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

Last updated: May 9, 2019

CMS Measure ID: CMS177v8
Version: 8
NQF Number: 1365e
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 Populationinfo-icon

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
Previous Version:
Measure Scoring: Proportion
Measure Type: Process
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.

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

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(s) or instrument(s) to assess suicide risk will meet numerator performance, so long as the minimum criteria noted above is evaluated. Standardized tools can be mapped to the concept Intervention, Performed: Suicide risk assessment (procedure) included in the numerator logic below, as no individual suicide risk assessment tool or instrument would satisfy the requirements alone.

Quality ID: 382
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 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 to align with clinical expert recommendations.

    Measure Section: Definition

    Source of Change: Expert Work Group Review

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

    Measure Section: Guidance

    Source of Change: Expert Work Group Review

  • Updated guidance statement to align with 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 Psych Visit - Family Psychotherapy (2.16.840.1.113883.3.526.3.1018): Added SNOMED CT extensional value set (2.16.840.1.113883.3.526.2.1780) including 1 code.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Group Psychotherapy (2.16.840.1.113883.3.526.3.1187): Added SNOMED CT extensional value set (2.16.840.1.113883.3.526.2.1779) including 1 code.

    Measure Section: Terminology

    Source of Change: Annual Update

  • 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