Adult Major Depressive Disorder (MDD): Suicide Risk Assessment

Last updated: October 25, 2017

CMS Measure ID: CMS161v6
Version: 6
NQF Number: 0104
Measure Description:

Percentage of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified

Initial Patient Population:

All patients aged 18 years and older with a diagnosis of major depressive disorder (MDD)

Denominator Statement:

Equals Initial Population

Denominator Exclusions:

None

Numerator Statement:

Patients with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified

Numerator Exclusions:

Not Applicable

Denominator Exceptions:

None

Measure Steward: PCPI(R) Foundation (PCPI[R])
Domain: Effective Clinical Care
Previous Version: Adult Major Depressive Disorder (MDD): Suicide Risk Assessment
Improvement Notation:

Higher score indicates better quality

Guidance:

This measure is an episode-of-care measure and should be reported for each instance of a new or recurrent episode of major depressive disorder (MDD); every new or recurrent episode will count separately in the Initial Population.

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 (ie, at the initial evaluation). For the purposes of this measure, an episode of 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 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.

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

The measure description outlined in the header for this measure states, 'patients aged 18 years and older' while the logic statement states, '>= 17 year(s) at: Measurement Period'. The logic statement, as written, captures patients who turn 18 years old during the measurement period so that these patients are included in the measure. 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.

Specifications

Release Notes

Header

  • ​Incremented eMeasure Version number.

    Measure Section: eMeasure Version number

    Source of Change: Measure Lead

  • ​Updated Copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • ​Updated Disclaimer.

    Measure Section: Disclaimer

    Source of Change: Measure Lead

  • Added Guidance per clinical experts' recommendations to incorporate a look-back period to more definitively identify recurrent episodes of Major Depressive Disorder.

    Measure Section: Guidance

    Source of Change: Measure Lead

Logic

  • Added an AND/AND NOT logic structure to more definitively identify recurrent episodes with a look-back period, per clinical experts' recommendations.

    Measure Section: Initial Population

    Source of Change: JIRA (CQM-1915)

  • Removed data element 'Diagnosis: Major Depressive Disorder-Active' from the Initial Population logic. Modified variable logic by adding an attribute for diagnosis of MDD to ensure the encounter(s) are MDD related.

    Measure Section: Initial Population

    Source of Change: JIRA (CQM-1915)

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 1 ICD10CM code (F32.89).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

External Resources