Measure EP_CMS177v2_NQF1365_CAMDD_SuicideRisk:
The denominator requires at least two of the following encounter types:
o Count >= 2 of:
OR: "Encounter, Performed: Office Visit"
OR: "Encounter, Performed: Outpatient Consultation"
OR: "Encounter, Performed: Patient Provider Interaction"
OR: "Encounter, Performed: Psych Visit - Diagnostic Evaluation"
OR: "Encounter, Performed: Psych Visit - Family Psychotherapy"
OR: "Encounter, Performed: Psychoanalysis"
OR: "Encounter, Performed: Group Psychotherapy"
OR: "Encounter, Performed: Psych Visit - Psychotherapy"
during "Measurement Period"
The numerator requires the following:
o AND: "Occurrence A of Intervention, Performed: Suicide Risk Assessment" during
OR: "Occurrence A of Encounter, Performed: Office Visit"
OR: "Occurrence A of Encounter, Performed: Outpatient Consultation"
OR: "Occurrence A of Encounter, Performed: Face-to-Face Interaction"
OR: "Occurrence A of Encounter, Performed: Psych Visit - Diagnostic Evaluation"
OR: "Occurrence A of Encounter, Performed: Psych Visit - Psychotherapy"
OR: "Occurrence A of Encounter, Performed: Psych Visit - Family Psychotherapy"
OR: "Occurrence A of Encounter, Performed: Psychoanalysis"
OR: "Occurrence A of Encounter, Performed: Group Psychotherapy"
So my questions are:
1) The “Face-to-Face Interaction” is included in the numerator but doesn’t count as one of the two encounters during the period. Is this intentional?
2) The numerator details provided above seem to imply that only one single encounter needs to include an intervention to pass the numerator. However, the guidance section states:
“…every visit for major depressive disorder should be counted as a measurable event for the measure calculation. For example, at every visit for MDD, the patient should have a suicide risk assessment.”
This guidance text seems to imply that I should check that there are no occurrences WITHOUT an associated Intervention. Which one is correct? In other words, if there are two encounters but only one related Intervention, should the numerator count?