SRA-A and SRA-BH-C NQF Measures Do Not Contain SRA Codes

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    • Type: Hosp Inpt eCQMs - Hospital Inpatient eCQMs
    • Resolution: Answered
    • Priority: Moderate
    • Component/s: None
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      Thank you for your question. There are three eCQMs which utilize suicide risk assessments: Adult Major Depressive Disorder (MDD): Suicide Risk Assessment, (CMS 161/NQF #0104e), Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment, (CMS 177/NQF #1365e), and Preventive Care and Screening: Screening for Depression and Follow-Up Plan (CMS 2/ NQF #0418e).

      Adult Major Depressive Disorder (MDD): Suicide Risk Assessment, (CMS 161) and Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment, (CMS 177) do not use a value set, but rather a direct reference code, SNOMED CT code, 225337009, “Suicide risk assessment (procedure)" within the measure logic to document that a suicide risk assessment was performed. These particular measures, which PCPI stewards, do not require a specific instrument, which is why the generic SNOMED CT code is utilized.

      Preventive Care and Screening: Screening for Depression and Follow-Up Plan (CMS 2), uses a value set, “Suicide Risk Assessment,” (OID: 2.16.840.1.113883.3.600.559), to document that a suicide risk assessment was performed as follow up after a patient screens positive for depression. This value set also contains the same SNOMED CT code, 225337009, with a few additional codes included which relate to one of the tools that is specified within the definition of the measure.

      Please note that the coding for the three measures has been built around guidance provided by clinical experts based upon the intent of the measures’ data elements and definitions. As a result, the coding has some overlap between the three measures as the content and context for each measure. We advise following coding, value sets, and logic built within the posted measure specifications for each measure to ensure accuracy of implementation.
      Show
      Thank you for your question. There are three eCQMs which utilize suicide risk assessments: Adult Major Depressive Disorder (MDD): Suicide Risk Assessment, (CMS 161/NQF #0104e), Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment, (CMS 177/NQF #1365e), and Preventive Care and Screening: Screening for Depression and Follow-Up Plan (CMS 2/ NQF #0418e). Adult Major Depressive Disorder (MDD): Suicide Risk Assessment, (CMS 161) and Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment, (CMS 177) do not use a value set, but rather a direct reference code, SNOMED CT code, 225337009, “Suicide risk assessment (procedure)" within the measure logic to document that a suicide risk assessment was performed. These particular measures, which PCPI stewards, do not require a specific instrument, which is why the generic SNOMED CT code is utilized. Preventive Care and Screening: Screening for Depression and Follow-Up Plan (CMS 2), uses a value set, “Suicide Risk Assessment,” (OID: 2.16.840.1.113883.3.600.559), to document that a suicide risk assessment was performed as follow up after a patient screens positive for depression. This value set also contains the same SNOMED CT code, 225337009, with a few additional codes included which relate to one of the tools that is specified within the definition of the measure. Please note that the coding for the three measures has been built around guidance provided by clinical experts based upon the intent of the measures’ data elements and definitions. As a result, the coding has some overlap between the three measures as the content and context for each measure. We advise following coding, value sets, and logic built within the posted measure specifications for each measure to ensure accuracy of implementation.
    • CMS161v7/NQF104
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      The NQF Measures for both SRA-A and SRA-BH-C do not contain the suicide risk assessment codes but are rather only shown in the CDF-BH which is CMS2v8, a completely different NQF number. We are unable to release measure flowcharts for upcoming reporting because of this error in the value sets.
      Show
      The NQF Measures for both SRA-A and SRA-BH-C do not contain the suicide risk assessment codes but are rather only shown in the CDF-BH which is CMS2v8, a completely different NQF number. We are unable to release measure flowcharts for upcoming reporting because of this error in the value sets.

          Assignee:
          Mathematica EC eCQM Team (Inactive)
          Reporter:
          Kirsten Donato (Inactive)
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