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

General eCQM Information

CMS Measure ID CMS177v9
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

This eCQM is an episode-based measure. A suicide risk assessment should be performed at every visit for major depressive disorder during the measurement period.

In recognition of the growing use of integrated and team-based care, the diagnosis of depression and the assessment for suicide risk need not be performed by the same provider or clinician.

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.

This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM.

Quality ID 382
Meaningful Measure Prevention, Treatment, and Management of Mental Health
Telehealth Eligible Yes
Next Version
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Release Notes

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

  • Updated disclaimer.

    Measure Section: Disclaimer

    Source of Change: Standards Update

  • Updated rationale to align with American Psychological Association (APA) formatting.

    Measure Section: Rationale

    Source of Change: Measure Lead

  • Updated reference to align with APA formatting.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Added guidance, based upon technical expert panel feedback, to recognize the appropriateness of team-based care for this measure.

    Measure Section: Guidance

    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

Logic

  • 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

  • QDM v5.5 standards update: Modified 'Encounter, Performed' diagnoses attribute to reference the diagnosis as a value set or direct reference code.

    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 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 Major Depressive Disorder Active (2.16.840.1.113883.3.526.3.1491): Deleted 10 ICD-9-CM codes (296.20, 296.21, 296.22, 296.23, 296.24, 296.30, 296.31, 296.32, 296.33, 296.34). Removed ICD-9 codes from all measures that do not have lookback periods or removed ICD-9 codes from all measures with lookback period for which the ICD-9 codes were no longer relevant.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Outpatient Consultation (2.16.840.1.113883.3.464.1003.101.12.1008): Deleted 1 SNOMED CT code (17436001) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Psych Visit - Diagnostic Evaluation (2.16.840.1.113883.3.526.3.1492): Deleted 1 SNOMED CT code (32537008) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Telehealth Services (2.16.840.1.113883.3.464.1003.101.12.1031): Deleted 2 CPT codes (98969, 99444) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Removed ICD-9-CM extensional value sets from applicable Groupings due to ICD-9-CM no longer being maintained and the measure not requiring historical lookback period.

    Measure Section: Terminology

    Source of Change: Measure Lead

Last Updated: May 05, 2021