[CQM-2895] CMS161v5_Adult Major Depressive Disorder (MDD): Suicide Risk Assessment Created: 11/13/17  Updated: 04/30/19  Resolved: 04/30/19

Status: Closed
Project: eCQM Issue Tracker
Component/s: Certification, Guidance

Type: EC eCQMs - Eligible Clinicians Priority: Moderate
Reporter: Shaheen Mohamed (Inactive) Assignee: Mathematica EC eCQM Team (Inactive)
Resolution: Done Votes: 0
Labels: cypress

Attachments: XML File 0_Adam_Warner.xml     PNG File CMS 161 vendor output.png    
Solution: Thank you for your question. The intent of this measure is for a suicide risk assessment to be performed during every encounter for a new or recurrent episode of Major Depressive Disorder (MDD). In version 5 of this eCQM, published in April 2016, the diagnosis of MDD must start during a particular encounter. Based on the information you provided, it does not appear that the encounter on December 2, 2016, would meet the initial population requirement, as the diagnosis of MDD did not start during that encounter. If, however, the MDD diagnosis had been documented in the patient’s EMR as starting during the December 2, 2016, encounter, the initial population criteria would be met for that encounter, and you would then assess whether or not the suicide risk assessment was performed during that encounter, thereby satisfying the numerator criteria. A suicide risk assessment must be performed at all encounters for a new diagnosis of MDD and all encounters for a recurrent diagnoses in order to meet numerator requirements for the measure.

In version 6 of this eCQM, published in May 2017 for 2018 reporting, we added constraints to the encounter for MDD diagnosis in an attempt to more accurately capture recurrent episodes of MDD.
Solution Posted On:
2017 Performance Period EC eCQMs:
CMS161v5/NQF0104
Comment Posted On:

 Description   

For CMS-161 patient has 3 qualifying encounters and has diagnosis for Major Depressive Disorder-Active associated with two encounters:Encounter, Performed: Psych Visit

CPT
90837
Start Time
December 2, 2016 8:00am
End Time
December 2, 2016 9:00am

Principal Diagnosis
Major Depression Including Remission
SNOMED-CT: 14183003
ICD-9-CM: 296.20
ICD-10-CM: F32.9

and Diagnosis: Major Depression

ICD-9-CM
296.20
SNOMED-CT
14183003
ICD-10-CM
F32.9
Start Time
October 1, 2016 4:05pm

Since the patient has 2 qualifying encounters associated with the diagnosis, both visits qualify the denominator criteria. However, the expected output requires the patient to have only one qualifying denominator visit.

Kindly suggest if the expected output is correct or not.


Generated at Sun Sep 21 15:33:00 UTC 2025 using Jira 10.3.9#10030009-sha1:eff8913ed2270ee44ab422c3609af4c4f36536d0.