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Clinical Quality Measures Report - Adult Major Depressive Disorder (MDD): Suicide Risk Assessment

This article covers the Clinical Quality Measure Report "Adult Major Depressive Disorder (MDD): Suicide Risk Assessment". This report is used to meet Clinical Quality Measure requirements for MIPS and Medicaid reporting programs. We'll cover the structure of the report and how it works so you can meet your Clinical Quality Measure requirements.

Overview of Measure
The Adult Major Depressive Disorder (MDD): Suicide Risk Assessment Report measures the percentage of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified.

A patient will be in the denominator when they have all of the following:

  • An age 18 or older
  • A visit during your reporting period 
  • A Depression diagnosis in their Problem List with an Onset Date matching the Procedure Date of their visit

A patient will be in the numerator when they have all of the following:

  • A Suicide Risk Assessment SNOMED code, 225337009, added to their EMR or EHR in the SNOMED code section with an Onset Start Date and End Date matching the Procedure Date of their visit

 

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Filters

  • Filter Providers: This filter allows you to narrow the generated data to include and exclude specific providers. When checked, any selected providers will be included in the results.
  • Filter Offices: This filter allows you to narrow the generated data to include and exclude specific Office references.
  • Filter Ethnicities: This filter will allow you to narrow the generated results to specific ethnicities as designated in a patient's record under the Patients Ability > Patient Tab > Race/Ethnicity sub-tab.
  • Filter Races: This filter will allow you to narrow the generated results to specific races as designated in a patient's record under the Patients Ability > Patient Tab > Race/Ethnicity sub-tab.
  • Filter Sex: This filter will allow you to narrow the generated results to specific genders as designated by the "Sex" field in the Patients Ability > Patient Tab > Sex drop down menu.
  • Filter Insurances: This filter allows you to narrow down results to patients that have the selected insurances added in the Patients Ability > Patient Tab > Insurance Sub-Tab.
  • Filter Tax Identification Numbers: This filters narrows results based on the provider's Tax ID numbers. In this case, it will narrow down to patients with the associated providers.
  • Filter National Provider Identifiers: This filters narrows results based on the provider's National Provider Identifier (NPI). In this case, it will narrow down to patients with the associated providers.
  • Filter Provider Types: This filter will narrow results by the Provider Taxonomy codes present in References > User > Provider Tab > Provider Taxonomy. To be precise, it will narrow the results to patients associated with providers with the selected Taxonomy codes entered in the User Reference.
  • Filter Problem Lists: This filter will narrow the results down to patients who have the selected diagnosis codes entered into their Problem Lists. You can find these in the Clinical Ability under the Problem List widget.
  • Filter Practice Address: This filter will narrow results down to patients who are associated with the Office with an address that matches the selected address.
  • Start/End Date: These fields allow you to narrow the range of the generated results to the specified date range.
  • Start Age/End Age: These drop downs allow you to narrow results down to patients with ages in between the range.

Results

Unexpanded

  • Group Name: For reports with multiple numerator requirements, this identifies the numerator that is being checked for. In this report's case, there is only one numerator requirement.
  • Numerator: The number of patient that meet the numerator requirements described above.
  • Denominator: The number of patients that meet the denominator requirements described above.
  • Percentage: The percentage of patients meeting both the numerator and denominator requirements.

First expansion

  • Patient #: The Patient Account Number for the Patient in question.
  • Patient Name: The name of the patient in question, formatted as last name/first name.
  • Episode: The procedure visit code for the patient in question which qualifies them as part of the denominator. 
  • Date: The date of the visit/episode in question.
  • In Numerator (Yes/No): This column identifies whether the patient in question meets the numerator requirements.
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