Adult Major Depressive Disorder (MDD): Suicide Risk Assessment

All patient visits during which a new diagnosis of MDD or a new diagnosis of recurrent MDD was identified for patients aged 18 years and older with a suicide risk assessment completed during the visit.

Date Reviewed: September 28, 2022

Measure Info

MIPS 107 CMIT ID 5813
Measure Type
Measure Steward
Clinical Topic Area

Care Setting
Emergency Department and Services
Data Source
Electronic Health Records

This clinical topic area is important and meaningful; however, the definition of a recurrent episode lacks evidence. The PMC recommends adding more evidence for the definition. This performance measure has been tested and proven to have high reliability and electronic health record (EHR) empirical validity. The code set captures the use of the suicide risk assessment accurately with a standardized code set. The timeframe of 105 days allows the physician to determine what is a recurrent episode. Developers should consider revising the specifications to stipulate that this is an episode associated with the initiation of new treatment for depression. The performance measure allows for several different standardized assessments to gauge suicide risk for ease of implementation.