Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk AssessmentFHIR - Draft dQM CMS Content Implementation Guide v2025.1.0

Draft dQM CMS Content Implementation Guide, published by cqframework. This guide is not an authorized publication; it is the continuous build for version 2025.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/cqframework/dqm-content-cms-2025/ and changes regularly. See the Directory of published versions

Measure: Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk AssessmentFHIR

Official URL: https://madie.cms.gov/Measure/CMS177FHIRChildMDDSuicideAssmt		Version: 1.0.000
Active as of 2026-01-16	Responsible: Mathematica	Computable Name: CMS177FHIRChildMDDSuicideAssmt
Other Identifiers: Short Name: CMS177FHIR (use: usual, ), UUID:50d1dfcf-e2bf-41e8-bc1c-c607e5a09e79 (use: official, ), UUID:2df449e3-aa29-4cbb-b042-9c6e583f200a (use: official, ), Endorser: 1365e (use: official, ), Publisher: 177FHIR (use: official, )
Copyright/Legal: Copyright 2025 Mathematica Inc. All Rights Reserved. The PCPI and American Medical Association’s (AMA) significant past efforts and contributions to the development and updating of the Measure is acknowledged.

Percentage of patient visits for those patients aged 6 through 16 at the start of the measurement period with a diagnosis of major depressive disorder (MDD) with an assessment for suicide risk

Metadata

Title Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk AssessmentFHIR

Version 1.0.000

Short Name CMS177FHIR

GUID (Version Independent) urn:uuid:50d1dfcf-e2bf-41e8-bc1c-c607e5a09e79

GUID (Version Specific) urn:uuid:2df449e3-aa29-4cbb-b042-9c6e583f200a

CMS Identifier 177FHIR

CMS Consensus Based Entity Identifier 1365e

Effective Period 2026-01-01 through 2026-12-31

Steward (Publisher) Mathematica

Developer Mathematica

Description

Percentage of patient visits for those patients aged 6 through 16 at the start of the measurement period with a diagnosis of major depressive disorder (MDD) with an assessment for suicide risk

The PCPI and American Medical Association's (AMA) significant past efforts and contributions to the development and updating of the Measure is acknowledged.

Disclaimer

The Measure is not a clinical guideline, does not establish a standard of medical care, and has not been tested for all potential applications. The Measure, while copyrighted, can be reproduced and distributed, without modification, for noncommercial purposes, e.g., use by health care providers in connection with their practices. Commercial use is defined as the sale, license, or distribution of the Measure for commercial gain, or incorporation of the Measure into a product or service that is sold, licensed or distributed for commercial gain.

Commercial uses of the Measure require a license agreement between the user and Mathematica. Neither Mathematica, the PCPI, nor the American Medical Association (AMA), nor the former AMA-convened Physician Consortium for Performance Improvement(R) (AMA-PCPI), nor their members shall be responsible for any use of the Measure. Mathematica encourages use of the Measure by other health care professionals, where appropriate.

THE MEASURE AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.

Limited proprietary coding may be contained in the Measure specifications for convenience. A license agreement must be entered prior to a third party's use of Current Procedural Terminology (CPT[R]) or other proprietary code set contained in the Measure. Any other use of CPT or other coding by a third party is strictly prohibited. Mathematica, the AMA, and former members of the PCPI disclaim all liability for use or accuracy of any CPT(R) or other coding contained in the specifications.

CPT(R) contained in the Measure specifications is copyright 2004-2024 American Medical Association. LOINC(R) is copyright 2004-2024 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2024 International Health Terminology Standards Development Organisation. ICD-10 is copyright 2024 World Health Organization. All Rights Reserved. Due to technical limitations, registered trademarks are indicated by (R) or [R].

Rationale

Research has shown that youth with major depressive disorder (MDD) are at a high risk for suicide attempts and completion - among the most significant and devastating sequelae of the disease (Fontanella et al., 2020). Suicide risk is a critical consideration in children and adolescents with MDD, and an important aspect of care that should be assessed at each visit and subsequently managed to minimize that risk. Additionally, the importance of the assessments is underscored by research (Fontanella et al., 2020; Luoma, Martin, & Pearson, 2002) that indicates that many individuals who die by suicide do make contact with primary care providers and mental health services beforehand. More specifically, approximately 15% of suicide victims aged 35 years or younger had seen a mental health professional within 1 month of suicide while approximately 23% had seen a primary care provider within 1 month of suicide (Luoma, Martin, & Pearson, 2002). A recent analysis of depression severity and suicidal ideation symptom trajectories (Witt et al., 2021) found that suicidal ideation among children and young adults (15-25 years) might not improve with depression symptom severity. This evidence suggests the potential utility of continued suicide risk screening even after improvements in depression symptoms. Better assessment and identification of suicide risk in the health care setting should lead to improved connection to treatment and reduction in suicide attempts and deaths by suicide.

Clinical Recommendation Statement

The evaluation must include assessment for the presence of harm to self or others (Birmaher et al., 2007).

Suicidal behavior exists along a continuum from passive thoughts of death to a clearly developed plan and intent to carry out that plan. Because depression is closely associated with suicidal thoughts and behavior, it is imperative to evaluate these symptoms at the initial and subsequent assessments. For this purpose, low burden tools to track suicidal ideation and behavior such as the Columbia-Suicidal Severity Rating Scale can be used. Also, it is crucial to evaluate the risk (e.g., age, sex, stressors, comorbid conditions, hopelessness, impulsivity) and protective factors (e.g., religious belief, concern not to hurt family) that might influence the desire to attempt suicide. The risk for suicidal behavior increases if there is a history of suicide attempts, comorbid psychiatric disorders (e.g., disruptive disorders, substance abuse), impulsivity and aggression, availability of lethal agents (e.g., firearms), exposure to negative events (e.g., physical or sexual abuse, violence), and a family history of suicidal behavior (Birmaher et al., 2007).

A careful and ongoing evaluation of suicide risk is necessary for all patients with major depressive disorder (Category I). Such an assessment includes specific inquiry about suicidal thoughts, intent, plans, means, and behaviors; identification of specific psychiatric symptoms (e.g., psychosis, severe anxiety, substance use) or general medical conditions that may increase the likelihood of acting on suicidal ideas; assessment of past and, particularly, recent suicidal behavior; delineation of current stressors and potential protective factors (e.g., positive reasons for living, strong social support); and identification of any family history of suicide or mental illness (Category I) (Gelenberg et al., 2010).

Citation

American Academy of Child and Adolescent Psychiatry. (2007). Practice parameter for the assessment and treatment of children and adolescents with depressive disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 46(11), 1503-1526. doi:10.1097/chi.0b013e318145ae1c

Citation

American Psychiatric Association. (2010). Practice guideline for the treatment of patients with major depressive disorder. 3rd edition. Retrieved from http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf (This guideline was reaffirmed in 2015.)

Citation

Fontanella, C. A., Warner, L. A., Steelesmith, D., Bridge, J. A., Sweeney, H. A., Campo, J. V. (2020). Clinical profiles and health services patterns of Medicaid-enrolled youths who died by suicide. Journal of the American Medical Association Pediatrics, 174(5), 470-477. doi:10.1001/jamapediatrics.2020.0002

Citation

Luoma, J. B., Martin, C. E., & Pearson, J. L. (2002). Contact with mental health and primary care providers before suicide: A review of the evidence. American Journal of Psychiatry, 159(6), 909-916. doi:10.1176/appi.ajp.159.6.909

Citation

Witt, K., Madsen, T., Berk, M., Dean, O., Chanen, A., McGorry, P.D., Cotton, S., Davey, C.G., Hetrick, S. (2021). Trajectories of change in depression symptoms and suicidal ideation over the course of evidence-based treatment for depression: Secondary analysis of a randomized controlled trial of cognitive behavioral therapy plus fluoxetine in young people. Australian and New Zealand Journal of Psychiatry, 55(5), 506-516. doi:10.1177/0004867421998763

Definition Numerator Definition: The specific type and magnitude of the suicide risk assessment is intended to be at the discretion of the individual clinician and should be specific to the needs of the patient. At a minimum, suicide risk assessment should evaluate: 1. Risk (e.g., age, sex, stressors, comorbid conditions, hopelessness, impulsivity) and protective factors (e.g., religious belief, concern not to hurt family) that may influence the desire to attempt suicide. 2. Current severity of suicidality. 3. Most severe point of suicidality in episode and lifetime.

Definition Numerator Definition: Low burden tools to track suicidal ideation and behavior such as the Columbia-Suicidal Severity Rating Scale can also be used. Because no validated assessment tool or instrument fully meets the aforementioned requirements for the suicide risk assessment, individual tools or instruments have not been explicitly included in coding.

Guidance (Usage) This dQM is an episode-based measure. An episode is defined as each eligible encounter for major depressive disorder (MDD) during the measurement period. A suicide risk assessment should be performed at every visit for MDD during the measurement period. In recognition of the growing use of integrated and team-based care, the diagnosis of depression and the assessment for suicide risk need not be performed by the same provider or clinician. Suicide risk assessments completed via telehealth services can also meet numerator performance. Use of a standardized tool(s) or instrument(s) to assess suicide risk will meet numerator performance, so long as the minimum criteria noted is evaluated. Standardized tools can be mapped to the code "Suicide risk assessment (procedure)" included in the numerator logic, as no individual suicide risk assessment tool or instrument would satisfy the requirements alone. This FHIR-based measure has been derived from the QDM-based measure: CMS177v14. Please refer to the HL7 QI-Core Implementation Guide (https://hl7.org/fhir/us/qicore/STU6/) for more information on QI-Core and mapping recommendations from QDM to QI-Core STU 6 (https://hl7.org/fhir/us/qicore/STU6/qdm-to-qicore.html).

Measure Group (Rate) (ID: Group_1)

Basis Encounter

Scoring Proportion

Improvement Notation Increased score indicates improvement

Type Process

Rate Aggregation None

Initial Population

ID: InitialPopulation_1
Description:

All patient visits for those patients aged 6 through 16 at the start of the measurement period with a diagnosis of major depressive disorder

Criteria: Initial Population

Denominator

ID: Denominator_1
Description:

Equals Initial Population

Criteria: Denominator

Numerator

ID: Numerator_1
Description:

Patient visits with an assessment for suicide risk

Criteria: Numerator

<p>For every patient evaluated by this measure also identify payer, race, ethnicity and sex</p>

Supplemental Data Elements

Supplemental Data Element ID: sde-ethnicity
Usage Code: Supplemental Data
Description: SDE Ethnicity
Logic Definition: SDE Ethnicity

Supplemental Data Element ID: sde-race
Usage Code: Supplemental Data
Description: SDE Race
Logic Definition: SDE Race

Supplemental Data Element ID: sde-sex
Usage Code: Supplemental Data
Description: SDE Sex
Logic Definition: SDE Sex

Supplemental Data Element ID: sde-payer
Usage Code: Supplemental Data
Description: SDE Payer
Logic Definition: SDE Payer

Measure Logic

Primary Library https://madie.cms.gov/Library/CMS177FHIRChildMDDSuicideAssmt

Contents Population Criteria
Logic Definitions
Terminology
Dependencies
Data Requirements
Parameters

Population Criteria

Measure Group (Rate) (ID: Group_1)

Initial Population

define "Initial Population":
  "Major Depressive Disorder Encounter" MDDEncounter
    where ( "AgeInYearsAt"(date from start of "Measurement Period") >= 6
        and "AgeInYearsAt"(date from start of "Measurement Period") <= 16
    )

Definition

Denominator

define "Denominator":
  "Initial Population"

Definition

Numerator

define "Numerator":
  "Encounter With Procedure For Suicide Risk Assessment"
    union "Encounter With Observation For Suicide Risk Assessment"

Definition

Logic Definitions

Logic Definition Library Name: SupplementalDataElements

define "SDE Sex":
  case
    when Patient.sex() = '248153007' then "Male (finding)"
    when Patient.sex() = '248152002' then "Female (finding)"
    else null
  end

Logic Definition Library Name: SupplementalDataElements

define "SDE Payer":
  [USQualityCore.Coverage: type in "Payer Type"] Payer
    return {
      code: Payer.type,
      period: Payer.period
    }

Logic Definition Library Name: SupplementalDataElements

define "SDE Ethnicity":
  (Patient.ethnicity()) E
    return Tuple {
      codes: { E.ombCategory } union E.detailed,
      display: E.text
    }

Logic Definition Library Name: SupplementalDataElements

define "SDE Race":
  (Patient.race()) R
    return Tuple {
      codes: R.ombCategory union R.detailed,
      display: R.text
    }

Logic Definition Library Name: CMS177FHIRChildMDDSuicideAssmt

define "SDE Sex":
  SDE."SDE Sex"

Logic Definition Library Name: CMS177FHIRChildMDDSuicideAssmt

define "Encounter With Condition Major Depressive Disorder":
  ( ["Encounter": "Office Visit"]
    union ["Encounter": "Outpatient Consultation"]
    union ["Encounter": "Psych Visit Diagnostic Evaluation"]
    union ["Encounter": "Psych Visit for Family Psychotherapy"]
    union ["Encounter": "Psych Visit Psychotherapy"]
    union ["Encounter": "Psychoanalysis"]
    union ["Encounter": "Group Psychotherapy"]
    union ["Encounter": "Telephone Visits"] ) ValidEncounter
    where ValidEncounter.status = 'finished'
      and ValidEncounter.period during day of "Measurement Period"
      and exists ( ( ["ConditionProblemsHealthConcerns": "Major Depressive Disorder Active"] MDDConditionProb
            where ValidEncounter.reasonReference.references ( MDDConditionProb )
        )
          union ( ["ConditionEncounterDiagnosis": "Major Depressive Disorder Active"] MDDEncDx
              where ValidEncounter.reasonReference.references ( MDDEncDx )
          )
      )

Logic Definition Library Name: CMS177FHIRChildMDDSuicideAssmt

define "Encounter With Reason Major Depressive Disorder":
  ( ["Encounter": "Office Visit"]
    union ["Encounter": "Outpatient Consultation"]
    union ["Encounter": "Psych Visit Diagnostic Evaluation"]
    union ["Encounter": "Psych Visit for Family Psychotherapy"]
    union ["Encounter": "Psych Visit Psychotherapy"]
    union ["Encounter": "Psychoanalysis"]
    union ["Encounter": "Group Psychotherapy"]
    union ["Encounter": "Telephone Visits"] ) ValidEncounter
    where ValidEncounter.status = 'finished'
      and ValidEncounter.period during day of "Measurement Period"
      and ( ValidEncounter.reasonCode in "Major Depressive Disorder Active" )

Logic Definition Library Name: CMS177FHIRChildMDDSuicideAssmt

define "Major Depressive Disorder Encounter":
  "Encounter With Condition Major Depressive Disorder"
    union "Encounter With Reason Major Depressive Disorder"

Logic Definition Library Name: CMS177FHIRChildMDDSuicideAssmt

define "Encounter With Procedure For Suicide Risk Assessment":
  "Major Depressive Disorder Encounter" MDDEncounter
    with ["Procedure": "Suicide risk assessment (procedure)"] SuicideRiskAssessmentProcedure
      such that SuicideRiskAssessmentProcedure.status = 'completed'
        and SuicideRiskAssessmentProcedure.performed.toInterval ( ) during MDDEncounter.period

Logic Definition Library Name: CMS177FHIRChildMDDSuicideAssmt

define "Encounter With Observation For Suicide Risk Assessment":
  "Major Depressive Disorder Encounter" MDDEncounter
    with ( ["ObservationScreeningAssessment": "Suicide risk assessment (procedure)"]
      union ["ObservationClinicalResult": "Suicide risk assessment (procedure)"] ) ObservationSuicideRiskAssmt
      such that ObservationSuicideRiskAssmt.effective.toInterval ( ) during MDDEncounter.period
        and ObservationSuicideRiskAssmt.status in { 'final', 'corrected', 'amended' }

Logic Definition Library Name: CMS177FHIRChildMDDSuicideAssmt

define "Numerator":
  "Encounter With Procedure For Suicide Risk Assessment"
    union "Encounter With Observation For Suicide Risk Assessment"

Logic Definition Library Name: CMS177FHIRChildMDDSuicideAssmt

define "Initial Population":
  "Major Depressive Disorder Encounter" MDDEncounter
    where ( "AgeInYearsAt"(date from start of "Measurement Period") >= 6
        and "AgeInYearsAt"(date from start of "Measurement Period") <= 16
    )

Logic Definition Library Name: CMS177FHIRChildMDDSuicideAssmt

define "Denominator":
  "Initial Population"

Logic Definition Library Name: CMS177FHIRChildMDDSuicideAssmt

define "SDE Payer":
  SDE."SDE Payer"

Logic Definition Library Name: CMS177FHIRChildMDDSuicideAssmt

define "SDE Ethnicity":
  SDE."SDE Ethnicity"

Logic Definition Library Name: CMS177FHIRChildMDDSuicideAssmt

define "SDE Race":
  SDE."SDE Race"