MIPS Clinical Quality Measures (CQMS)
MEASURE TYPE: Process – High Priority
Description
Percentage of adult aged 18 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
This measure is to be submitted a minimum of once per performance period for patients with mental and/or substance use disorder AND suicidal thoughts, behaviors, or risk symptoms who are seen during the performance period. This measure is intended to reflect the quality of services provided for patients with suicidal ideation or behavior symptoms or are at increased risk (based on clinician’s evaluation) with whom a suicide safety plan is initiated, reviewed, or updated within 24 hours of clinical encounter and within 120 days after initiation. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who provided the measure- specific denominator coding.
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.
NOTE: Patient encounters for this measure conducted via telehealth (including but not limited to encounters coded with GQ, GT, 95, POS 02, POS 10) 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.
There are two 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)
- 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.
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 (Submission Criteria 1)
Patients aged 18 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 18 years and older on the date of the index encounter
AND
Diagnosis for any mental, behavioral, or substance use disorder (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, F50.02, F50.2, F50.81, F50.82, 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): 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, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99242*, 99243*, 99244*, 99245*, 99401*, 99402*, 99403*, 99404*, 99406, 99407, 99408*, 99409*, 99421, 99422, 99423, 99441, 99442, 99443
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 (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
OR
Patients who died during the measurement period: M1356
Numerator (Submission 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)
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 (Submission Criteria 2)
Patients aged 18 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 18 years and older on the date of the index encounter
AND
Diagnosis for any mental, behavioral, or substance use disorder (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, F50.02, F50.2, F50.81, F50.82, 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): 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, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99242*, 99243*, 99244*, 99245*, 99401*, 99402*, 99403*, 99404*, 99406, 99407, 99408*, 99409*, 99421, 99422, 99423, 99441, 99442, 99443
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 (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
OR
Patients who died during the measurement period: M1356
Numerator (Submission 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).
CLINICAL RECOMMENDATION STATEMENTS:
Suicide safety plan is a brief intervention that involves working in collaboration with the patient, who is at risk for suicide, to identify and document a written list of warning signs of that the patient is becoming suicidal; coping strategies; sources of support; and means restrictions (Stanley et al., 2016). It must include the following 6 steps, where the provider helps the patient:
- Recognize the warning signs of the suicidal crisis.
- Learn how to employ internal coping strategies without needing to contact another person.
- Understand the need for and benefits of socializing with family members or others who may offer distraction from the suicidal crisis.
- Contact family members or friends who may help them resolve the suicidal crisis.
- Contact mental health professionals or agencies.
- Identify ways to make their environment safe (e.g., reduce their access to lethal means, such as firearms).
COPYRIGHT:
© 2023 APA and NCQA. All rights reserved.
THE MEASURE AND SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY KIND.
The measure specification was developed by and is co-owned by the American Psychiatric Association (APA) and the National Committee for Quality Assurance (NCQA). Funding was provided by the Centers for Medicare & Medicaid Services under Grant # 1V1CMS331640-01-01 (“Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Funding Opportunity: Measure Development for the Quality Payment Program (Mental Health/Substance Use Care)). The measure specification, while copyrighted by APA and NCQA, is subject to public disclosure and dissemination and can be reproduced and distributed, without modification, for non-commercial purposes (e.g., use by healthcare providers in connection with their practices). A commercial use is defined as any sale, license or distribution of the measure into a product or service that is sold, licensed or distributed for commercial gain. Commercial use of the measure specification requires a license agreement between the intended user and APA or NCQA. Neither APA, its members, nor NCQA shall be responsible for any use made of the measure specification. The measure specification is not a clinical guideline, and does not establish a standard of medical care, and has not been tested for all potential applications. The measure specification is provided “as is” without warranty of any kind and the APA and NCQA make no representations, warranties, or endorsement about the quality of any organization or clinician that uses or reports performance measures. The APA and NCQA have no liability to anyone who relies on such measure specifications. The APA and NCQA hold a copyright in these materials and can alter these materials at any time. These materials may not be modified by anyone other than the APA or NCQA. © 2023 APA and NCQA, all rights reserved.
Limited proprietary coding is contained in the measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. APA, its members, and NCQA disclaim all liability for use or accuracy of any coding contained in the specifications.
CPT® contained in the Measure specifications is copyright 2004-2023 American Medical Association. LOINC® copyright 2004-2023 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms® (SNOMED CT®) copyright 2004-2023 International Health Terminology Standards Development Organisation. ICD-10 copyright 2023 World Health Organization. All Rights Reserved.
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