2026 COLLECTION TYPE:
MERIT-BASED INCENTIVE PAYMENT SYSTEM (MIPS) CLINICAL QUALITY MEASURE (CQM)
MEASURE TYPE:
Process – High Priority
DESCRIPTION:
Percentage of patients aged 12 years and older with suicidal ideation or behavior symptoms (based on results of a standardized assessment tool or screening tool) or increased suicide risk (based on the clinician’s evaluation or clinician-rating tool) for whom a suicide safety plan is initiated, reviewed, and/or updated in collaboration between the patient and their clinician.
INSTRUCTIONS:
Reporting Frequency:
This measure is to be submitted a minimum of once per performance period for denominator eligible cases as defined in the denominator criteria.
Intent and Clinician Applicability:
This measure is intended to reflect the quality of services provided for patients with suicidal ideation or behavior symptoms. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who provided the measure-specific denominator coding.
Measure Strata and Performance Rates:
This measure contains two strata defined by two submission criteria. This measure produces two performance rates
There are 2 Submission Criteria for this measure:
- All patients for whom a suicide safety plan is initiated, reviewed, or updated (concurrent or within 24 hours of clinical encounter)
AND
- All patients for whom a suicide safety plan is initiated, reviewed, or updated in collaboration between the individual and their clinician at the time the suicidal ideation, behavior or risk is identified (concurrent or within 24 hours of clinical encounter) (i.e., individuals who satisfy Numerator 1) AND reviewed and updated within 120 days after initiation
This measure will be calculated with 2 performance rates:
- Percentage of patients for whom a suicide safety plan is initiated, reviewed, or updated in collaboration between the patient and their clinician (concurrent or within 24 hours of clinical encounter)
- Percentage of patients for whom a suicide safety plan is initiated, reviewed, or updated in collaboration between the individual and their clinician at the time the suicidal ideation, behavior or risk is identified (concurrent or within 24 hours of clinical encounter) AND reviewed and updated within 120 days after initiation.
For accountability reporting in the CMS MIPS program, the rate for Submission Criteria 2 is used for performance.
Implementation Considerations:
For the purposes of MIPS, this patient-process measure is submitted a minimum of once per patient during the performance period. The most advantageous quality data code will be used if the measure is submitted more than once.
Telehealth:
TELEHEALTH ELIGIBLE: This measure is appropriate for and applicable to the telehealth setting. Patient encounters conducted via telehealth using encounter code(s) found in the denominator encounter criteria are allowed for this measure. Therefore, if the patient meets all denominator criteria for a telehealth encounter, it would be appropriate to include them in the denominator eligible patient population. Telehealth eligibility is at the measure level for inclusion within the denominator eligible patient population and based on the measure specification definitions which are independent of changes to coding and/or billing practices.
Measure Submission:
The quality data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third party intermediaries that utilize this collection type for submissions; however, these codes may be submitted for those third party intermediaries that utilize Medicare Part B claims data. The coding provided to identify the measure criteria: Denominator or Numerator, may be an example of coding that could be used to identify patients that meet the intent of this clinical topic. When implementing this measure, please refer to the ‘Reference Coding’ section to determine if other codes or code languages that meet the intent of the criteria may also be used within the medical record to identify and/or assess patients. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.
SUBMISSION CRITERIA 1: ALL PATIENTS FOR WHOM A SUICIDE SAFETY PLAN IS INITIATED, REVIEWED, OR UPDATED (CONCURRENT OR WITHIN 24 HOURS OF CLINICAL ENCOUNTER)
DENOMINATOR (CRITERIA 1):
Patients aged 12 years and older with a mental and/or substance use disorder with suicidal ideation and/or behavior symptoms or suicide risk at a clinical encounter during the denominator identification period.
Definitions:
Suicidal ideation and/or behavior symptoms – Suicidal ideation and behavior should be assessed using a standardized assessment tool such as the Columbia Suicide Severity Rating Scale (C-SSRS) – ‘Screen Version’. The C-SSRS is a patient self-reported tool that enquires about wish for death, thoughts of suicide, suicidal thoughts with method without specific thoughts or intent, suicidal intent without and with specific plan, and suicide behavior. A “Yes” on the C-SSRS questions 1 or 2 indicates the need to initiate the Suicide Safety Plan. Other patient-reported assessment tools that qualify for this measure include but are not limited to: Patient Health Questionnaire (PHQ-9) – Item 9. The PHQ-9 is a routinely used scale in behavioral health and primary care. Item 9 of the instrument asks whether the patient has thoughts that they would be better off dead, or of hurting themselves. A “Yes” on PHQ-9 Item 9 indicates the need to initiate the Suicide Safety Plan.
Suicide risk based on clinician’s evaluation or a clinician-rated tool – A clinician may determine a patient at increased suicide risk by evaluation and clinical judgment or the use of a standardized tool, such as the Clinician Rating of Potential Suicide Risk (CRPSR). The CRPSR is a single item clinician-rated tool that was developed and tested during the DSM-5 Field Trials. The assessment tool includes a listing of risk factors for suicide and a description of a what very high-risk patient might look like. The clinician is asked to consider the list of risk factors and the description of a very high-risk patient in their clinical evaluation of the patient, and to rate the patient’s risk for suicide and the need for suicide prevention as part of the patient’s current clinical management. A non-zero score on the CRPSR indicates the need to initiate the Suicide Safety Plan. Other clinician rated assessment tools that qualify for this measure include but are not limited to: Suicide Assessment Five-step Evaluation & Triage (SAFE-T), SAFE-T Protocol with CSSRS (Columbia Risk & Protective Factors) Lifetime/Recent, CSSRS (Columbia Risk & Protective Factors) Lifetime/Recent.
Denominator Identification Period – The period in which individuals can have an encounter at which suicidal thoughts or behaviors are found by a standardized assessment or screening tool OR a clinician determines increased suicide risk by evaluation or the results of a clinician-rated tool. The “denominator identification period” is the 12-month window starting 4 months prior to the measurement year and ending 8 months into the measurement year (September 1 of the previous year thru August 31 of the current year).
Index Assessment – The clinical encounter when the patient first reports suicidal thoughts and/or behaviors OR is deemed at elevated suicide risk by their clinician is counted as the index assessment. If there are multiple qualifying assessments during the denominator identification period, the first qualifying assessment is counted as the index.
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 1 (Eligible Cases):
Patients aged 12 years and older on the date of the index encounter
AND
Diagnosis for any mental, behavioral, or substance use disorder on the date of the index encounter (ICD-10-CM): F10.10, F10.11, F10.120, F10.121, F10.129, F10.130, F10.131, F10.132, F10.139, F10.14, F10.150, F10.151, F10.159, F10.180, F10.181, F10.182, F10.188, F10.19, F10.20, F10.21, F10.220, F10.221, F10.229, F10.230, F10.231, F10.232, F10.239, F10.24, F10.250, F10.251, F10.259, F10.26, F10.27, F10.280, F10.281, F10.282, F10.288, F10.29, F10.90, F10.91, F10.920, F10.921, F10.929, F10.930, F10.931, F10.932, F10.939, F10.94, F10.950, F10.951, F10.959, F10.96, F10.97, F10.980, F10.981, F10.982, F10.988, F10.99, F11.10, F11.11, F11.120, F11.121, F11.122, F11.129, F11.13, F11.14, F11.150, F11.151, F11.159, F11.181, F11.182, F11.188, F11.19, F11.20, F11.21, F11.220, F11.221, F11.222, F11.229, F11.23, F11.24, F11.250, F11.251, F11.259, F11.281, F11.282, F11.288, F11.29, F11.90, F11.91, F11.920, F11.921, F11.922, F11.929, F11.93, F11.94, F11.950, F11.951, F11.959, F11.981, F11.982, F11.988, F11.99, F12.10, F12.11, F12.120, F12.121, F12.122, F12.129, F12.13, F12.150, F12.151, F12.159, F12.180, F12.188, F12.19, F12.20, F12.21, F12.220, F12.221, F12.222, F12.229, F12.23, F12.250, F12.251, F12.259, F12.280, F12.288, F12.29, F12.90, F12.91, F12.920, F12.921, F12.922, F12.929, F12.93, F12.950, F12.951, F12.959, F12.980, F12.988, F12.99, F13.10, F13.11, F13.120, F13.121, F13.129, F13.130, F13.131, F13.132, F13.139, F13.14, F13.150, F13.151, F13.159, F13.180, F13.181, F13.182, F13.188, F13.19, F13.20, F13.21, F13.220, F13.221, F13.229, F13.230, F13.231, F13.232, F13.239, F13.24, F13.250, F13.251, F13.259, F13.26, F13.27, F13.280, F13.281, F13.282, F13.288, F13.29, F13.90, F13.91, F13.920, F13.921, F13.929, F13.930, F13.931, F13.932, F13.939, F13.94, F13.950, F13.951, F13.959, F13.96, F13.97, F13.980, F13.981, F13.982, F13.988, F13.99, F14.10, F14.11, F14.120, F14.121, F14.122, F14.129, F14.13, F14.14, F14.150, F14.151, F14.159, F14.180, F14.181, F14.182, F14.188, F14.19, F14.20, F14.21, F14.220, F14.221, F14.222, F14.229, F14.23, F14.24, F14.250, F14.251, F14.259, F14.280, F14.281, F14.282, F14.288, F14.29, F14.90, F14.91, F14.920, F14.921, F14.922, F14.929, F14.93, F14.94, F14.950, F14.951, F14.959, F14.980, F14.981, F14.982, F14.988, F14.99, F15.10, F15.11, F15.120, F15.121, F15.122, F15.129, F15.13, F15.14, F15.150, F15.151, F15.159, F15.180, F15.181, F15.182, F15.188, F15.19, F15.20, F15.21, F15.220, F15.221, F15.222, F15.229, F15.23, F15.24, F15.250, F15.251, F15.259, F15.280, F15.281, F15.282, F15.288, F15.29, F15.90, F15.91, F15.920, F15.921, F15.922, F15.929, F15.93, F15.94, F15.950, F15.951, F15.959, F15.980, F15.981, F15.982, F15.988, F15.99, F16.10, F16.11, F16.120, F16.121, F16.122, F16.129, F16.14, F16.150, F16.151, F16.159, F16.180, F16.183, F16.188, F16.19, F16.20, F16.21, F16.220, F16.221, F16.229, F16.24, F16.250, F16.251, F16.259, F16.280, F16.283, F16.288, F16.29, F16.90, F16.91, F16.920, F16.921, F16.929, F16.94, F16.950, F16.951, F16.959, F16.980, F16.983, F16.988, F16.99, F17.200, F17.201, F17.203, F17.208, F17.209, F17.210, F17.211, F17.213, F17.218, F17.219, F17.220, F17.221, F17.223, F17.228, F17.229, F17.290, F17.291, F17.293, F17.298, F17.299, F18.10, F18.11, F18.120, F18.121, F18.129, F18.14, F18.150, F18.151, F18.159, F18.17, F18.180, F18.188, F18.19, F18.20, F18.21, F18.220, F18.221, F18.229, F18.24, F18.250, F18.251, F18.259, F18.27, F18.280, F18.288, F18.29, F18.90, F18.91, F18.920, F18.921, F18.929, F18.94, F18.950, F18.951, F18.959, F18.97, F18.980, F18.988, F18.99, F19.10, F19.11, F19.120, F19.121, F19.122, F19.129, F19.130, F19.131, F19.132, F19.139, F19.14, F19.150, F19.151, F19.159, F19.16, F19.17, F19.180, F19.181, F19.182, F19.188, F19.19, F19.20, F19.21, F19.220, F19.221, F19.222, F19.229, F19.230, F19.231, F19.232, F19.239, F19.24, F19.250, F19.251, F19.259, F19.26, F19.27, F19.280, F19.281, F19.282, F19.288, F19.29, F19.90, F19.91, F19.920, F19.921, F19.922, F19.929, F19.930, F19.931, F19.932, F19.939, F19.94, F19.950, F19.951, F19.959, F19.96, F19.97, F19.980, F19.981, F19.982, F19.988, F19.99, F20.0, F20.1, F20.2, F20.3, F20.5, F20.81, F20.89, F20.9, F21, F22, F23, F24, F25.0, F25.1, F25.8, F25.9, F28, F29, 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, F31.9, F32.0, F32.1, F32.2, F32.3, F32.4, F32.5, F32.81, F32.89, F32.9, F32.A, F33.0, F33.1, F33.2, F33.3, F33.40, F33.41, F33.42, F33.8, F33.9, F34.0, F34.1, F34.81, F34.89, F34.9, F39, F40.00, F40.01, F40.02, F40.10, F40.11, F40.210, F40.218, F40.220, F40.228, F40.230, F40.231, F40.232, F40.233, F40.240, F40.241, F40.242, F40.243, F40.248, F40.290, F40.291, F40.298, F40.8, F40.9, F41.0, F41.1, F41.3, F41.8, F41.9, F42.2, F42.3, F42.4, F42.8, F42.9, F43.0, F43.10, F43.11, F43.12, F43.20, F43.21, F43.22, F43.23, F43.24, F43.25, F43.29, F43.81, F43.89, F43.9, F44.0, F44.1, F44.2, F44.4, F44.5, F44.6, F44.7, F44.81, F44.89, F44.9, F45.0, F45.1, F45.20, F45.21, F45.22, F45.29, F45.41, F45.42, F45.8, F45.9, F48.1, F48.2, F48.8, F48.9, F50.00, F50.01, F50.010, F50.011, F50.012, F50.013, F50.019, F50.02, F50.020, F50.021, F50.022, F50.023, F50.029, F50.2, F50.20, F50.21, F50.22, F50.23, F50.24, F50.81, F50.810, F50.811, F50.812, F50.813, F50.819, F50.82, F50.83, F50.84, F50.89, F50.9, F51.01, F51.02, F51.03, F51.04, F51.05, F51.09, F51.11, F51.12, F51.13, F51.19, F51.3, F51.4, F51.5, F51.8, F51.9, F52.0, F52.1, F52.21, F52.22, F52.31, F52.32, F52.4, F52.5, F52.6, F52.8, F52.9, F53.0, F53.1, F54, F55.0, F55.1, F55.2, F55.3, F55.4, F55.8, F59, F60.0, F60.1, F60.2, F60.3, F60.4, F60.5, F60.6, F60.7, F60.81, F60.89, F60.9, F63.0, F63.1, F63.2, F63.3, F63.81, F63.89, F63.9, F64.0, F64.1, F64.2, F64.8, F64.9, F65.0, F65.1, F65.2, F65.3, F65.4, F65.50, F65.51, F65.52, F65.81, F65.89, F65.9, F66, F68.10, F68.11, F68.12, F68.13, F68.8, F68.A, F69, F90.0, F90.1, F90.2, F90.8, F90.9, F91.0, F91.1, F91.2, F91.3, F91.8, F91.9, F93.0, F93.8, F93.9, F94.0, F94.1, F94.2, F94.8, F94.9, F95.0, F95.1, F95.2, F95.8, F95.9, F98.0, F98.1, F98.21, F98.29, F98.3, F98.4, F98.5, F98.8, F98.9, F99
AND
Patient encounter during the denominator identification period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 90839, 90845, 90847, 90849, 90853, 90865, 90875*, 90876*, 90880, 90901, 90912, 96112, 96116, 96125, 96127, 96130, 96132, 96136, 96138, 96146, 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015, 98016, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99242*, 99243*, 99244*, 99245*, 99401*, 99402*, 99403*, 99404*, 99406, 99407, 99408*, 99409*, 99421, 99422, 99423, 99492, 99493, 99484, G0323, G0556, G0557, G0558, G0560
AND
Suicidal Ideation and/or Behavior Symptoms based on the C-SSRS or equivalent assessment: M1352
OR
Suicide risk based on their clinician’s evaluation or a clinician-rated tool: M1355
AND NOT
DENOMINATOR EXCLUSIONS:
Patients whose functional capacity or motivation (or lack thereof) to improve may impact the accuracy of results of validated tools such as delirium, dementia, intellectual disabilities, and pervasive and specific development disorders: M1479
OR
Patients who died during the measurement period: M1356
Reference Coding:
Denominator Exclusion for Patient Situations that may Impact Accuracy of Results [M1479] may be defined by the following coding only (ICD-10-CM):
F01.50, F01.511, F01.518, F01.52, F01.53, F01.54, F01.A0, F01.A11, F01.A18, F01.A2, F01.A3, F01.A4, F01.B0, F01.B11, F01.B18, F01.B2, F01.B3, F01.B4, F01.C0, F01.C11, F01.C18, F01.C2, F01.C3, F01.C4, F02.80, F02.811, F02.818, F02.82, F02.83, F02.84, F02.A0, F02.A11, F02.A18, F02.A2, F02.A3, F02.A4, F02.B0, F02.B11, F02.B18, F02.B2, F02.B3, F02.B4, F02.C0, F02.C11, F02.C18, F02.C2, F02.C3, F02.C4, F03.90, F03.911, F03.918, F03.92, F03.93, F03.94, F03.A0, F03.A11, F03.A18, F03.A2, F03.A3, F03.A4, F03.B0, F03.B11, F03.B18, F03.B2, F03.B3, F03.B4, F03.C0, F03.C11, F03.C18, F03.C2, F03.C3, F03.C4, F04, F05, F06.0, F06.1, F06.2, F06.30, F06.31, F06.32, F06.33, F06.34, F06.4, F06.70, F06.71, F06.8, F07.0, F07.81, F07.89, F07.9, F09, F70, F71, F72, F73, F78.A1, F78.A9, F79, F80.0, F80.1, F80.2, F80.4, F80.81, F80.82, F80.89, F80.9, F81.0, F81.2, F81.81, F81.89, F81.9, F82, F84.0, F84.2, F84.3, F84.5, F84.8, F84.9, F88, F89, QA00101, QA00102, QA00109, QA0011, QA0012, QA0013, QA00131, QA00139, QA00141, QA00142, QA00149, QA00151, QA00159, QA08
NUMERATOR (CRITERIA 1):
Patients for whom a completed suicide safety plan is initiated, reviewed, or updated in collaboration between the patient and their clinician at the time the suicidal ideation behavior or risk is identified (concurrent or within 24 hours of index clinical encounter), during the measurement period.
Definition:
Suicide Safety Plan – A brief intervention that involves the patient with suicidal ideation, behavior or risk and their clinician working in collaboration to identify and document: a written list of warning signs, internal coping strategies the patient can use to stay safe without involving others, sources of support (including access to professional services), and ways to make their environment safe.
Numerator Options:
Performance Met: Patients who had a completed suicide safety plan initiated, reviewed or updated in collaboration with their clinician (concurrent or within 24 hours) of the index clinical encounter (M1350)
OR
Performance Not Met: Patients who did not have a completed suicide safety plan initiated, reviewed or updated in collaboration with their clinician (concurrent or within 24 hours) of the index clinical encounter (M1353)
AND
SUBMISSION CRITERIA 2: ALL PATIENTS FOR WHOM A SUICIDE SAFETY PLAN IS INITIATED, REVIEWED, OR UPDATED CONCURRENT WITH THE INDEX ASSESSMENT AND WITHIN 120 DAYS AFTER INITIATION
DENOMINATOR (CRITERIA 2):
Patients aged 12 years and older with a mental and/or substance use disorder with suicidal ideation and/or behavior symptoms or suicide risk at a clinical encounter during the denominator identification period.
Definitions:
Suicidal ideation and/or behavior symptoms – Suicidal ideation and behavior should be assessed using a standardized assessment tool such as the Columbia Suicide Severity Rating Scale (C-SSRS) – ‘Screen Version’. The C-SSRS is a patient self-reported tool that enquires about wish for death, thoughts of suicide, suicidal thoughts with method without specific thoughts or intent, suicidal intent without and with specific plan, and suicide behavior. A “Yes” on the C-SSRS questions 1 or 2 indicates the need to initiate the Suicide Safety Plan. Other patient-reported assessment tools that qualify for this measure include but are not limited to: Patient Health Questionnaire (PHQ-9) – Item 9. The PHQ-9 is a routinely used scale in behavioral health and primary care. Item 9 of the instrument asks whether the patient has thoughts that they would be better off dead, or of hurting themselves. A “Yes” on PHQ-9 Item 9 indicates the need to initiate the Suicide Safety Plan.
Suicide risk based on clinician’s evaluation or a clinician-rated tool – A clinician may determine a patient at increased suicide risk by evaluation and clinical judgment or the use of a standardized tool, such as the CRPSR. The Clinician Rating of Potential Suicide Risk (CRPSR) is a single item clinician-rated tool that was developed and tested during the DSM-5 Field Trials. The assessment tool includes a listing of risk factors for suicide and a description of a what very high-risk patient might look like. The clinician is asked to consider the list of risk factors and the description of a very high-risk patient in their clinical evaluation of the patient, and to rate the patient’s risk for suicide and the need for suicide prevention as part of the patient’s current clinical management. A non-zero score on the CRPSR indicates the need to initiate the Suicide Safety Plan. Other clinician rated assessment tools that qualify for this measure include but are not limited to: Suicide Assessment Five-step Evaluation & Triage (SAFE-T), SAFE-T Protocol with CSSRS (Columbia Risk & Protective Factors) Lifetime/Recent, CSSRS (Columbia Risk & Protective Factors) Lifetime/Recent.
Denominator Identification Period – The period in which individuals can have an encounter at which suicidal thoughts or behaviors are found by a standardized assessment or screening tool OR a clinician determines increased suicide risk by evaluation or the results of a clinician-rated tool. The “denominator identification period” is the 12-month window starting 4 months prior to the measurement year and ending 8 months into the measurement year (September 1 of the previous year through August 31 of the current year).
Index Assessment – The clinical encounter when the patient first reports suicidal thoughts and/or behaviors OR is deemed at elevated suicide risk by their clinician is counted as the “index assessment”. If there are multiple qualifying assessments during the denominator identification period, the first qualifying assessment is counted as the index.
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 2 (Eligible Cases):
Patients aged 12 years and older on the date of the index encounter
AND
Diagnosis for any mental, behavioral, or substance use disorder on the date of the index encounter (ICD-10-CM): F10.10, F10.11, F10.120, F10.121, F10.129, F10.130, F10.131, F10.132, F10.139, F10.14, F10.150, F10.151, F10.159, F10.180, F10.181, F10.182, F10.188, F10.19, F10.20, F10.21, F10.220, F10.221, F10.229, F10.230, F10.231, F10.232, F10.239, F10.24, F10.250, F10.251, F10.259, F10.26, F10.27, F10.280, F10.281, F10.282, F10.288, F10.29, F10.90, F10.91, F10.920, F10.921, F10.929, F10.930, F10.931, F10.932, F10.939, F10.94, F10.950, F10.951, F10.959, F10.96, F10.97, F10.980, F10.981, F10.982, F10.988, F10.99, F11.10, F11.11, F11.120, F11.121, F11.122, F11.129, F11.13, F11.14, F11.150, F11.151, F11.159, F11.181, F11.182, F11.188, F11.19, F11.20, F11.21, F11.220, F11.221, F11.222, F11.229, F11.23, F11.24, F11.250, F11.251, F11.259, F11.281, F11.282, F11.288, F11.29, F11.90, F11.91, F11.920, F11.921, F11.922, F11.929, F11.93, F11.94, F11.950, F11.951, F11.959, F11.981, F11.982, F11.988, F11.99, F12.10, F12.11, F12.120, F12.121, F12.122, F12.129, F12.13, F12.150, F12.151, F12.159, F12.180, F12.188, F12.19, F12.20, F12.21, F12.220, F12.221, F12.222, F12.229, F12.23, F12.250, F12.251, F12.259, F12.280, F12.288, F12.29, F12.90, F12.91, F12.920, F12.921, F12.922, F12.929, F12.93, F12.950, F12.951, F12.959, F12.980, F12.988, F12.99, F13.10, F13.11, F13.120, F13.121, F13.129, F13.130, F13.131, F13.132, F13.139, F13.14, F13.150, F13.151, F13.159, F13.180, F13.181, F13.182, F13.188, F13.19, F13.20, F13.21, F13.220, F13.221, F13.229, F13.230, F13.231, F13.232, F13.239, F13.24, F13.250, F13.251, F13.259, F13.26, F13.27, F13.280, F13.281, F13.282, F13.288, F13.29, F13.90, F13.91, F13.920, F13.921, F13.929, F13.930, F13.931, F13.932, F13.939, F13.94, F13.950, F13.951, F13.959, F13.96, F13.97, F13.980, F13.981, F13.982, F13.988, F13.99, F14.10, F14.11, F14.120, F14.121, F14.122, F14.129, F14.13, F14.14, F14.150, F14.151, F14.159, F14.180, F14.181, F14.182, F14.188, F14.19, F14.20, F14.21, F14.220, F14.221, F14.222, F14.229, F14.23, F14.24, F14.250, F14.251, F14.259, F14.280, F14.281, F14.282, F14.288, F14.29, F14.90, F14.91, F14.920, F14.921, F14.922, F14.929, F14.93, F14.94, F14.950, F14.951, F14.959, F14.980, F14.981, F14.982, F14.988, F14.99, F15.10, F15.11, F15.120, F15.121, F15.122, F15.129, F15.13, F15.14, F15.150, F15.151, F15.159, F15.180, F15.181, F15.182, F15.188, F15.19, F15.20, F15.21, F15.220, F15.221, F15.222, F15.229, F15.23, F15.24, F15.250, F15.251, F15.259, F15.280, F15.281, F15.282, F15.288, F15.29, F15.90, F15.91, F15.920, F15.921, F15.922, F15.929, F15.93, F15.94, F15.950, F15.951, F15.959, F15.980, F15.981, F15.982, F15.988, F15.99, F16.10, F16.11, F16.120, F16.121, F16.122, F16.129, F16.14, F16.150, F16.151, F16.159, F16.180, F16.183, F16.188, F16.19, F16.20, F16.21, F16.220, F16.221, F16.229, F16.24, F16.250, F16.251, F16.259, F16.280, F16.283, F16.288, F16.29, F16.90, F16.91, F16.920, F16.921, F16.929, F16.94, F16.950, F16.951, F16.959, F16.980, F16.983, F16.988, F16.99, F17.200, F17.201, F17.203, F17.208, F17.209, F17.210, F17.211, F17.213, F17.218, F17.219, F17.220, F17.221, F17.223, F17.228, F17.229, F17.290, F17.291, F17.293, F17.298, F17.299, F18.10, F18.11, F18.120, F18.121, F18.129, F18.14, F18.150, F18.151, F18.159, F18.17, F18.180, F18.188, F18.19, F18.20, F18.21, F18.220, F18.221, F18.229, F18.24, F18.250, F18.251, F18.259, F18.27, F18.280, F18.288, F18.29, F18.90, F18.91, F18.920, F18.921, F18.929, F18.94, F18.950, F18.951, F18.959, F18.97, F18.980, F18.988, F18.99, F19.10, F19.11, F19.120, F19.121, F19.122, F19.129, F19.130, F19.131, F19.132, F19.139, F19.14, F19.150, F19.151, F19.159, F19.16, F19.17, F19.180, F19.181, F19.182, F19.188, F19.19, F19.20, F19.21, F19.220, F19.221, F19.222, F19.229, F19.230, F19.231, F19.232, F19.239, F19.24, F19.250, F19.251, F19.259, F19.26, F19.27, F19.280, F19.281, F19.282, F19.288, F19.29, F19.90, F19.91, F19.920, F19.921, F19.922, F19.929, F19.930, F19.931, F19.932, F19.939, F19.94, F19.950, F19.951, F19.959, F19.96, F19.97, F19.980, F19.981, F19.982, F19.988, F19.99, F20.0, F20.1, F20.2, F20.3, F20.5, F20.81, F20.89, F20.9, F21, F22, F23, F24, F25.0, F25.1, F25.8, F25.9, F28, F29, 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, F31.9, F32.0, F32.1, F32.2, F32.3, F32.4, F32.5, F32.81, F32.89, F32.9, F32.A, F33.0, F33.1, F33.2, F33.3, F33.40, F33.41, F33.42, F33.8, F33.9, F34.0, F34.1, F34.81, F34.89, F34.9, F39, F40.00, F40.01, F40.02, F40.10, F40.11, F40.210, F40.218, F40.220, F40.228, F40.230, F40.231, F40.232, F40.233, F40.240, F40.241, F40.242, F40.243, F40.248, F40.290, F40.291, F40.298, F40.8, F40.9, F41.0, F41.1, F41.3, F41.8, F41.9, F42.2, F42.3, F42.4, F42.8, F42.9, F43.0, F43.10, F43.11, F43.12, F43.20, F43.21, F43.22, F43.23, F43.24, F43.25, F43.29, F43.81, F43.89, F43.9, F44.0, F44.1, F44.2, F44.4, F44.5, F44.6, F44.7, F44.81, F44.89, F44.9, F45.0, F45.1, F45.20, F45.21, F45.22, F45.29, F45.41, F45.42, F45.8, F45.9, F48.1, F48.2, F48.8, F48.9, F50.00, F50.01, F50.010, F50.011, F50.012, F50.013, F50.019, F50.02, F50.020, F50.021, F50.022, F50.023, F50.029, F50.2, F50.20, F50.21, F50.22, F50.23, F50.24, F50.81, F50.810, F50.811, F50.812, F50.813, F50.819, F50.82, F50.83, F50.84, F50.89, F50.9, F51.01, F51.02, F51.03, F51.04, F51.05, F51.09, F51.11, F51.12, F51.13, F51.19, F51.3, F51.4, F51.5, F51.8, F51.9, F52.0, F52.1, F52.21, F52.22, F52.31, F52.32, F52.4, F52.5, F52.6, F52.8, F52.9, F53.0, F53.1, F54, F55.0, F55.1, F55.2, F55.3, F55.4, F55.8, F59, F60.0, F60.1, F60.2, F60.3, F60.4, F60.5, F60.6, F60.7, F60.81, F60.89, F60.9, F63.0, F63.1, F63.2, F63.3, F63.81, F63.89, F63.9, F64.0, F64.1, F64.2, F64.8, F64.9, F65.0, F65.1, F65.2, F65.3, F65.4, F65.50, F65.51, F65.52, F65.81, F65.89, F65.9, F66, F68.10, F68.11, F68.12, F68.13, F68.8, F68.A, F69, F90.0, F90.1, F90.2, F90.8, F90.9, F91.0, F91.1, F91.2, F91.3, F91.8, F91.9, F93.0, F93.8, F93.9, F94.0, F94.1, F94.2, F94.8, F94.9, F95.0, F95.1, F95.2, F95.8, F95.9, F98.0, F98.1, F98.21, F98.29, F98.3, F98.4, F98.5, F98.8, F98.9, F99
AND
Patient encounter during the denominator identification period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 90839, 90845, 90847, 90849, 90853, 90865, 90875*, 90876*, 90880, 90901, 90912, 96112, 96116, 96125, 96127, 96130, 96132, 96136, 96138, 96146, 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015, 98016, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99242*, 99243*, 99244*, 99245*, 99401*, 99402*, 99403*, 99404*, 99406, 99407, 99408*, 99409*, 99421, 99422, 99423, 99492, 99493, 99484, G0323, G0556, G0557, G0558, G0560
AND
Suicidal Ideation and/or Behavior Symptoms based on the C-SSRS or equivalent assessment: M1352
OR
Suicide risk based on their clinician’s evaluation or a clinician-rated tool: M1355
AND NOT
DENOMINATOR EXCLUSIONS:
Patients whose functional capacity or motivation (or lack thereof) to improve may impact the accuracy of results of validated tools such as delirium, dementia, intellectual disabilities, and pervasive and specific development disorders: M1479
OR
Patients who died during the measurement period: M1356
Reference Coding:
Denominator Exclusion for Patient Situations that may Impact Accuracy of Results [M1479] may be defined by the following coding only (ICD-10-CM):
F01.50, F01.511, F01.518, F01.52, F01.53, F01.54, F01.A0, F01.A11, F01.A18, F01.A2, F01.A3, F01.A4, F01.B0, F01.B11, F01.B18, F01.B2, F01.B3, F01.B4, F01.C0, F01.C11, F01.C18, F01.C2, F01.C3, F01.C4, F02.80, F02.811, F02.818, F02.82, F02.83, F02.84, F02.A0, F02.A11, F02.A18, F02.A2, F02.A3, F02.A4, F02.B0, F02.B11, F02.B18, F02.B2, F02.B3, F02.B4, F02.C0, F02.C11, F02.C18, F02.C2, F02.C3, F02.C4, F03.90, F03.911, F03.918, F03.92, F03.93, F03.94, F03.A0, F03.A11, F03.A18, F03.A2, F03.A3, F03.A4, F03.B0, F03.B11, F03.B18, F03.B2, F03.B3, F03.B4, F03.C0, F03.C11, F03.C18, F03.C2, F03.C3, F03.C4, F04, F05, F06.0, F06.1, F06.2, F06.30, F06.31, F06.32, F06.33, F06.34, F06.4, F06.70, F06.71, F06.8, F07.0, F07.81, F07.89, F07.9, F09, F70, F71, F72, F73, F78.A1, F78.A9, F79, F80.0, F80.1, F80.2, F80.4, F80.81, F80.82, F80.89, F80.9, F81.0, F81.2, F81.81, F81.89, F81.9, F82, F84.0, F84.2, F84.3, F84.5, F84.8, F84.9, F88, F89, QA00101, QA00102, QA00109, QA0011, QA0012, QA0013, QA00131, QA00139, QA00141, QA00142, QA00149, QA00151, QA00159, QA08
NUMERATOR (CRITERIA 2):
Patients for whom a suicide safety plan is initiated, reviewed, or updated in collaboration between the individual and their clinician at the time the suicidal ideation, behavior or risk is identified (concurrent or within 24 hours of clinical encounter) AND reviewed and updated within 120 days after the index clinical encounter after initiation.
Definitions:
Suicide Safety Plan – A brief intervention that involves the patient with suicidal ideation, behavior or risk and their clinician working in collaboration to identify and document: a written list of warning signs, internal coping strategies the patient can use to stay safe without involving others, sources of support (including access to professional services), and ways to make their environment safe.
Measurement Period – A 16-month period, starting 4 months prior to the previous performance period through the 12 months of the of the current performance period.
Numerator Options:
Performance Met: Patients who had a suicide safety plan initiated, reviewed, or updated AND reviewed and updated in collaboration with the patient and their clinician concurrent or within 24 hours of clinical encounter and within 120 days after initiation (M1351)
OR
Performance Not Met: Patients who did not have a suicide safety plan initiated, reviewed, or updated OR reviewed and updated in collaboration with the patient and their clinician concurrent or within 24 hours of clinical encounter and within 120 days after initiation (M1354)
RATIONALE
Suicide safety planning (SSP), which involves counseling the suicidal individual around reducing access to lethal means, teaching brief problem-solving and coping skills, and helping the individual increase social support and identify emergency contacts is effective and critical in suicide prevention as echoed in recent clinical practice guidelines and recommendations from the Joint Commission (Stanley et al., 2016). It has been identified as the best practice for suicide prevention by the American Foundation for Suicide Prevention and the Suicide Prevention Resource (Action Alliance, 2018). In fact, this effective suicide prevention initiative has been found to be clinically useful and feasible by both suicidal individuals and clinicians, associated with reduction in suicidal behaviors (Brodsky et a., 2018). Individuals with suicidal ideation and behaviors also report that the SSP helps them maintain their safety and increases the likelihood of them remaining in care (Stanley et al., 2016).
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