#370: Depression Remission at Twelve Months

Quality ID

370

eMeasure ID

CMS159v6

NQF

0710

High Priority Measure

Yes

Specifications

EHR Registry

Measure Type

Outcome

Specialty

Family Medicine Internal Medicine Mental/Behavioral Health

Measure description

The percentage of patients 18 years of age or older with major depression or dysthymia who reached remission 12 months (+/- 30 days) after an index visit.

 

Instructions

This measure is to be submitted once per performance period for patients with an encounter during the denominator identification period with a diagnosis of depression and an initial PHQ-9 greater than nine (index event). This measure may be submitted by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

NOTE: To be considered denominator eligible for this measure, the patient must have both the diagnosis of depression or dysthymia and a PHQ-9 Score greater than 9 documented on the same date (index event) and this date occurs during denominator identification period (11/1/2016 to 10/31/2017). Encounters in a Psychiatric, Behavioral, or Mental Health Setting require the diagnosis of depression or dysthymia to be a primary diagnosis.

Measure Submission:

The listed denominator criteria is used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions allowed by the measure. The quality-data codes listed do not need to be submitted for registry submissions; however, these codes may be submitted for those registries that utilize claims data.

 

Denominator

Patients age 18 and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 score greater than nine during the index visit

Definition:

Denominator Identification Period- The period in which eligible patients can have an index event. The denominator identification period occurs prior to the measure assessment period and is defined as 13 months to one month prior to the start of the measurement assessment period. The denominator identification period is from 11/1/2016 to 10/31/2017. For patients with an index event, there needs to be enough time following index for the patients to have the opportunity to reach remission twelve months +/- 30 days after the index date.

Index Date - The date on which the first instance of elevated PHQ-9 greater than nine AND diagnosis of depression or dysthymia occurs during the denominator identification period (11/1/2016 to 10/31/2017).

Measure Assessment Period - The index date marks the start of the measurement assessment period for each patient which is 13 months (12 months +/- 30 days) in length to allow for a follow-up PHQ-9 between 11 and 13 months following the index date. This assessment period is fixed and does not “start over” with a higher PHQ-9 that may occur after the index date.

Note: Data collection for this measure is structured to align with the Depression Remission at 6 Months measure (Quality ID #411). Data is captured on the same denominator patients and then measuring them at two distinct points in time, both at six months and at twelve months. The thirteen month assessment period is held constant for these two measures. This means that patient is not re-indexing with a high PHQ-9 until that measure assessment period is elapsed.

Denominator Criteria (Eligible Cases):

Patients aged ≥ 18 years

AND

Diagnosis for MDD (ICD-10-CM): F32.0, F32.1, F32.2, F32.3, F32.4, F32.5, F32.9, F33.0, F33.1, F33.2, F33.3, F33.40, F33.41, F33.42, F33.9, F34.1

AND

Patient encounter during the denominator identification period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, G0402, G0438, G0439, 99441, 99442, 99443, 99444

AND

Index Date PHQ-9 Score greater than 9 documented during the twelve month denominator identification period: G9511

AND NOT

DENOMINATOR EXCLUSIONS:

Patients with an active diagnosis of bipolar disorder anytime prior to the end of the measure assessment period

OR

Patients with an active diagnosis of personality disorder anytime prior to the end of the measure assessment period

OR

Patients who died anytime prior to the end of the measure assessment period

OR

Patients who received hospice or palliative care service any time during denominator identification period or the measure assessment period

OR

Patients who were permanent nursing home residents any time during denominator identification period or the measure assessment period

 

Numerator

Patients who achieved remission at twelve months as demonstrated by a twelve month (+/- 30 days) PHQ-9 score of less than five

Definitions:

Remission - a PHQ-9 score of less than five.

Twelve Months - the point in time from the index date extending out twelve months then allowing a grace period of thirty days prior to and thirty days after this date. The most recent PHQ-9 score less than five obtained during this two month period is deemed as remission at twelve months, values obtained prior to or after this period are not counted as numerator compliant (remission).

Numerator Options:

Performance Met: Remission at twelve months as demonstrated by a twelve month (+/-30 days) PHQ-9 score of less than 5 (G9509)

OR

Performance Not Met: Remission at twelve months not demonstrated by a twelve month (+/-30 days) PHQ-9 score of less than five. Either PHQ-9 score was not assessed or is greater than or equal to 5 (G9510)

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