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Adult Major Depressive Disorder (MDD): Suicide Risk Assessment

General eCQM Information

CMS Measure ID CMS161v10
NQF Number 0104e
Measure Description

All patient visits during which a new diagnosis of MDD or a new diagnosis of recurrent MDD was identified for patients aged 18 years and older with a suicide risk assessment completed during the visit

Initial Population Patient visits during which a new diagnosis of MDD, single or recurrent episode, was identified
Denominator Statement

Equals Initial Population

Denominator Exclusions

None

Numerator Statement

Patient visits during which a new diagnosis of MDD, single or recurrent episode, was identified and a suicide risk assessment was completed during the visit

Numerator Exclusions

Not Applicable

Denominator Exceptions

None

Measure Steward Mathematica
Domain Effective Clinical Care
Measure Scoring Proportion
Measure Type Process
Improvement Notation

Higher score indicates better quality

Guidance

This eCQM is an episode-based measure and should be reported for each instance of a new or recurrent episode of major depressive disorder (MDD) during the measurement period. This measure should be reported for each eligible encounter during which a new or recurrent episode of MDD is identified.

As the guidelines state, it is important to assess for additional factors which may increase or decrease suicide risk, such as presence of additional symptoms (e.g., psychosis, severe anxiety, hopelessness, severe chronic pain); presence of substance abuse, history and seriousness of previous attempts, particularly, recent suicidal behavior, current stressors and potential protective factors (e.g., positive reasons for living, strong social support), family history of suicide or mental illness or recent exposure to suicide, impulsivity and potential for risk to others, including history of violence or violent or homicidal ideas, plans, or intentions, and putting one's affairs in order (e.g., giving away possessions, writing a will). In addition, although the measure focuses on the initial visit, it is critical that suicide risk be monitored especially for the 90 days following the initial visit and throughout MDD treatment.

It is expected that a suicide risk assessment will be completed at the visit during which a new diagnosis is made or at the visit during which a recurrent episode is first identified (i.e., at the initial evaluation). For the purposes of this measure, an episode of major depressive disorder (MDD) would be considered to be recurrent if a patient has not had an MDD-related encounter in the past 105 days. If there is a gap of 105 or more days between visits for major depressive disorder (MDD), that would imply a recurrent episode. The 105-day look-back period is an operational provision and not a clinical recommendation, or definition of relapse, remission, or recurrence.

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.

Use of a standardized tool(s) or instrument(s) to assess suicide risk will meet numerator performance. Standardized tools can be mapped to the concept "Intervention, Performed": "Suicide risk assessment (procedure)" included in the numerator logic below.

The logic statement for the age requirement, as written, captures patients who turn 18 years old during the measurement period so that these patients are included in the measure, so long as the minimum criteria noted above is evaluated. To ensure all patients with major depressive disorder (MDD) are assessed for suicide risk, there are two clinical quality measures addressing suicide risk assessment; CMS 177 covers children and adolescents aged 6 through 17, and CMS 161 covers the adult population aged 18 years and older, 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 (https://ecqi.healthit.gov/qdm) for more information on the QDM.

Quality ID 107
Meaningful Measure Prevention, Treatment, and Management of Mental Health
Telehealth Eligible Yes
Previous Version

Release Notes

Header

  • Updated the eCQM version number.

    Measure Section: eCQM Version Number

    Source of Change: Annual Update

  • Updated Measure Steward.

    Measure Section: Measure Steward

    Source of Change: Measure Lead

  • Updated Measure Developer.

    Measure Section: Measure Developer

    Source of Change: Measure Lead

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated disclaimer.

    Measure Section: Disclaimer

    Source of Change: Annual Update

  • Updated Rationale section in measure header to include evidence from current literature.

    Measure Section: Rationale

    Source of Change: Measure Lead

  • Updated formatting of Clinical Recommendations Statement in measure header for better readability and to clarify the organization of this section.

    Measure Section: Clinical Recommendation Statement

    Source of Change: Measure Lead

  • Updated references.

    Measure Section: Reference

    Source of Change: Annual Update

  • Added clarifying language to guidance section of episode-based measures to define the episode.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Updated Guidance section in measure header to standardize language about episode-based reporting.

    Measure Section: Guidance

    Source of Change: Annual Update

Logic

  • Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-6.2.000). Updated the 'Inpatient Encounter' definition to include a 'day of' timing clarification. Added the following timing functions: Normalize Interval, Has Start, Has End, Latest, Latest Of, Earliest, and Earliest Of. Please see individual measure details for application of specific timing functions.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Added new NormalizeInterval function to timing attributes to decrease implementation burden due to variable use of timing attributes for select QDM data types. The NormalizeInterval function was applied, where applicable, for the following data elements: Assessment, Performed; Device, Applied; Diagnostic Study, Performed; Intervention, Performed; Laboratory Test, Performed; Medication, Administered; Medication, Dispensed; Physical Exam, Performed; Procedure, Performed; Substance, Administered.

    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): Added 2 SNOMED CT codes (10811121000119102, 191604000) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

Last Updated: Jul 08, 2021