download chevron-down chevron-right chevron-with-circle-down chevron-with-circle-up check circle-with-minus circle-with-plus export help-with-circle inbox link mail old-phone star-outlined star user v-card close close close Back to top
Top

Depression Utilization of the PHQ-9 Tool

Last updated: September 14, 2018

CMS Measure ID: CMS160v7
Version: 7
NQF Number: 0712
Measure Description:

The percentage of adolescent patients 12 to 17 years of age and adult patients age 18 and older with the diagnosis of major depression or dysthymia who have a completed PHQ-9 during each applicable 4 month period in which there was a qualifying depression encounter

Initial Patient Population:

Adolescent patients 12 to 17 years of age and adult patients 18 years of age and older with an office visit and the diagnosis of major depression or dysthymia during the four month period

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 have a PHQ-9 or PHQ-9M tool administered at least once during the four-month period

Numerator Exclusions:

Not applicable

Denominator Exceptions:

None

Measure Steward: MN Community Measurement
Domain: Effective Clinical Care
Previous Version:
Improvement Notation:

Higher scores indicate better quality

Guidance:

If a patient has a qualifying diagnosis and encounter in more than one of the 4 month periods within the measurement year, the patient must be counted (denominatorinfo-icon and numeratorinfo-icon) in each qualifying 4 month period. For example, a patient could be counted in the first and third 4 month periods.

Quality ID: 371
Meaningful Measure: Prevention, Treatment, and Management of Mental Health

Specifications

Release Notes

Header

  • Updated Version Number.

    Measure Section: eMeasure Version number

    Source of Change: Measure Lead

  • ​Replaced qualifying visit, with qualifying depression encounter in the Measure Description to better align with measure intent.

    Measure Section: Description

    Source of Change: Measure Lead

  • Added an adolescent population (12 to 17 years of age) to the measure and stratificationinfo-icon of the denominatorinfo-icon population (Strata 1: 12 to 17 years of age and Strata 2: 18 years of age and older) to better align with measure intent.

    Measure Section: Description

    Source of Change: Measure Lead

  • Updated Copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Added an adolescent population (12 to 17 years of age) to the measure and stratification of the denominator population (Strata 1: 12 to 17 years of age and Strata 2: 18 years of age and older) to better align with measure intent.

    Measure Section: Stratification

    Source of Change: Measure Lead

  • Added an adolescent population (12 to 17 years of age) to the measure and stratification of the denominator population (Strata 1: 12 to 17 years of age and Strata 2: 18 years of age and older) to better align with measure intent.

    Measure Section: Rationale

    Source of Change: Measure Lead

  • Added an adolescent population (12 to 17 years of age) to the measure and stratification of the denominator population (Strata 1: 12 to 17 years of age and Strata 2: 18 years of age and older) to better align with measure intent.

    Measure Section: Clinical Recommendation Statement

    Source of Change: Measure Lead

  • Added an adolescent population (12 to 17 years of age) to the measure and stratification of the denominator population (Strata 1: 12 to 17 years of age and Strata 2: 18 years of age and older) to better align with measure intent.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Added an adolescent population (12 to 17 years of age) to the measure and stratification of the denominator population (Strata 1: 12 to 17 years of age and Strata 2: 18 years of age and older) to better align with measure intent.

    Measure Section: Initial Populationinfo-icon

    Source of Change: Measure Lead

  • Added an adolescent population (12 to 17 years of age) to the measure and stratification of the denominator population (Strata 1: 12 to 17 years of age and Strata 2: 18 years of age and older) to better align with measure intent.

    Measure Section: Numeratorinfo-icon

    Source of Change: Measure Lead

Logic

  • Added an adolescent population (12 to 17 years of age) to the measure and stratification of the denominator population (Strata 1: 12 to 17 years of age and Strata 2: 18 years of age and older) to better align with measure intent.

    Measure Section: Initial Population

    Source of Change: Measure Lead

  • Removed the use of the 'Principal Diagnosis' attribute for the Psychiatric Visit. Added diagnoses of Schizophrenia or Psychotic Disorder and Pervasive Developmental Disorder to Denominator Exclusionsinfo-icon. This change allows more accurate identification of the patient population.

    Measure Section: Initial Population

    Source of Change: JIRAinfo-icon (CQMinfo-icon-2613)

  • Replaced the Office Visit (2.16.840.1.113883.3.464.1003.101.12.1001), Psych Visit (2.16.840.113883.3.67.1.101.3.2445) and Face to Face Interaction – No ED (2.16.840.1.113762.1.4.1080.1) value setsinfo-icon with the new Contact or Office Visit (2.16.840.1.113762.1.4.1080.5) value setinfo-icon to more accurately identify encounters with patients being treated for depression.

    Measure Section: Initial Population

    Source of Change: Measure Lead

  • Removed the use of the 'Principal Diagnosis' attribute for the Psychiatric Visit. Added diagnoses of Schizophrenia or Psychotic Disorder and Pervasive Developmental Disorder to Denominator Exclusions. This change allows more accurate identification of the patient population.

    Measure Section: Denominator

    Source of Change: JIRA (CQM-2613)

  • Replaced the Office Visit (2.16.840.1.113883.3.464.1003.101.12.1001), Psych Visit (2.16.840.113883.3.67.1.101.3.2445) and Face to Face Interaction – No ED (2.16.840.1.113762.1.4.1080.1) value sets with the new Contact or Office Visit (2.16.840.1.113762.1.4.1080.5) value set to more accurately identify encounters with patients being treated for depression.

    Measure Section: Denominator

    Source of Change: Measure Lead

  • Modified the relationship logic of the denominator exclusions so they are associated with the respective encounter or 4-month assessment period to better align with measure intent.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Removed the use of the 'Principal Diagnosis' attribute for the Psychiatric Visit. Added diagnoses of Schizophrenia or Psychotic Disorder and Pervasive Developmental Disorder to Denominator Exclusions. This change allows more accurate identification of the patient population.

    Measure Section: Denominator Exclusions

    Source of Change: JIRA (CQM-2613)

  • Replaced the Office Visit (2.16.840.1.113883.3.464.1003.101.12.1001), Psych Visit (2.16.840.113883.3.67.1.101.3.2445) and Face to Face Interaction – No ED (2.16.840.1.113762.1.4.1080.1) value sets with the new Contact or Office Visit (2.16.840.1.113762.1.4.1080.5) value set to more accurately identify encounters with patients being treated for depression.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Added an adolescent population (12 to 17 years of age) to the measure and stratification of the denominator population (Strata 1: 12 to 17 years of age and Strata 2: 18 years of age and older) to better align with measure intent.

    Measure Section: Stratification

    Source of Change: Measure Lead

  • Removed the use of the 'Principal Diagnosis' attribute for the Psychiatric Visit. Added diagnoses of Schizophrenia or Psychotic Disorder and Pervasive Developmental Disorder to Denominator Exclusions. This change allows more accurate identification of the patient population.

    Measure Section: Stratification

    Source of Change: JIRA (CQM-2613)

  • Replaced the Office Visit (2.16.840.1.113883.3.464.1003.101.12.1001), Psych Visit (2.16.840.113883.3.67.1.101.3.2445) and Face to Face Interaction – No ED (2.16.840.1.113762.1.4.1080.1) value sets with the new Contact or Office Visit (2.16.840.1.113762.1.4.1080.5) value set to more accurately identify encounters with patients being treated for depression.

    Measure Section: Stratification

    Source of Change: Measure Lead

  • Added supplemental timing attributes to most datatypes in QDMinfo-icon 5.3 to facilitate accurate retrieval of time related information within CQLinfo-icon logic. Timing attributes now include a time interval, such as prevalence period or relevant period, and/or actual time of documentation with Author Datetime. Relevant period is the general method to describe start and stop times for datatypes. Prevalence period is used for some datatypes to more accurately define onset and abatement times.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Assigned cardinality to each attribute to be more explicit in guiding specificationinfo-icon and implementation of QDM data elements. Cardinality refers to the number of instances of the attribute that can be included in the measure description. Cardinality for most attributes is 0.. 1 (i.e., can occur up to 1 time), but some attributes have a cardinality of 0.. * (i.e., can occur multiple times).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • CQL libraries contain sets of CQL definitions, or CQL expression statements. A context statement, patient or population, can now be used in a CQL library to clearly establish how the subsequent list of CQL expressions will be interpreted. A 'Population' context will interpret the CQL expression with reference to the entire population of the item being counted, patients or encounters. A 'Patient' context will interpret the CQL expression with reference to a single patient. Context statements are not required, but one or more context statements may be used within a library to help clarify how the CQL expressions will be interpreted. Patient context is the default if none is specified.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Replaced measure-defined definitions with similar definitions and functions from CQL shared libraries for consistency across measures.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated measure logic from Quality Data Model (QDM)-based logic to Clinical Quality Language (CQL)-based logic. Information on CQL can be found at the eCQI Resource centerinfo-icon (https://ecqi.healthit.gov/cql). Information about specific versions of the new standards in use for CMS reporting periods can be found at the eCQI Resource Center (https://ecqi.healthit.gov/ecqm-tools-key-resources). Switching from QDM to CQL brings with it many changes, as well as enhanced expression capability, but only those changes with significant impact will be outlined in technical release notes. For example, in the case of timing operators, changes may only be summarized if those changes impact the measure calculation.

    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 sets.

  • Value set Care Services in Long-Term Residential Facility (2.16.840.1.113883.3.464.1003.101.12.1014): Added SNOMEDCT extensional value set (2.16.840.1.113883.3.464.1003.101.11.1262) including 2 codes.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Major Depression Including Remission (2.16.840.113883.3.67.1.101.3.2444): Added 4 SNOMEDCT codes (16265951000119109, 16266831000119100, 16266991000119108, 726772006).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Personality Disorder (2.16.840.1.113883.3.67.1.101.1.246): Deleted 17 ICD9CM codes. Deleted 10 ICD10CM codes (F21, F60.0, F60.1, F60.2, F60.5, F60.6, F60.7, F60.81, F60.89, F60.9). Deleted 24 SNOMEDCT codes.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Contact or Office Visit (2.16.840.1.113762.1.4.1080.5): Added Contact or Office Visit.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Schizophrenia or Psychotic Disorder (2.16.840.1.113883.3.464.1003.105.12.1104): Added Schizophrenia or Psychotic Disorder.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Pervasive Developmental Disorder (2.16.840.1.113883.3.464.1003.105.12.1152): Added Pervasive Developmental Disorder.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Payer (2.16.840.1.114222.4.11.3591): Added 11 SOP codes (299, 32127, 32128, 391, 517, 524, 614, 621, 622, 623, 629) and deleted 3 SOP codes (63, 64, 69).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Replaced the Office Visit, Psych Visit and Face to Face Interaction – No ED value sets with the new Contact or Office Visit value set to more accurately identify encounters with patients being treated for depression.

    Measure Section: QDM Data Elements

    Source of Change: Measure Lead

  • Replaced LOINC single code value sets with direct referenced codes. A direct referenced code is a single concept code that is used to describe a clinical element directly within the logic. The use of direct referenced codes replaces the need for single code value sets. Measures using other code systems in single value sets may optionally transition to direct referenced codes.

    Measure Section: QDM Data Elements

    Source of Change: Standards Update

  • Value set Schizophrenia or Psychotic Disorder (2.16.840.1.113883.3.464.1003.105.12.1104): Added 3 SNOMEDCT codes (191536002, 191537006, 191540006).

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

  • Value set Payer (2.16.840.1.114222.4.11.3591): Deleted 1 SOP code (24).

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

  • Value set Major Depression Including Remission (2.16.840.113883.3.67.1.101.3.2444): Added 2 SNOMEDCT codes (10811121000119102, 10811161000119107).

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

External Resources