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

Last updated: May 3, 2018

CMS Measure ID: CMS177v6
Version: 6
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: PCPI(R) Foundation (PCPI[R])
Domain: Patient Safety
Next Version:
Previous Version:
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

  • ​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

  • Updated Clinical Recommendation Statement.

    Measure Section: Clinical Recommendation Statement

    Source of Change: Measure Lead

Logic

  • 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: Measure Lead

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