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Adult Major Depressive Disorder (MDD): Suicide Risk Assessment

Last updated: May 9, 2019

CMS Measure ID: CMS161v8
Version: 8
NQF Number: 104e
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 Population:

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

Denominator Statement:

Equals Initial Populationinfo-icon

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:
Measure Scoring: Proportion
Measure Type: Process
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 Populationinfo-icon.

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.

Suicide risk assessments completed via telehealth services can also meet numeratorinfo-icon 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 measuresinfo-icon 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.

Quality ID: 107
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 measure updates.

    Measure Section: Rationale

    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 for 'Suicide Risk Assessment' to reflect clinical expert recommendations.

    Measure Section: Definition

    Source of Change: Measure Lead

  • Updated guidance statement to align with measure changes and per clinical expert recommendations.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Updated guidance statement related to telehealth encounters based on clinical expert recommendations.

    Measure Section: Guidance

    Source of Change: Expert Work Group Review

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

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

Logic

  • 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 ‘Major Depressive Disorder Encounter’ definition to allow for Telehealth Services encounters to meet visit requirements based upon clinical expert recommendations.

    Measure Section: Multiple Sections

    Source of Change: Expert Work Group Review

  • 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 Setinfo-icon

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 Major Depressive Disorder-Active (2.16.840.1.113883.3.526.3.1491): Added 17 SNOMED CT codes.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Psychoanalysis (2.16.840.1.113883.3.526.3.1141): Added SNOMED CT extensional value set (2.16.840.1.113883.3.526.2.1778) including 2 codes.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Psych Visit - Diagnostic Evaluation (2.16.840.1.113883.3.526.3.1492): Added SNOMED CT extensional value set (2.16.840.1.113883.3.526.2.1776) including 5 codes.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Psych Visit - Psychotherapy (2.16.840.1.113883.3.526.3.1496): Added SNOMED CT extensional value set (2.16.840.1.113883.3.526.2.1777) including 13 codes.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Telehealth Services (2.16.840.1.113883.3.464.1003.101.12.1031): Added Telehealth Services.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Direct reference code for Birth date (LOINC Code (21112-8)) 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