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  1. eCQM Issue Tracker
  2. CQM-6333

2023 eCQM Measure 161 - Denominator Clarification re: MDD diagnosis eligibliity

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    • Icon: EC eCQMs - Eligible Clinicians EC eCQMs - Eligible Clinicians
    • Resolution: Answered
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    • None
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    • Susan Joy RN
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      ​Thank you for your inquiry on CMS161v12: Adult Major Depressive Disorder (MDD): Suicide Risk Assessment. For Question #1, in order to qualify for the Initial Population, the clinician would need an encounter diagnosis of MDD (i.e., MDD would need to be addressed during the encounter). The MDD diagnosis would need to be documented as an encounter diagnosis. For Question #2, for situations where a patient has an active diagnosis of MDD and overlaps the encounter, but the patient was seen for another problem (e.g., sore throat), this would not count as a MDD encounter.
       
      Major Depressive Disorder Encounter
      ( ["Encounter, Performed": "Psych Visit Diagnostic Evaluation"]
        union ["Encounter, Performed": "Emergency Department Evaluation and Management Visit"]
        union ["Encounter, Performed": "Office Visit"]
        union ["Encounter, Performed": "Outpatient Consultation"]
        union ["Encounter, Performed": "Psych Visit Psychotherapy"]
        union ["Encounter, Performed": "Psychoanalysis"]
        union ["Encounter, Performed": "Telehealth Services"] ) ValidEncounter
        where exists ( ValidEncounter.diagnoses EncounterDiagnosis
            where EncounterDiagnosis.code in "Major Depressive Disorder Active"
        )

      Show
      ​Thank you for your inquiry on CMS161v12: Adult Major Depressive Disorder (MDD): Suicide Risk Assessment. For Question #1, in order to qualify for the Initial Population, the clinician would need an encounter diagnosis of MDD (i.e., MDD would need to be addressed during the encounter). The MDD diagnosis would need to be documented as an encounter diagnosis. For Question #2, for situations where a patient has an active diagnosis of MDD and overlaps the encounter, but the patient was seen for another problem (e.g., sore throat), this would not count as a MDD encounter.   Major Depressive Disorder Encounter ( ["Encounter, Performed": "Psych Visit Diagnostic Evaluation"]   union ["Encounter, Performed": "Emergency Department Evaluation and Management Visit"]   union ["Encounter, Performed": "Office Visit"]   union ["Encounter, Performed": "Outpatient Consultation"]   union ["Encounter, Performed": "Psych Visit Psychotherapy"]   union ["Encounter, Performed": "Psychoanalysis"]   union ["Encounter, Performed": "Telehealth Services"] ) ValidEncounter   where exists ( ValidEncounter.diagnoses EncounterDiagnosis       where EncounterDiagnosis.code in "Major Depressive Disorder Active"   )
    • CMS0161v11
    •  It affects our overall performance rating and benchmark scoring if patients who don't meet the denominator criteria are included in the measure.

      Our documentation charts a patient's diagnosis two ways. First is listing any diagnosis addressed at the time of a specific visit at the top of our EMR page. Second, at the bottom of the page, diagnoses are listed in a Problem list format with a status classification of "Active, Resolved, etc."  The Problem list indicates 'ongoing' diagnoses under treatment but not attached to a specific visit.  

      Question 1 - For the purposes of measure 161 denominator criteria, can I only use an MDD diagnosis specifically documented and dated to match the date of the MDD encounter?

      Question 2 - Or, for Denominator criteria, is it also acceptable to use an MDD diagnosis from the EMR Problem list which indicates an ongoing or "overlap" diagnosis applying to all encounters throughout the measurement period?

            edave Mathematica EC eCQM Team
            SusanJoy Susan Joy
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