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Depression Remission at Twelve Months

eCQMs for 2017 Performance Period

Last updated: May 3, 2018

CMS Measure ID: CMS159v5
Version: 5
NQF Number: 0710
Measure Description:

Patients age 18 and older with major depression or dysthymia and an initial Patient Health Questionnaire (PHQ-9) score greater than nine who demonstrate remission at twelve months (+/- 30 days after an index visit) defined as a PHQ-9 score less than five. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment.
Initial Patient Population:

Patients age 18 and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 score greater than nine during the index visit
Denominator Statement:

Equals Initial Populationinfo-icon
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
Numerator Statement:

Patients who achieved remission at twelve months as demonstrated by a twelve month (+/- 30 days grace period) PHQ-9 score of less than five
Numerator Exclusions:

Not Applicable
Denominator Exceptions:

None
Measure Steward: MN Community Measurement
Domain: Effective Clinical Care
Next Version:
CMS159v6
Improvement Notation:

Higher score indicates better quality
Guidance:

None
Quality ID: 370
High Priority Measure: Yes
Data Submission Method: CMS Web Interface,EHR,Registry
Specialty Measure Set: Mental/Behavioral Health,General Practice/Family Medicine

Specifications

Release Notes

Header

  • Updated the Clinical Recommendation Statement to include all PHQ-9 questions.

    Section: Clinical Recommendation Statement

    Source: Measure Lead

  • Updated Copyright.

    Section: Copyright

    Source: Annual Update

  • Updated the Definition statement to better reflect the measure intent.

    Section: Definition

    Source: Measure Lead

  • ​Simplified the Description statement by changing 'Adult patients' to 'Patients'.

    Section: Description

    Source: Measure Lead

  • The header Description did not indicate that remission at twelve months includes a grace period. Description updated to 'remission at twelve months (+/- 30 days) after an index visit'.

    Section: Description

    Source: Measure Lead

  • Incremented eMeasure Version number.

    Section: eMeasure Version number

    Source: Annual Update

  • ​Simplified the Initial Populationinfo-icon header statement by changing 'Adult patients' to 'Patients'.

    Section: Initial Population

    Source: Measure Lead

  • To better meet the measure intent, updated the Initial Population to reflect the patient age at the index encounter, rather than the age at the Measurement Period.

    Section: Initial Population

    Source: Measure Lead

  • ​Simplified the Numeratorinfo-icon header statement by changing 'Adult patients' to 'Patients'.

    Section: Numerator

    Source: Measure Lead

Logic

  • Replaced datatypes 'Diagnosis, Active; Diagnosis, Inactive; Diagnosis, Resolved' with the re-specified 'Diagnosis' datatype to conform to QDMinfo-icon 4.2 changes.

    Section: Denominator Exclusionsinfo-icon

    Source: QDM Standards

  • To better meet the measure intent and to establish consistency between measures CMS159 and CMS160, revised the Denominator Exclusions timing logic. Timing for 'Intervention, Order' and 'Encounter, Performed' has been updated to '<= 1 year(s) starts before end of Measurement Period'; timing for 'Expired' and 'Diagnoses' has been updated to 'starts before end of Measurement Period'.

    Section: Denominator Exclusions

    Source: Measure Lead

  • To better meet the measure intent, updated the Initial Population to reflect the patient age at the index encounter, rather than the age at the Measurement Period.

    Section: Initial Population

    Source: Measure Lead

  • Replaced datatypes 'Diagnosis, Active; Diagnosis, Inactive; Diagnosis, Resolved' with the re-specified 'Diagnosis' datatype to conform to QDM 4.2 changes.

    Section: QDM Data Elements

    Source: QDM Standards

  • Replaced 'Diagnosis, Active: XXX (ordinality: Principal)' datatype with 'Encounter, Performed: XXX (principal diagnosis)' datatype to conform with QDM 4.2 changes and provide more accurate logic.

    Section: QDM Data Elements

    Source: QDM Standards

  • Value setinfo-icon Face to Face Interaction - No ED (2.16.840.1.113762.1.4.1080.1): OID changed from 2.16.840.1.113762.1.4.1080.2 to 2.16.840.1.113762.1.4.1080.1.

    Section: QDM Data Elements

    Source: None

  • Value set Principal (2.16.840.1.113883.3.117.1.7.1.14): Removed Principal value set from measure.

    Section: QDM Data Elements

    Source: None

  • Replaced datatypes 'Diagnosis, Active; Diagnosis, Inactive; Diagnosis, Resolved' with the re-specified 'Diagnosis' datatype to conform to QDM 4.2 changes.

    Section: QDM Variables

    Source: QDM Standards

  • Replaced 'Diagnosis, Active: XXX (ordinality: Principal)' datatype with 'Encounter, Performed: XXX (principal diagnosis)' datatype to conform with QDM 4.2 changes and provide more accurate logic.

    Section: QDM Variables

    Source: QDM Standards

  • To establish consistency across measures CMS159 and CMS160, updated the encounter timing logic in the $DepressionEncounter, $DepressionF2FSnomed and $DepressionEncounterBH variables from 'starts before start' and 'ends after start' to 'ends before start'. Also updated the corresponding numeric month timings to more accurately reflect the measure intent.

    Section: QDM Variables

    Source: Measure Lead

  • Value set Face to Face Interaction - No ED (2.16.840.1.113762.1.4.1080.1): OID changed from 2.16.840.1.113762.1.4.1080.2 to 2.16.840.1.113762.1.4.1080.1.

    Section: QDM Variables

    Source: None

Value Set

  • Value set Face to Face Interaction - No ED (2.16.840.1.113762.1.4.1080.1): OID changed from 2.16.840.1.113762.1.4.1080.2 to 2.16.840.1.113762.1.4.1080.1.

    Section: None

    Source: None

  • Value set Major Depression (2.16.840.1.113762.1.4.1080.3): Created with 12 ICD9CM codes.

    Section: None

    Source: None

  • Value set Major Depression Including Remission (2.16.840.113883.3.67.1.101.3.2444): Added extensional value set Major Depression (2.16.840.1.113762.1.4.1080.3).

    Section: None

    Source: None

  • Value set Major Depression Including Remission (2.16.840.113883.3.67.1.101.3.2444): Deleted 2 ICD9CM codes (298.0, 311). Added 6 SNOMEDCT codes (251000119105, 281000119103, 321717001, 450714000, 191606003, 68019004).

    Section: None

    Source: None

  • Value set Personality Disorder (2.16.840.1.113883.3.67.1.101.1.246): Deleted 2 ICD10CM codes (F68.8, F69).

    Section: None

    Source: None

  • Value set Principal (2.16.840.1.113883.3.117.1.7.1.14): Removed Principal value set from measure.

    Section: None

    Source: None

External Resources