CMS Measure ID: #370
Collection Type: CQM
Reporting Frequency: Once per patient per year
Outcome: Yes
High Priority: Yes
NQS Domain: Effective Clinical Care
Measure Age: > 2 years
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 (PHQ-9) 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 (11/1/2021 to 10/31/2022).
This measure will be calculated with 2 performance rates:
1) 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
2) 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.
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
2023 Benchmarks (from 2021 CMS data)
eCQM
Topped out: No
Capped at 7: No
Decile 0: 0 – 0.51
Decile 1: 0.52 – 1.91
Minimum: 1.92 – 3.12
Decile 3: 3.13 – 4.46
Decile 4: 4.47 – 5.93
Decile 5: 5.94 – 7.99
Decile 6: 8 – 9.72
Decile 7: 9.73 – 12.19
Decile 8: 12.2 – 16.66
Decile 9: 16.67 – 24.65
Decile 10: 24.66 – 100
Denominator
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 11/1/2021 to 10/31/2022. 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 (11/1/2021 to 10/31/2022). 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 NOTE: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for MIPS CQMs.
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, 99384*, 99394*, 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
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 11/1/2021 to 10/31/2022. 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 (11/1/2021 to 10/31/2022). 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 NOTE: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for MIPS CQMs.
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, 99385*, 99386*, 99387*, 99395*, 99396*, 99397*, 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
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 PHQ-9 or PHQ-9M score was not assessed or is greater than or equal to 5 (M1020)
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 PHQ-9 or PHQ-9M score was not assessed or is greater than or equal to 5 (G9510)
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