Standards Update

  • Added text to indicate clarify which assessment can be used for the follow-up assessment.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Updated text to clarify patients diagnosed with a personality disorder emotionally labile should be excluded, and align with updated value sets.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

Logic

  • Updated logic to reflect accurate name of the value set Palliative or Hospice Care (2.16.840.1.113883.3.600.1.1579).

    Measure Section: Denominator Exclusions

    Source of Change: ONC Project Tracking System (Jira): CQM-3637

  • Updated the alias 'PalliativeCareOrder' in the 'Palliative Care Order' definition to better differentiate from the 'Encounter Palliative Care' definition's alias.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Updated the 'Palliative Care Order' definition logic to be consistent with the alias name and assessment period name changes.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Removed null text to streamline stratification logic.

    Measure Section: Stratification

    Source of Change: Measure Lead

  • QDM v5.5 standards update: Added 'relevantDatetime' attribute to QDM datatypes. 'RelevantDatetime' indicates when the action occurred whereas 'authorDatetime' indicates when the action was recorded.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated Clinical Quality Language (CQL) expression to conform with the HL7 Standard: Clinical Quality Language Specification, Release 1 STU 4 (CQL 1.4).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated the names of CQL definitions, functions, and/or aliases for clarification and to align with the CQL Style Guide.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated the term follow-up assessment period to measure assessment period to increase consistency between the header and the logic.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Updated version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-5.0.000). Updated definitions and functions in the MAT Global Common Functions Library to align with standards changes, CQL Style Guide, and to include one new function related to calculating length of hospital stays with observation stays.

    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 Bipolar Disorder (2.16.840.1.113883.3.67.1.101.1.128): Added 5 SNOMEDCT codes (231444002, 767632000, 767633005, 271000119101, 23741000119105) based on review by technical experts to better capture relevant exclusions.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Personality Disorder Emotionally Labile (2.16.840.1.113883.3.67.1.101.1.246): Added 1 SNOMEDCT code (191765005) based on review by technical experts to better capture relevant exclusions.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • ​Value set Contact or Office Visit (2.16.840.1.113762.1.4.1080.5): Added 3 CPT codes (99421, 99422, 99423) based on terminology update. Added 3 HCPCS codes (G2061, G2062, G2063) based on terminology update.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set (2.16.840.1.113883.3.67.1.101.1.246): Renamed grouping value set to Personality Disorder Emotionally Labile to more accurately reflect the codes included in the value set. Renamed extensional value sets (2.16.840.1.113883.3.67.1.101.1.247, 2.16.840.1.113883.3.67.1.101.1.248, 2.16.840.1.113883.3.67.1.101.1.249) within the grouping value set to more accurately reflect the codes included in the value set.

    Measure Section: Terminology

    Source of Change: Measure Lead

Last Updated: Dec 13, 2021