Depression Care summary
The Depression measure suite should be thought of as two separate measures
1: Clinic level population counts and
2: Patient level data file
1. The clinic level population counts is a process measure that assess how often the tool is administered/used. It includes 2 counts and is simply a count (number) of patients that were billed with an encounter with an eligible diagnosis. Billing data should be used for this count, but the problem list can be used to identify exclusions if you wish. The clinic counts include 12 counts total. This includes the following:
Adults (six counts total: 2 counts per period):
Count 1 period 1; Count 2 period 1
Count 1 period 2; Count 2 period 2
Count 1 period 3; Count 2 period 3
Adolescents (six counts total: 2 counts per period):
Count 1 period 1; Count 2 period 1
Count 1 period 2; Count 2 period 2
Count 1 period 3; Count 2 period 3
Clinic Level Population Counts: This measure has three measure periods:
Period A: Jan 1- April 30;
Period B: May 1- Aug 31;
Period C: Sept 1- Dec 31 (Period C= publicly reported Measure 3C)
Count 1 is the denominator and should be a count of all unique patients that had an encounter with an eligible diagnosis (ICD code in Depression value set) within the measure period. Please only count patients once per period but a patient should be counted in each period in which they had an eligible encounter, so a patient can be counted a maximum of three times if they had an encounter billed with a depression diagnosis in each period.
Count 2 is the numerator and should count all patients from count 1 that completed a PHQ9/PHQ9M tool within the measure period. Again, please only count patients once per period but a patient should be counted in each period in which they completed a tool. Patients should only be counted in this count if they were eligible for count 1 so your rate should not be greater than 100%.
2. The patient level data file should be thought of as the second measure, however it actually consists of 6 measures in one. This is a longitudinal prospective measure that tracks a cohort of indexed patients through three submission cycles.
In order to index, a patient needs to:
- Have an eligible diagnosis (ICD code from the value set)
- And the patient needs to complete a PHQ9/PHQ9M tool with a result of 10 or higher.
- The patient needs to have had an eligible “encounter”. For this measure, an encounter can be an office visit, psychiatry, psychotherapy, telephone or online encounter. The tool can be completed either on the same day or up to 7 days before the eligible encounter.
- The patient needs to be 12 years of age or older at the time of the encounter. This creates an index event.
- Finally, the patient must not be locked in to a previous index 14-month assessment window. All assessments completed within the 14-month assessment window will be considered as follow-up scores and a patient cannot re-index within their 14-month assessment window.
When a patient indexes, the portal will identify the patient ID associated with the index and it will store this patient ID for 14 months. The portal will then assess all subsequent assessments submitted with that same patient ID to determine if the patient is numerator compliant for the follow-up, response or remission measures. Each patient has a unique 14-month assessment window that is calculated from the initial index event.
It is critical to make sure that the patient IDs are consistently formatted the same way each year in order to link follow-up scores to previous indexes. If you have questions about how your patient IDs were previously submitted, you can let us know and we can provide a list of previously indexed patients for comparison. Please check your patient ID format to ensure they are formatted the same as previous submissions before you submit data.
There are two options for submitting the patient level data file. It sounds like you will submit option 1, which is recommended.
Option 1: submit all PHQ9/PHQ9M assessments completed from 1/1/2021 – 12/31/2021 that are from patients 12+ years old. The portal will identify which assessments are new indexes, follow-up scores or neither. This is the best way to ensure that you are getting credit for all follow-up scores.
Option 2: Involves two steps-
1: You will need to submit all follow-up assessments from patients previously indexed between 11/1/2019 – 12/31/2020. You can download a list of previously indexed patients from the data portal by following these instructions.
2: You will need to identify all new index assessments from 1/1/2021 – 12/31/2021. This would be all assessments completed with the indexing criteria mentioned above.
Exclusions for this measure are also complex. It is not acceptable to exclude patients up-front because the measure is calculated from three submission cycles. For option 1, you would submit all patients with an eligible exclusion in your data file but you would include the MNCM exclusion code and an exclusion date. This will alert the portal to remove the patient from your denominator if the patient previously indexed to ensure that the patient will not negatively impact your rates.