Adult Major Depressive Disorder (MDD): Suicide Risk Assessment

Last updated: June 9, 2017

CMS Measure ID: CMS161v5
Version: 5
NQF Number: 0104
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 Patient Population:

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

Denominator Statement:

Equals Initial Population

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
Next Version: Adult Major Depressive Disorder (MDD): Suicide Risk Assessment
Previous Version: Adult Major Depressive Disorder (MDD): Suicide Risk Assessment
Improvement Notation:

Higher score indicates better quality

Guidance:

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 (ie, at the initial evaluation). This measure is an episode-of-care measure and should be reported for each instance of a new or recurrent episode of MDD; every new or recurrent episode will count separately in the Initial Population.

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.

The measure description outlined in the header for this measure states, 'patients aged 18 years and older' while the logic statement states, '>= 17 year(s) at: Measurement Period'. The logic statement, as written, captures patients who turn 18 years old during the measurement period so that these patients are included in the measure. To ensure all patients with major depressive disorder (MDD) are assessed for suicide risk, there are two clinical quality measures 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.

Quality ID: 107
High Priority Measure: No
Data Submission Method: EHR

Specifications

Release Notes

Header

  • ​Updated Copyright.

    Section: Copyright

    Source: Annual Update

  • Updated Disclaimer.

    Section: Disclaimer

    Source: Measure Lead

  • Incremented eMeasure Version number.

    Section: eMeasure Version number

    Source: Annual Update

  • Updated Measure Developer.

    Section: Measure Developer

    Source: Measure Lead

  • Updated Measure Steward.

    Section: Measure Steward

    Source: Measure Lead

Logic

  • Replaced datatypes 'Diagnosis, Active; Diagnosis, Inactive; Diagnosis, Resolved' with the re-specified 'Diagnosis' datatype to conform to QDM 4.2 changes.

    Section: Initial Population

    Source: QDM Standards

  • Replaced datatypes 'Diagnosis, Active; Diagnosis, Inactive; Diagnosis, Resolved' with the re-specified 'Diagnosis' datatype to conform to QDM 4.2 changes.

    Section: QDM Data Elements

    Source: QDM Standards

External Resources