eCQM Depression Remission at Twelve Months (CMS159v5)

Note: Access to the EHR features described in this article may differ for practices who have already purchased a Practice Fusion EHR subscription plan. Please contact Practice Fusion Customer Service for additional information.

eMeasure ID:

CMS 159v5

Measure Type:

Outcome

MIPS High Priority Measure:

Yes

Quality ID:

370

Eligible for Quality Programs:

  • Merit-Based Incentive Payment System (MIPS)
  • Medicaid EHR Incentive Program (Meaningful Use)

Performance Benchmark for MIPS:

No historic benchmark exists for this measure. For measures with no historic benchmark, MIPS will attempt to calculate benchmarks based on 2017 performance data. If no historic benchmark exists and no benchmark can be calculated, the measure will receive 3 points if performance data is submitted.

Description:

Patients age 18 and older with major depression or dysthymia and an initial Patient Health Questionnaire (PHQ-9) score greater than nine who demonstrate remission at twelve months (+/- 30 days after an index visit) defined as a PHQ-9 score less than five. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment.

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

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

    • Denominator Exclusions:

      • Patients who died

      • Patients who received hospice or palliative care services

      • Patients who were permanent nursing home residents

      • Patients with a diagnosis of bipolar disorder

      • Patients with a diagnosis of personality disorder

    • Denominator Exceptions: None

eCQM Patient Reports

eCQM Patient Reports can help you identify patient care gaps and improve the performance of your quality measures. Click on the blue result numbers in the eCQM Dashboard to see the patient report for this measure.

The eCQM Patient Reports list the individual patients included in the measure’s population, which measure cohorts the patient is in, and contact information for the patient to streamline any downstream communication that may be needed to fulfill the measure requirements. You can choose to print the patient list for a measure or export it as a CSV.

The measure cohorts included in the eCQM Patient Report for CMS 159v5 Depression Remission at Twelve Months are:

  • Initial patient population
  • Denominator
  • Numerator
  • Exclusion

Denominator Requirements

The following requirements must be met in order for patients in the Practice Fusion EHR to be included in the measure denominator.

  1. The patient must have a signed SOAP note during the measurement period that has an encounter type from the Face-to-Face Interaction - No ED value set.

    1. See Table 1 for example encounter types eligible for this measure denominator

    2. The patient should complete a PHQ-9 assessment during this encounter, but the PHQ-9 result does not need to be associated with the encounter in Practice Fusion to count towards the measure.

    3. Click here to learn how to configure encounter types in Practice Fusion.

  2. Patient must be 18 years of age or older during the encounter described in Step 1.

  3. Patient must have an active diagnosis of major depression or dysthymia (see Table 1 for examples of qualifying diagnoses).

    1. The diagnosis must have a start date that is on or before the date of the denominator-eligible encounter.

    2. The diagnosis cannot have a stop date during the measurement period or it will not be considered active.

  4. Patient must have a PHQ-9 recorded in the denominator-eligible encounter flowsheet with a score of >9. The start date of the PHQ-9 must be the same as the Date of Service of the denominator-eligible encounter outlined in Step 1.

    1. Click here to learn how to add a new Test/Panel/Study to your flowsheet in the Practice Fusion EHR.

    2. To add a PHQ-9 score, search for “PHQ-9” or “Patient Health Questionnaire” when adding a Test/Panel/Study to your flowsheet.

    3. If score results were not previously recorded in the patient flowsheet, results may be added to the flowsheet and backdated to meet measure requirements.

Table 1. CMS 159v5 Denominator Value Sets

Value Set Name & Type

Example Data Elements

PF Suggested Workflow

Face-to-Face Interaction - No ED

Encounter

  • Office visit (SNOMED 185349003)
  • Nurse visit (SNOMED 19681004)
  • Nursing home visit (SNOMED 207195004)
  • Home visit (SNOMED 439708006)
  • Visit out of hours  (SNOMED 185463005)
  • Patient-initiated encounter (SNOMED 270427003)
  • Follow-up encounter (SNOMED 390906007)

  • Select the appropriate encounter type from the drop-down menu at the top of the SOAP note, or configure your encounter types to add one not available by default
  • Click here to learn how to configure encounter types in Practice Fusion.

Major depression Diagnosis

  • Major depressive disorder, single episode, mild (ICD-10 F32.0)
  • Major depressive disorder, recurrent, moderate (ICD-10 F33.1)

  • Record the diagnosis in the Diagnoses or Assessments section of the patient encounter and assign the appropriate start date.
  • The diagnosis must have a start date that is on or before the date of the denominator-eligible encounter to qualify for the measure. 

Dysthymia

Diagnosis

  • Dysthymic disorder (ICD-10 F34.1)

PHQ-9

Assessment Tool

  • Patient Health Questionnaire 9 item (PHQ-9) total score [Reported] (LOINC 44261-6)

  • In the denominator-eligible encounter, record the PHQ-9 score in the appropriate flowsheet observation row. 
  • To add a PHQ-9 score, search for “PHQ-9” or “Patient Health Questionnaire” when adding a Test/Panel/Study to your flowsheet.
  • For details on how to add a new Test/Panel/Study to your flowsheet, click here.


Numerator Requirements

The following requirements must be met in order for patients in the Practice Fusion EHR to be included in the measure numerator.

  1. The denominator-eligible patient must have another PHQ-9 score (result < 5) recorded in the medical record that has a date more than 10 months, but less than 13 months, from the original PHQ-9 score from the denominator.

    1. The PHQ-9 with a result of < 5 must be recorded in a flowsheet (see Table 2 for numerator value sets).

      1. Click here to learn how to add a new Test/Panel/Study to your flowsheet  in the Practice Fusion EHR.

    2. If score results were not previously recorded in the patient flowsheet, results may be added to the flowsheet and backdated to ensure the date is appropriate for the measure.  

Table 2. CMS 159v6 Numerator Value Sets

Value Set Name & Type

Data Element

PF Suggested Workflow

PHQ-9

Assessment Tool

  • Patient Health Questionnaire 9 item (PHQ-9) total score [Reported] (LOINC 44261-6)

  • In the numerator-eligible encounter, record the PHQ-9 score in the appropriate flowsheet observation row. 
  • To add a PHQ-9 score, search for “PHQ-9” or “Patient Health Questionnaire” when adding a Test/Panel/Study to your flowsheet.
  • For more details on how to add a new Test/Panel/Study to your flowsheet, click here.


Denominator Exclusion Requirements

This measure excludes patients who meet the following criteria from the denominator of the measure:

  • Patients who died
  • Patients who received hospice or palliative care services
  • Patients who were permanent nursing home residents
  • Patients with a diagnosis of bipolar disorder
  • Patients with a diagnosis of personality disorder

See Table 3 for suggested workflows for recording denominator exclusions for this measure.

Table 3. Practice Fusion Suggested Workflows for CMS 159v5 Denominator Exclusions

Denominator Exclusion

Practice Fusion Suggested Workflow

Patients who died

  • A date of death that is during the measurement period is recorded in the patient chart. In the patient's profile, next to "Patient information" click Add more information, then Date of death. Fill in the date of death and click Save.

Patients who received hospice or palliative care services

  • In the Screenings/Interventions/Assessments section of the patient encounter, search for one of the appropriate palliative care services listed below and select the item:

    • Palliative care (regime/therapy) (SNOMED 103735009)

    • Hospice care (regime/therapy) (SNOMED 385763009)

  • Once selected, record and save the following information in the modal window that opens:

    • Status: Ordered

    • Start date: Must be during the measurement period to be eligible for the exclusion

      • If the service was ordered on the same date of service as the encounter in which it is recorded in the Screenings/Interventions/Assessments section, a start or end date should not be entered for the screening.

Patients with a diagnosis of bipolar disorder

  • Patient has an active diagnosis of bipolar disorder with a valid start date and no stop date recorded in his/her chart. Examples of eligible bipolar diagnoses include:

    • Manic episode without psychotic symptoms, mild (ICD-10 F30.11)

    • Bipolar II disorder (ICD-10 F31.81)

Patients with a diagnosis of personality disorder

  • Patient has an active diagnosis of personality disorder with a valid start date and no stop date recorded in his/her chart. Examples of eligible personality disorder diagnoses include:

    • Paranoid personality disorder (ICD-10 F60.0)

    • Borderline personality disorder (ICD-10 F60.3)


More Information

eCQMs

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  2. How​ ​do​ ​I​ ​create​ ​a​ ​group​ ​in​ ​the​ ​eCQM​ ​Dashboard?
  3. eCQM Depression Remission at Twelve Months (CMS159v5)
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