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Type: EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals
Resolution: Done
Priority: Major
Component/s: Measure
Labels:
None

Solution:

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Thank you for your question. For CMS 161, Adult and Adult Major Depressive Disorder (MDD): Suicide Risk Assessment, in order for a patient to be included in the initial population, they must have an encounter during which the major depressive disorder (MDD) diagnosis is addressed. Within the measure logic, the MDD diagnosis is captured as an attribute of the encounter during the measurement period. A start time and stop time for the diagnosis may not be captured. In addition, the MDD diagnosis may not necessarily come from the problem list. Instead, the MDD diagnosis may come from billing data, or the “encounter diagnosis” to determine if the MDD diagnosis was addressed during a specific encounter to determine if the numerator action is applicable. Therefore, the patient scenarios provided don’t necessarily align with how the measure is now specified, as we no longer utilize the QDM Category Diagnosis, where the onset and/or abatement (or absence of one) is important. It would be presumed only active diagnoses would be applicable as an “encounter diagnosis,” to be addressed during a specific encounter.

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Thank you for your question. For CMS 161, Adult and Adult Major Depressive Disorder (MDD): Suicide Risk Assessment, in order for a patient to be included in the initial population, they must have an encounter during which the major depressive disorder (MDD) diagnosis is addressed. Within the measure logic, the MDD diagnosis is captured as an attribute of the encounter during the measurement period. A start time and stop time for the diagnosis may not be captured. In addition, the MDD diagnosis may not necessarily come from the problem list. Instead, the MDD diagnosis may come from billing data, or the “encounter diagnosis” to determine if the MDD diagnosis was addressed during a specific encounter to determine if the numerator action is applicable. Therefore, the patient scenarios provided don’t necessarily align with how the measure is now specified, as we no longer utilize the QDM Category Diagnosis, where the onset and/or abatement (or absence of one) is important. It would be presumed only active diagnoses would be applicable as an “encounter diagnosis,” to be addressed during a specific encounter.
Measure Type:
EP
Measure Title:
Adult Major Depressive Disorder (MDD): Suicide Risk Assessment

Initial Population
• "New or Recurrent Major Depressive Disorder Encounter" NewOrRecurrentMDDEncounter
o with ["Patient Characteristic Birthdate"] BirthDate
o such that Global."CalendarAgeInYearsAt"(BirthDate.birthDatetime, start of "Measurement Period")>=17

Definitions

New or Recurrent Major Depressive Disorder Encounter
•
o "Major Depressive Disorder Encounter" NewOrRecurrentMDDEncounter
o without "Major Depressive Disorder Encounter" PriorMDDEpisodeEncounter
o such that PriorMDDEpisodeEncounter !~ NewOrRecurrentMDDEncounter
o and PriorMDDEpisodeEncounter.relevantPeriod ends 104 days or less before day of start of NewOrRecurrentMDDEncounter.relevantPeriod
o where NewOrRecurrentMDDEncounter.relevantPeriod during "Measurement Period"

Major Depressive Disorder Encounter
•
o ( ["Encounter, Performed": "Psych Visit - Diagnostic Evaluation"]
o union ["Encounter, Performed": "Emergency Department Visit"]
o union ["Encounter, Performed": "Office Visit"]
o union ["Encounter, Performed": "Outpatient Consultation"]
o union ["Encounter, Performed": "Psych Visit - Psychotherapy"]
o union ["Encounter, Performed": "Psychoanalysis"] ) ValidEncounter
o where exists ( ValidEncounter.diagnoses EncounterDiagnosis
o where EncounterDiagnosis in "Major Depressive Disorder-Active"
o )

Consider below patient in denominator for following :

Patient P1: