seeking clarification of CMS 177 - Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment.

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    • Type: EC eCQMs - Eligible Clinicians
    • Resolution: Done
    • Priority: Moderate
    • Component/s: Guidance
    • 207-662-4264
    • MaineHealth
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      ​The list of applicable encounters for this measure is identified in the variable, as noted within the issue above. However, to satisfy the measure logic in both the initial population/denominator and the numerator, a specific occurrence of one of those types of visits is evaluated. This would mean that, assuming the measurement period was calendar year 2016, a 12 year old patient who had a diagnosis of MDD starting March 15, 2016, which continued into the following year AND had an office visit on March 15, 2016, and a psych visit-diagnostic evaluation on July 15, 2016, should have suicide risk assessments performed at both of those visits. If a suicide risk assessment was only performed at one of the two visits, the measure would be met for ½ of the eligible denominator population (50% pass rate). For additional information on interpreting the QDM – specifically, variables and occurrencing – please visit the eCQI Resource Center (https://ecqi.healthit.gov/qdm) to review the QDM. Please note, for the measure version noted within this issue, QDM 4.2 was utilized.
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      ​The list of applicable encounters for this measure is identified in the variable, as noted within the issue above. However, to satisfy the measure logic in both the initial population/denominator and the numerator, a specific occurrence of one of those types of visits is evaluated. This would mean that, assuming the measurement period was calendar year 2016, a 12 year old patient who had a diagnosis of MDD starting March 15, 2016, which continued into the following year AND had an office visit on March 15, 2016, and a psych visit-diagnostic evaluation on July 15, 2016, should have suicide risk assessments performed at both of those visits. If a suicide risk assessment was only performed at one of the two visits, the measure would be met for ½ of the eligible denominator population (50% pass rate). For additional information on interpreting the QDM – specifically, variables and occurrencing – please visit the eCQI Resource Center ( https://ecqi.healthit.gov/qdm ) to review the QDM. Please note, for the measure version noted within this issue, QDM 4.2 was utilized.
    • CMS177v5/NQF1365

      The guidance for CMS 177 - Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment states: "A suicide risk assessment should be performed at every visit for major depressive disorder during the measurement period."

      Am I correct in interpreting this to mean the following:
      1. The numerator should include only encounters (of the types listed below) for major depressive disorder during which a suicide risk assessment was administered
      2. The denominator would include all encounters (of the types listed below) for major depressive disorder

      • $MDDEncounters177 =
        • Union of:
        o "Encounter, Performed: Office Visit"
        o "Encounter, Performed: Outpatient Consultation"
        o "Encounter, Performed: Face-to-Face Interaction"
        o "Encounter, Performed: Psych Visit - Diagnostic Evaluation"
        o "Encounter, Performed: Psych Visit - Family Psychotherapy"
        o "Encounter, Performed: Psychoanalysis"
        o "Encounter, Performed: Group Psychotherapy"
        o "Encounter, Performed: Psych Visit - Psychotherapy"
        o during "Measurement Period"

            Assignee:
            Mathematica EC eCQM Team (Inactive)
            Reporter:
            Laura Boldebook (Inactive)
            Laura Boldebook (Inactive)
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              Created:
              Updated:
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