Measure Description
The percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event date.
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 Patient Health Questionnaire – 9 item version (PHQ9) or Patient Health Questionnaire – 9 Modified for Teens and Adolescents (PHQ-9M) greater than nine (index event). This measure may be submitted by Merit-based Incentive Payment System (MIPS) 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 or PHQ-9M score greater than 9 documented on the same date or up to seven days prior to encounter (index event) and this date occurs during denominator identification period (11/1/2020 to 10/31/2021).
This measure will be calculated with 2 performance rates:
- Percentage of adolescent patients (aged 12-17 years) with a diagnosis of major depression or dysthymia and an initial PHQ-9 or PHQ-9M score greater than nine during the index event who reached remission at twelve months as demonstrated by a twelve month (+/-60 days) PHQ-9 or PHQ-9M score of less than 5
- Percentage of adult patients (aged 18 years or older) with a diagnosis of major depression or dysthymia and an initial PHQ-9 or PHQ-9M score greater than nine during the index event who reached remission at twelve months as demonstrated by a twelve month (+/-60 days) PHQ-9 or PHQ-9M score of less than 5
NOTE: Patient encounters for this measure conducted via telehealth (e.g., encounters coded with GQ, GT, 95, or POS 02 modifiers) are allowable
Measure Submission Type:
Measure data may be submitted by individual MIPS eligible clinicians, groups, or third party intermediaries. The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions as allowed by the measure. The quality data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third party intermediaries that utilize Medicare Part B claims data. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.
Denominator (Submission Criteria 1)
Adolescent patients 12 to 17 years of age with a diagnosis of major depression or dysthymia and an initial PHQ-9 or PHQ-9M score greater than nine during the index event
Definitions:
Denominator Identification Period – The period in which eligible patients can have an index event. The “denominator identification period” occurs prior to the measurement period and is defined as 14 months to two months prior to the start of the measurement period. The “denominator identification period” is from 11/1/2020 to 10/31/2021. 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 +/- 60 days after the index event date.
Index Event Date – The date on which the first instance of elevated PHQ-9 or PHQ-9M greater than nine AND diagnosis of depression or dysthymia occurs during the denominator identification period (11/1/2020 to 10/31/2021). Patients may be screened using PHQ-9 or PHQ-9M up to seven days prior to the encounter (including the day of the encounter).
Measure Assessment Period – The index event date marks the start of the measurement assessment period for each patient which is 14 months (12 months +/- 60 days). This assessment period is fixed and does not “start over” with a higher PHQ-9 or PHQ-9M that may occur after the index event date.
Denominator Criteria (Eligible Cases) 1:
Patients aged ≥ 12 years and ≤ 17 years on date of index
AND
Diagnosis for Major Depression or Dysthymia (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, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, G0402, G0438, G0439, 99421, 99422, 99423, 99441, 99442, 99443, 96156, 96158, 96159
AND
Index Event Date PHQ-9 or PHQ-9M 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 any time prior to the end of the measure assessment period
- The following codes would be sufficient to define the Denominator Exclusion of bipolar disorder: F30.10, F30.11, F30.12, F30.13, F30.2, F30.3, F30.4, F30.8, F30.9, F31.0, F31.10, F31.11, F31.12, F31.13, F31.2, F31.30, F31.31, F31.32, F31.4, F31.5, F31.60, F31.61, F31.62, F31.63, F31.64, F31.70, F31.71, F31.72, F31.73, F31.74, F31.75, F31.76, F31.77, F31.78, F31.81, F31.89 or F31.9
- For historical reference purposes these ICD-9 codes if documented would be sufficient to define the Denominator Exclusion of bipolar disorder: 296.00, 296.01, 296.02, 296.03, 296.04, 296.05, 296.06, 296.10, 296.11, 296.12, 296.13, 296.14, 296.15, 296.16, 296.40, 296.41, 296.42, 296.43, 296.44, 296.45, 296.46, 296.50, 296.51, 296.52, 296.53, 296.54, 296.55, 296.56, 296.60, 296.61, 296.62, 296.63, 296.64, 296.65, 296.66, 296.7, 296.80, 296.81, 296.82 or 296.89
OR
Patients with an active diagnosis of personality disorder any time prior to the end of the measure assessment period
- The following codes would be sufficient to define the Denominator Exclusion of personality disorder: F34.0, F60.3, F60.4, F68.10, F68.11, F68.12 or F68.13
- For historical reference purposes these ICD-9 codes if documented would be sufficient to define the Denominator Exclusion of personality disorder: 301.13, 301.50, 301.51 or 301.83
OR
Patients with an active diagnosis of schizophrenia or psychotic disorder any time prior to the end of the measure assessment period
- The following codes would be sufficient to define the Denominator Exclusion of schizophrenia or psychotic disorder: F20.0, F20.1, F20.2, F20.3, F20.5, F20.81, F20.89, F20.9, F21, F23, F25.0, F25.1, F25.8, F25.9, F28 or F29
- For historical reference purposes these ICD-9 codes if documented would be sufficient to define the Denominator Exclusion of schizophrenia or psychotic disorder: 295.00, 295.01, 295.02, 295.03, 295.04, 295.05, 295.10, 295.11, 295.12, 295.13, 295.14, 295.15, 295.20, 295.21, 295.22, 295.23, 295.24, 295.25, 295.30, 295.31, 295.32, 295.33, 295.34, 295.35, 295.40, 295.41, 295.42, 295.43, 295.44, 295.45, 295.50, 295.51, 295.52, 295.53, 295.54, 295.55, 295.60, 295.61, 295.62, 295.63, 295.64, 295.65, 295.70, 295.71, 295.72, 295.73, 295.74, 295.75, 295.80, 295.81, 295.82, 295.83, 295.84, 295.85, 295.90, 295.91, 295.92, 295.93, 295.94, 295.95, 298.0, 298.1, 298.4, 298.8 or 298.9
OR
Patients with an active diagnosis of pervasive developmental disorder any time prior to the end of the measure assessment period
- The following codes would be sufficient to define the Denominator Exclusion of pervasive developmental disorder: F84.0, F84.3, F84.8 or F84.9
- For historical reference purposes these ICD-9 codes if documented would be sufficient to define the Denominator Exclusion of pervasive developmental disorder: 299.00, 299.01, 299.10, 299.11, 299.80, 299.81, 299.90 or 299.91
OR
Patients who died any time 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
- The following code would be sufficient to define the Denominator Exclusion of hospice or palliative care: Z51.5
OR
Patients who were permanent nursing home residents any time during denominator identification period or the measure assessment period
Numerator (Submission Criteria 1)
Adolescent patients aged 12 to 17 years of age who achieved remission at twelve months as demonstrated by a twelve month (+/- 60 days) PHQ-9 or PHQ-9M score of less than five
Definitions:
Remission – a PHQ-9 or PHQ-9M score of less than five.
Twelve Months – Is defined as the point in time from the index event date extending out “twelve months” and then allowing a grace period of sixty days prior to and sixty days after this date. The most recent PHQ-9 or PHQ-9M score less than five obtained during this four 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: Adolescent patients 12 to 17 years of age with major depression or dysthymia who reached remission at twelve months as demonstrated by a twelve month (+/-60 days) PHQ-9 or PHQ-9M score of less than 5 (M1019)
OR
Performance Not Met: Adolescent patients 12 to 17 years of age with major depression or dysthymia who did not reach remission at twelve months as demonstrated by a twelve month (+/-60 days) PHQ-9 or PHQ-9M score of less than 5. Either PHQ9 or PHQ-9M score was not assessed or is greater than or equal to 5 (M1020)
Denominator (Submission Criteria 2)
Adult patients aged 18 and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 or PHQ-9M score greater than nine during the index event
Definitions:
Denominator Identification Period – The period in which eligible patients can have an index event. The “denominator identification period” occurs prior to the measurement period and is defined as 14 months to two months prior to the start of the measurement period. The “denominator identification period” is from 11/1/2020 to 10/31/2021. For patients with an index event, there needs to be enough time following index for the patients to have the opportunity to reach remission 12 months +/- 60 days after the index event date
Index Event Date – The date on which the first instance of elevated PHQ-9 or PHQ-9M greater than 9 AND diagnosis of depression or dysthymia occurs during the denominator identification period (11/1/2020 to 10/31/2021). Patients may be screened using PHQ-9 or PHQ-9M up to 7 days prior to the encounter (including the day of the encounter).
Measure Assessment Period – The index event date marks the start of the “measurement assessment period” for each patient which is 14 months (12 months +/- 60 days). This assessment period is fixed and does not “start over” with a higher PHQ-9 or PHQ-9M that may occur after the index event date.
Denominator Criteria (Eligible Cases) 2:
Patients aged ≥ 18 years on date of index
AND
Diagnosis for Major Depression or Dysthymia (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, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, G0402, G0438, G0439, 99421, 99422, 99423, 99441, 99442, 99443, 96156, 96158, 96159
AND
Index Event Date PHQ-9 or PHQ-9M 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 any time prior to the end of the measure assessment period
- The following codes would be sufficient to define the Denominator Exclusion of bipolar disorder: F30.10, F30.11, F30.12, F30.13, F30.2, F30.3, F30.4, F30.8, F30.9, F31.0, F31.10, F31.11, F31.12, F31.13, F31.2, F31.30, F31.31, F31.32, F31.4, F31.5, F31.60, F31.61, F31.62, F31.63, F31.64, F31.70, F31.71, F31.72, F31.73, F31.74, F31.75, F31.76, F31.77, F31.78, F31.81, F31.89 or F31.9
- For historical reference purposes these ICD-9 codes if documented would be sufficient to define the Denominator Exclusion of bipolar disorder: 296.00, 296.01, 296.02, 296.03, 296.04, 296.05, 296.06, 296.10, 296.11, 296.12, 296.13, 296.14, 296.15, 296.16, 296.40, 296.41, 296.42, 296.43, 296.44, 296.45, 296.46, 296.50, 296.51, 296.52, 296.53, 296.54, 296.55, 296.56, 296.60, 296.61, 296.62, 296.63, 296.64, 296.65, 296.66, 296.7, 296.80, 296.81, 296.82 or 296.89
OR
Patients with an active diagnosis of personality disorder any time prior to the end of the measure assessment period
- The following codes would be sufficient to define the Denominator Exclusion of personality disorder: F34.0, F60.3, F60.4, F68.10, F68.11, F68.12 or F68.13
- For historical reference purposes these ICD-9 codes if documented would be sufficient to define the Denominator Exclusion of personality disorder: 301.13, 301.50, 301.51 or 301.83.
OR
Patients with an active diagnosis of schizophrenia or psychotic disorder any time prior to the end of the measure assessment period
- The following codes would be sufficient to define the Denominator Exclusion of schizophrenia or psychotic disorder: F20.0, F20.1, F20.2, F20.3, F20.5, F20.81, F20.89, F20.9, F21, F23, F25.0, F25.1, F25.8, F25.9, F28 or F29
- For historical reference purposes these ICD-9 codes if documented would be sufficient to define the Denominator Exclusion of schizophrenia or psychotic disorder: 295.00, 295.01, 295.02, 295.03, 295.04, 295.05, 295.10, 295.11, 295.12, 295.13, 295.14, 295.15, 295.20, 295.21, 295.22, 295.23, 295.24, 295.25, 295.30, 295.31, 295.32, 295.33, 295.34, 295.35, 295.40, 295.41, 295.42, 295.43, 295.44, 295.45, 295.50, 295.51, 295.52, 295.53, 295.54, 295.55, 295.60, 295.61, 295.62, 295.63, 295.64, 295.65, 295.70, 295.71, 295.72, 295.73, 295.74, 295.75, 295.80, 295.81, 295.82, 295.83, 295.84, 295.85, 295.90, 295.91, 295.92, 295.93, 295.94, 295.95, 298.0, 298.1, 298.4, 298.8 or 298.9
OR
Patients with an active diagnosis of pervasive developmental disorder any time prior to the end of the measure assessment period
- The following codes would be sufficient to define the Denominator Exclusion of pervasive developmental disorder: F84.0, F84.3, F84.8 or F84.9
- For historical reference purposes these ICD-9 codes if documented would be sufficient to define the Denominator Exclusion of pervasive developmental disorder: 299.00, 299.01, 299.10, 299.11, 299.80, 299.81, 299.90 or 299.91
OR
Patients who died any time 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
- The following code would be sufficient to define the Denominator Exclusion of hospice or palliative care: Z51.5
OR
Patients who were permanent nursing home residents any time during denominator identification period or the measure assessment period
Numerator (Submission Criteria 2)
Adult patients aged 18 years of age and older who achieved remission at twelve months as demonstrated by a twelve month (+/- 60 days) PHQ-9 or PHQ-9M score of less than five
Definitions:
Remission – a PHQ-9 or PHQ-9M score of less than five
Twelve Months – If defined as the point in time from the index event date extending out “twelve months” and then allowing a grace period of sixty days prior to and sixty days after this date. The most recent PHQ-9 or PHQ-9M score less than five obtained during this four 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: Adult patients 18 years of age or older with major depression or dysthymia who reached remission at twelve months as demonstrated by a twelve month (+/-60 days) PHQ-9 or PHQ-9M score of less than 5 (G9509)
OR
Performance Not Met: Adult patients 18 years of age or older with major depression or dysthymia who did not reach remission at twelve months as demonstrated by a twelve month (+/-60 days) PHQ-9 or PHQ-9M score of less than 5. Either PHQ9 or PHQ-9M score was not assessed or is greater than or equal to 5 (G9510)
Rationale
Adults:
Depression is a common and treatable mental disorder. 8.1% of American adults age 20 and over had depression in a given 2 week period. Women (10.4%) were almost twice as likely as were men (5.5%) to have had depression. The prevalence of depression among adults decreased as family income levels increase. About 80% of adults with depression reported at least some difficulty with work, home, or social activities because of their depression symptoms (Centers for Disease Control and Prevention, 2018).
Depression is a risk factor for development of chronic illnesses such as diabetes and CHD and adversely affects the course, complications and management of chronic medical illness. Both maladaptive health risk behaviors and psychobiological factors associated with depression may explain depression's negative effect on outcomes of chronic illness. (Katon, W.J., 2011)
Adolescents and Adults:
The Centers for Disease Control and Prevention states that during 2009-2012 an estimated 7.6% of the U.S. population aged 12 and over had depression, including 3% of Americans with severe depressive symptoms. Almost 43% of persons with severe depressive symptoms reported serious difficulties in work, home and social activities, yet only 35% reported having contact with a mental health professional in the past year.r.
Depression is associated with higher mortality rates in all age groups. People who are depressed are 30 times more likely to take their own lives than people who are not depressed and five times more likely to abuse drugs. Depression is the leading cause of medical disability for people aged 14 – 44. Depressed people lose 5.6 hours of productive work every week when they are depressed, fifty percent of which is due to absenteeism and short-term disability.
Adolescents:
In 2014, an estimated 2.8 million adolescents age 12 to 17 in the United States had at least one major depressive episode (MDE) in the past year. This represented 11.4% of the U.S. population. The same survey found that only 41.2 percent of those who had a MDE received treatment in the past year. The 2013 Youth Risk Behavior Survey of students grades 9 to 12 indicated that during the past 12 months 39.1% of female (F) and 20.8% of male (M) students indicated feeling sad or hopeless almost every day for at least 2 weeks,16.9% (F) and 10.3% (M) indicated a planned suicide attempt, and 10.6% (F) and 5.4% (M) attempted suicide. Adolescent-onset depression is associated with chronic depression in adulthood. Many mental health conditions (anxiety, bipolar, depression, eating disorders, and substance abuse) are evident by age 14. The 12-month prevalence of MDEs increased from 8.7% in 2005 to 11.3% in 2014 in adolescents and from 8.8% to 9.6% in young adults (both P < .001). The increase was larger and statistically significant only in the age range of 12 to 20 years. The trends remained significant after adjustment for substance use disorders and sociodemographic factors. Mental health care contacts overall did not change over time; however, the use of specialty mental health providers increased in adolescents and young adults, and the use of prescription medications and inpatient hospitalizations increased in adolescents. In 2015, 9.7% of adolescents in Minnesota (MN) who were screened for depression or other mental health conditions, screened positively
Clinical Recommendation Statements
Adults:
Source: Institute for Clinical Systems Improvement (ICSI) Health Care Guideline for Adult Depression in Primary Care (Trangle, 2016)
Recommendations and algorithm notations supporting depression outcomes and duration of treatment according to ICSI's Health Care Guideline:
Recommendation: Clinicians should establish and maintain follow-up with patients. Appropriate, reliable follow-up is highly correlated with improved response and remission scores. It is also correlated with the improved safety and efficacy of medications and helps prevent relapse.
Proactive follow-up contacts (in person, telephone) based on the collaborative care model have been shown to significantly lower depression severity (Unutzer, 2002). In the available clinical effectiveness trials conducted in real clinical practice settings, even the addition of a care manager leads to modest remission rates (Trivedi, 2006; Unutzer, 2002). Interventions are critical to educating the patient regarding the importance of preventing relapse, safety and efficacy of medications, and management of potential side effects. Establish and maintain initial follow-up contact intervals (office, phone, other) (Hunkeler, 2000; Simon, 2000).
PHQ-9 as monitor and management tool. The PHQ-9 is an effective management tool, as well, and should be used routinely for subsequent visits to monitor treatment outcomes and severity. It can also help the clinician decide if/how to modify the treatment plan (Duffy, 2008; Lowe, 2004). Using a measurement-based approach to depression care, PHQ-9 results and side effect evaluation should be combined with treatment algorithms to drive patients toward remission. A five-point drop in PHQ-9 score is considered the minimal clinically significant difference (Trivedi, 2009).
The goals of treatment should be to achieve remission, reduce relapse and recurrence, and return to previous level of occupational and psychosocial function.
If using a PHQ-9 tool, remission translates to PHQ-9 score of less than 5 (Kroenke, 2001). Results from the STAR*D study showed that remission rates lowered with more treatment steps, but the overall cumulative rate was 67% (Rush, 2006).
Response and remission take time. In the STAR*D study, longer times than expected were needed to reach response or remission. In fact, one-third of those who ultimately responded did so after six weeks. Of those who achieved remission by Quick Inventory of Depressive Symptomatology (QIDS), 50% did so only at or after six weeks of treatment (Trivedi, 2006). If the primary care clinician is seeing some improvement, continue working with that patient to augment or increase dosage to reach remission. This can take up to three months.
This measure assesses achievement of remission, which is a desired outcome of effective depression treatment and monitoring.
Adult Depression in Primary Care - Guideline Aims
- Increase the percentage of patients with major depression or persistent depressive disorder who have improvement in outcomes from treatment for major depression or persistent depressive disorder
- Increase the percentage of patients with major depression or persistent depressive disorder who have follow-up to assess for outcomes from treatment.
- Improve communication between the primary care physician and the mental health care clinician (if patient is comanaged).
Adolescents:
Source: American Academy of Child and Adolescent Psychiatry Practice Parameter for the Assessment and Treatment of Children and Adolescents with Depressive Disorders (2007) http://www.jaacap.com/article/S0890-8567(09)62053-0/pdf
Recommendations: Recommendations supporting depression outcomes and duration of treatment according to AACAP guideline:
- Treatment of depressive disorders should always include an acute and continuation phase; some children may also require maintenance treatment. The main goal of the acute phase is to achieve response and ultimately full symptomatic remission (definitions below).
- Each phase of treatment should include psychoeducation, supportive management, and family and school involvement.
- Education, support, and case management appear to be sufficient treatment for the management of depressed children and adolescents with an uncomplicated or brief depression or withmild psychosocial impairment.
- For children and adolescents who do not respond to supportive psychotherapy or who have more complicated depressions, a trial with specific types of psychotherapy and/or antidepressants is indicated.
Sources:
Guidelines for Adolescent Depression in Primary Care (GLAD-PC) (2018)
http://pediatrics.aappublications.org/content/141/3/e20174081
Guidelines for adolescent depression in primary care (GLAD-PC): II. Treatment and ongoing management
http://pediatrics.aappublications.org/content/141/3/e20174082 Recommendations supporting depression outcomes and duration of treatment according to GLAD-PC:
Recommendations for Ongoing Management of Depression:
- Mild depression: consider a period of active support and monitoring before starting other evidence based treatment
- Moderate or severe major clinical depression or complicating factors:
- o consultation with mental health specialist with agreed upon roles
- evidence based treatment (cognitive behavioral therapy (CBT) or interpersonal psychotherapy (IPT) and/or antidepressant selective serotonin reuptake inhibitor (SSRI))
- Monitor for adverse effects during antidepressant therapy
- clinical worsening, suicidality, unusual changes in behavior
- Systematic and regular tracking of goals and outcomes
- improvement in functioning status and resolution of depressive symptoms
Regardless of the length of treatment, all patients should be monitored on a monthly basis for 6 to 12 months after the full resolution of symptoms