Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment

Last updated: July 12, 2017

CMS Measure ID: CMS177v4
Version: 4
NQF Number: 1365
Measure Description:

Percentage of patient visits for those patients aged 6 through 17 years with a

diagnosis of major depressive disorder with an assessment for suicide risk

Initial Patient Population:

All patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder

Denominator Statement:

Equals Initial Population

Denominator Exclusions:

None

Numerator Statement:

Patient visits with an assessment for suicide risk

Numerator Exclusions:

Not Applicable

Denominator Exceptions:

None

Measure Steward: American Medical Association-convened Physician Consortium for Performance Improvement(R) (AMA-PCPI)
Domain: Patient Safety
Next Version: Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment
Previous Version: Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment
Measure Score: Proportion
Improvement Notation:

Higher score indicates better quality

Guidance:

A suicide risk assessment should be performed at every visit for major depressive disorder during the measurement period.

This measure is an episode-of-care measure; the level of analysis for this measure is every visit for major depressive disorder during the measurement period. For example, at every visit for MDD, the patient should have a suicide risk assessment.

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.

Specifications

Release Notes

Header

  • Added Item Count field. The Item Count identifies the unit of measure for the eCQM. For this episode-of-care measure, the unit of measure is each visit or encounter.
  • Copyright updated.
  • Definition updated.
  • Disclaimer updated.
  • eMeasure version number incremented.
  • Guidance updated.
  • Reference updated.

Logic

  • Introduced the new timing operator 'overlaps' to replace two lines of logic (AND/AND NOT) or to enforce when an event or set of events occur to meet the measure intent.
  • Introduced variable $MDDEncounters177 to allow re-use of logical expressions and reduce redundancy/complexity.
  • Removed 'Count >= 2' requirement from Initial Population based on clinical input.
  • Removed data element Patient Provider Interaction from measure.
  • Replaced 'ORs' with 'Union of' operator to provide a mechanism for specifying that qualifying event(s) must be a member of at least one of the data elements being unioned (if appropriate for measure intent).
  • Replaced 'Patient Characteristic Birthdate' with 'Age at' operator.

Value Sets

  • Value set Patient Provider Interaction (OID 2.16.840.1.113883.3.526.3.1012): Removed value set from this measure.

External Resources