2019 CMS Web Interface

[Pages:31]MH-1 (NQF 0710): Depression Remission at Twelve Months 2019

2019 CMS Web Interface

MH-1 (NQF 0710): Depression Remission at Twelve Months

Measure Steward: MNCM

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MH-1 (NQF 0710): Depression Remission at Twelve Months 2019

Contents INTRODUCTION ........................................................................................................................................................4 CMS WEB INTERFACE SAMPLING INFORMATION ..............................................................................................5 BENEFICIARY SAMPLING .......................................................................................................................................5 NARRATIVE MEASURE SPECIFICATION ...............................................................................................................6 DESCRIPTION: .........................................................................................................................................................6 IMPROVEMENT NOTATION: ...................................................................................................................................6 INITIAL POPULATION: .............................................................................................................................................6 DENOMINATOR: ....................................................................................................................................................... 6 DENOMINATOR EXCLUSIONS:...............................................................................................................................6 DENOMINATOR EXCEPTIONS:...............................................................................................................................6 NUMERATOR:........................................................................................................................................................... 6 NUMERATOR EXCLUSIONS: ..................................................................................................................................6 DEFINITIONS: ...........................................................................................................................................................6 GUIDANCE: ............................................................................................................................................................... 7 SUBMISSION GUIDANCE.........................................................................................................................................8 PATIENT CONFIRMATION.......................................................................................................................................8 SUBMISSION GUIDANCE.........................................................................................................................................9 DENOMINATOR CONFIRMATION ...........................................................................................................................9 SUBMISSION GUIDANCE.......................................................................................................................................11 DENOMINATOR CONFIRMATION .........................................................................................................................11 SUBMISSION GUIDANCE.......................................................................................................................................12 DENOMINATOR CONFIRMATION .........................................................................................................................12 SUBMISSION GUIDANCE.......................................................................................................................................13 NUMERATOR SUBMISSION ..................................................................................................................................13 SUBMISSION GUIDANCE.......................................................................................................................................14 NUMERATOR SUBMISSION ..................................................................................................................................14 DOCUMENTATION REQUIREMENTS....................................................................................................................15 APPENDIX I: PERFORMANCE CALCULATION FLOW ........................................................................................16 APPENDIX II: DOWNLOADABLE RESOURCE MAPPING TABLE.......................................................................23 APPENDIX III: MEASURE RATIONALE AND CLINICAL RECOMMENDATION STATEMENTS .........................24 RATIONALE: ...........................................................................................................................................................24 CLINICAL RECOMMENDATION STATEMENTS:...................................................................................................24 APPENDIX IV: USE NOTICES, COPYRIGHTS, AND DISCLAIMERS ...................................................................28

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COPYRIGHT ...........................................................................................................................................................28

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INTRODUCTION There are a total of 10 individual measures included in the 2019 CMS Web Interface targeting high-cost chronic conditions, preventive care, and patient safety. The measures documents are represented individually and contain measure specific information. The corresponding coding documents are posted separately in an Excel format.

The measure documents are being provided to allow group practices and Accountable Care Organizations (ACOs) an opportunity to better understand each of the 10 individual measures included in the 2019 CMS Web Interface data submission method. Each measure document contains information necessary to submit data through the CMS Web Interface.

Narrative specifications, supporting submission documentation, and calculation flows are provided within each document. Please review all of the measure documentation in its entirety to ensure complete understanding of these measures.

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CMS WEB INTERFACE SAMPLING INFORMATION BENEFICIARY SAMPLING For more information on the sampling process and methodology please refer to the 2019 CMS Web Interface Sampling Document, which will be made available during the performance year at .

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NARRATIVE MEASURE SPECIFICATION

DESCRIPTION: The percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event.

IMPROVEMENT NOTATION: Higher score indicates better quality

INITIAL POPULATION: Adolescent patients 12 to 17 years of age and adult patients 18 years of age and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 or PHQ-9M score greater than nine during the index event.

DENOMINATOR: Equals Initial Population

DENOMINATOR EXCLUSIONS: Patients with a diagnosis of bipolar disorder Patients with a diagnosis of personality disorder Patients with a diagnosis of schizophrenia or psychotic disorder Patients with a diagnosis of pervasive developmental disorder Patients who were permanent nursing home residents

DENOMINATOR EXCEPTIONS: None

NUMERATOR: Adolescent patients 12 to 17 years of age and adult patients 18 years of age and older who achieved remission at twelve months as demonstrated by a twelve month (+/- 60 days) PHQ-9 or PHQ-9M score of less than five.

NUMERATOR EXCLUSIONS: Not Applicable

DEFINITION: Denominator Identification Period - The period in which eligible patients can have an index event. The denominator identification period occurs prior to the measurement period and is defined as 14 months to two months prior to the start of the measurement period. The denominator identification period is from 11/1/2017 to 10/31/2018. For patients with an index event, there needs to be enough time following index for the patients to have the opportunity to reach remission twelve months +/- 60 days after the index event date.

Index Event Date - The date in which the first instance of elevated PHQ-9 or PHQ-9M greater than nine AND diagnosis of depression or dysthymia occurs during the denominator identification measurement period (11/1/2017 to 10/31/2018).

Measure Assessment Period - The index event date marks the start of the measurement assessment period for each patient which is 14 months (12 months +/- 60 days) in length to allow for a follow-up PHQ-9 or PHQ-9M between 10 and 14 months following the index event. This assessment period is fixed and does not "start over" with a higher PHQ-9 or PHQ-9M that may occur after the index event date.

Remission - Is defined as a PHQ-9 or PHQ-9M score of less than five.

Twelve Months - Is defined as the point in time from the index event date extending out twelve months and then allowing a grace period of sixty days prior to and sixty days after this date. The most recent PHQ-9 or PHQ-9M score

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less than five obtained during this four month period is deemed as remission at twelve months, values obtained prior to or after this period are not counted as numerator compliant (remission). GUIDANCE: None

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SUBMISSION GUIDANCE

PATIENT CONFIRMATION

Establishing patient eligibility for submission requires the following:

o Determine if the patient's medical record can be found

o If you can locate the medical record select "Yes"

OR

o If you cannot locate the medical record select "No - Medical Record Not Found"

OR

o Determine if the patient is qualified for the sample

If the patient is deceased, in hospice, moved out of the country or did not have Feefor-Service (FFS) Medicare as their primary payer select "Not Qualified for Sample", select the applicable reason from the provided drop-down menu, and enter the date the patient became ineligible

Guidance Patient Confirmation

If "No ? Medical Record Not Found" or "Not Qualified for Sample" is selected, the patient is completed but not confirmed. The patient will be "skipped" and another patient must be submitted in their place, if available. The CMS Web Interface will automatically skip any patient for whom "No ? Medical Record Not Found" or "Not Qualified for Sample" is selected in all other measures into which they have been sampled.

If "Not Qualified for Sample" is selected and the date is unknown, you may enter the last date of the measurement period (i.e., 12/31/2019).

The Measurement Period is defined as January 1 ? December 31, 2019.

NOTE:

- In Hospice: Select this option if the patient is not qualified for sample due to being in hospice care at any time during the measurement period (this includes non-hospice patients receiving palliative goals or comfort care)

- Moved out of Country: Select this option if the patient is not qualified for sample because they moved out of the country any time during the measurement period

- Deceased: Select this option if the patient died during the measurement period - Non-FFS Medicare: Select this option if the patient was enrolled in Non-FFS Medicare at any time during

the measurement period (i.e., commercial payers, Medicare Advantage, Non-FFS Medicare, HMOs, etc.) This exclusion is intended to remove beneficiaries for whom Fee-for-Service Medicare is not the primary payer.

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