Overview
CMS161v8 (2020)
CMS161v9 (2021)
CMS161v10 (2022)
Identifiers
| CMS eCQM ID | NQF eCQM ID | NQF | MIPS Quality ID |
| CMS161v10 | 0104e | – | 107 |
*MIE only supports data collection and reporting using eCQM specifications
Definitions
| Description | All patient visits during which a new diagnosis of MDD or a new diagnosis of recurrent MDD was identified for patients aged 18 years and older with a suicide risk assessment completed during the visit |
| Initial Patient Population | Patient visits during which a new diagnosis of MDD, single or recurrent episode, was identified |
| Denominator | Equals Initial Population |
| Denominator Exclusions | – |
| Numerator | Patient visits during which a new diagnosis of MDD, single or recurrent episode, was identified and a suicide risk assessment was completed during the visit |
| Numerator Exclusions | – |
| Denominator Exceptions | – |
Additional Information
| Measure Type | Process measure |
| Measure Scoring | Proportion measure |
| Granularity | Episode of MDD |
| Improvement Notation | Higher score indicates better quality |
| Domain | Effective Clinical Care |
Clinical Instructions
New UI Visit Encounter (valid RC202109+)
Original Visit Encounter
Evidence
Initial Patient Population
| Name | Value Set |
| Diagnosis: Major Depressive Disorder-Active | 2.16.840.1.113883.3.526.3.1491 |
| Encounter, Performed: Emergency Department Visit | 2.16.840.1.113883.3.464.1003.101.12.1010 |
| Encounter, Performed: Office Visit | 2.16.840.1.113883.3.464.1003.101.12.1001 |
| Encounter, Performed: Outpatient Consultation | 2.16.840.1.113883.3.464.1003.101.12.1008 |
| Encounter, Performed: Psych Visit - Diagnostic Evaluation | 2.16.840.1.113883.3.526.3.1492 |
| Encounter, Performed: Psych Visit - Psychotherapy | 2.16.840.1.113883.3.526.3.1496 |
| Encounter, Performed: Psychoanalysis | 2.16.840.1.113883.3.526.3.1141 |
| Encounter, Performed: Telehealth Services | 2.16.840.1.113883.3.464.1003.101.12.1031 |
Numerator
| Name | Value Set |
| Intervention, Performed: Suicide risk assessment (procedure) | SNOMEDCT Code 225337009 |