Bipolar Disorder and Major Depression: Appraisal for alcohol or chemical substance use

Last updated: May 3, 2018

CMS Measure ID: CMS169v3
Version: 3
NQF Number: 0110
Measure Description:

Percentage of patients with depression or bipolar disorder with evidence of an initial assessment that includes an appraisal for alcohol or chemical substance use.

Initial Patient Population:

Patients 18 years of age or older at the start of the measurement period.

Denominator Statement:

Patients in the Initial Patient Population with a new diagnosis of unipolar depression or bipolar disorder during the first 323 days of the measurement period, and evidence of treatment for unipolar depression or bipolar disorder within 42 days of diagnosis. The existence of a 'new diagnosis' is established by the absence of diagnoses and treatments of unipolar depression or bipolar disorder during the 180 days prior to the diagnosis.

Denominator Exclusions:


Numerator Statement:

Patients in the denominator with evidence of an assessment for alcohol or other substance use following or concurrent with the new diagnosis, and prior to or concurrent with the initiation of treatment for that diagnosis.

(Note: the endorsed measure calls for the assessment to be performed prior to discussion of the treatment plan with the patient, but the current approach was considered more feasible in an EHR setting. The “Assessment for Alcohol or Other Drug Use” required in the numerator is meant to capture a provider's assessment of the patient's symptoms of substance use. The essence of the measure is to avoid treating the patient for unipolar depression or bipolar disorder without an assessment of their use of alcohol or other drugs.)

Numerator Exclusions:


Denominator Exceptions:


Measure Steward: Center for Quality Assessment & Improvement in Mental Health (CQAIMH)
Domain: Effective Clinical Care
Next Version:
Measure Score: Proportion
Score Type: Process
Improvement Notation:

Higher score indicates better quality


The intent of the measure is that the assessment be performed for a single episode for each patient. Due to current limitations of the eMeasure specification system, it is possible for there to be up to two treatment episodes per patient, identified through up to two index episodes. As a result, the numerator criteria of this measure can be satisfied if a substance use assessment is performed within either treatment episode. Future versions of the measure should address this issue.


External Resources