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EP_CMS177v2_NQF1365_CAMDD_SuicideRisk

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    • Icon: EC eCQMs - Eligible Clinicians EC eCQMs - Eligible Clinicians
    • Resolution: Answered
    • Icon: Minor Minor
    • Measure
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      Response to Question 1: Yes, this is intentional. The values included in "Face to Face Interaction" are a subset of those values included in "Patient Provider Interaction". So technically, the "face to face interaction" is included in the Count >=2: Encounter, Performed. In addition to the values included in the "Face to Face Interaction" value set, the "Patient Provider Interaction" value set also includes virtual interactions such as phone, text, email, etc. While we allow these virtual interactions to be counted as the minimum # of visits with the EP during the measurement period, the encounter where the measure action is evaluated needs to occur at a face-to-face interaction, which is why we only include the latter in the logic phrase that references the diagnosis.

      Response to Question 2: The current HQMF standard has limitations surrounding what is counted in the measure, or the unit of analysis. For example, HQMF can count measures that are looking at counting the patient, but it currently cannot count each visit; HQMF can outline the logic to be evaluated at a single visit and it is up to the implementer to implement the measure in accordance with the correct unit of analysis. This is why the steward has outlined the correct implementation – at every visit – in the guidance section. We recommend that for every denominator eligible patient visit, there be an associated suicide risk assessment.
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      Response to Question 1: Yes, this is intentional. The values included in "Face to Face Interaction" are a subset of those values included in "Patient Provider Interaction". So technically, the "face to face interaction" is included in the Count >=2: Encounter, Performed. In addition to the values included in the "Face to Face Interaction" value set, the "Patient Provider Interaction" value set also includes virtual interactions such as phone, text, email, etc. While we allow these virtual interactions to be counted as the minimum # of visits with the EP during the measurement period, the encounter where the measure action is evaluated needs to occur at a face-to-face interaction, which is why we only include the latter in the logic phrase that references the diagnosis. Response to Question 2: The current HQMF standard has limitations surrounding what is counted in the measure, or the unit of analysis. For example, HQMF can count measures that are looking at counting the patient, but it currently cannot count each visit; HQMF can outline the logic to be evaluated at a single visit and it is up to the implementer to implement the measure in accordance with the correct unit of analysis. This is why the steward has outlined the correct implementation – at every visit – in the guidance section. We recommend that for every denominator eligible patient visit, there be an associated suicide risk assessment.
    • CMS177v1/NQF1365
    • Affects coding for this measure

      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?

            rtallapragada Ramya Tallapragada (Inactive)
            adetola Adetola Adetunji (Inactive)
            Adetola Adetunji (Inactive)
            Cindy Cullen
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