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Depression Remission at Twelve Months

Last updated: May 9, 2019

CMS Measure ID: CMS159v8
Version: 8
NQF Number: 710e
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 Patient 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 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

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
Previous Version:
Measure Scoring: Proportion
Measure Type: Outcome
Improvement Notation:

Higher score indicates better quality

Guidance:

None

Quality ID: 370
Meaningful Measure: Prevention, Treatment, and Management of Mental Health

Specifications

Release Notes

Header

  • Updated eCQMinfo-icon version number.

    Measure Section: eCQM Version number

    Source of Change: Measure Lead

  • Added 'e' to NQFinfo-icon 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 rationale statement to align with most recent literature and revised text to include the acronym MDE for major depressive episode.

    Measure Section: Rationale

    Source of Change: Measure Lead

  • Updated clinical recommendation statement by deleting definitions for Response, Remission, Recovery, Relapse, and Recurrence to improve clarity.

    Measure Section: Clinical Recommendation Statement

    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 with addition of text for Index Event Date to align with measure intent: '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).'

    Measure Section: Definition

    Source of Change: ONC Project Tracking System (JIRA)info-icon: CQMinfo-icon-3045

  • Updated initial populationinfo-icon statement with addition of text to align with measure intent: 'or up to 7 days prior to.'

    Measure Section: Initial Population

    Source of Change: ONC Project Tracking System (JIRA): CQM-3045

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

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

Logic

  • Revised logic to allow the PHQ-9/PHQ-9M depression assessment to be administered during the index encounter or up to 7 days prior to the encounter.

    Measure Section: Initial Population

    Source of Change: ONC Project Tracking System (JIRA): CQM-3045

  • Revised logic to replace the direct reference code with the 'PHQ 9 and PHQ 9M Tools' value setinfo-icon to improve alignmentinfo-icon with measure intent.

    Measure Section: Numeratorinfo-icon

    Source of Change: Measure Lead

  • Updated the names of Clinical Quality Language (CQL)info-icon definitions, functions, and/or aliases for clarification and to align with CQL Style Guideinfo-icon.

    Measure Section: Definitions and Functions

    Source of Change: Standards Update

  • Updated Clinical Quality Language (CQL) expression to conform with the HL7info-icon Standard: Clinical Quality Language Specificationinfo-icon, Release 1 STUinfo-icon 3 (CQL 1.3).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated definitions and functions in the Measure Authoring Tool (MATinfo-icon) 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 VSACinfo-icon is the source of truth for the value set content, please visit the VSAC for downloads of current value setsinfo-icon.

  • Value set (2.16.840.1.113883.3.600.1.1579): Renamed to Palliative or Hospice Care.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set PHQ 9 and PHQ 9M Tools (2.16.840.1.113883.3.67.1.101.1.263): Added PHQ 9 and PHQ 9M Tools.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Bipolar Disorder (2.16.840.1.113883.3.67.1.101.1.128): Added 8 SNOMED CT codes (133091000119105, 261000119107, 723903001, 723905008, 765176007, 767631007, 767635003, 767636002).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Personality Disorder (2.16.840.1.113883.3.67.1.101.1.246): Added 6 SNOMED CT codes (21586000, 24315006, 33693007, 430744005, 430751001, 76105009).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Schizophrenia or Psychotic Disorder (2.16.840.1.113883.3.464.1003.105.12.1104): Added 4 SNOMED CT codes (31027006, 36158005, 55736003, 88975006).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Major Depression Including Remission (2.16.840.113883.3.67.1.101.3.2444): Added 2 SNOMED CT codes (16264901000119109, 104851000119103).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Replaced direct reference code 'Patient Health Questionnaire 9 item (PHQ-9) total score [Reported]' using 'LOINC Code (44261-6)' with value set 'PHQ 9 and PHQ 9M Tools' (2.16.840.1.113883.3.67.1.101.1.263).

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Direct reference code for Birth date (LOINC Code (21112-8)) now displayed in Human Readable.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Direct reference code for Dead (finding) (SNOMED CT Code (419099009)) now displayed in Human Readable.

    Measure Section: Terminology

    Source of Change: Annual Update

  • ​Removed code systeminfo-icon versions from direct reference codes. Please refer to Appendix A of the Electronic Clinical Quality Measureinfo-icon Logic and Implementation Guidance document for a list of code system versions used in the eCQM specificationsinfo-icon for 2020 reporting/performance.

    Measure Section: Terminology

    Source of Change: Standards Update

  • Standardized purpose statement language in value sets across eCQMsinfo-icon. 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

External Resources