Measure ID: MIPS 504·Suicide Prevention·2026 Performance Year

2026 MIPS Measure #504: Initiation, Review, and/or Update to Suicide Safety Plan for Individuals with Suicidal

Percentage of patients aged 12 years and older with suicidal ideation or behavior symptoms (based on results of a standardized assessment tool or screening tool) or increased suicide risk (based on the clinician's evaluation or clinician- rating tool) for whom a suicide safety plan is initiated, reviewed, and/or updated in collaboration between the patient and their clinician.

Process – High PrioritySuicide PreventionMental Health
Measure ID:MIPS 504 (Quality ID 504)
Collection:MIPS CQM
Topped Out:No
View CMS Spec ↗

Measure Specification

This measure produces 2 performance rates. Each rate has its own eligible population, numerator, and reporting codes.

Rate 1
Eligible Population
Eligible patients based on diagnosis codes
ANDDiagnosis for any mental, behavioral, or substance use disorder on the date of the index encounter (ICD- 10-CM)
ANDPatient encounter during the denominator identification period
ANDSuicidal Ideation and/or Behavior Symptoms based on the C-SSRS or equivalent assessment: M1352
ORSuicide risk based on their clinician's evaluation or a clinician-rated tool: M1355
Exclusions
M1479Patients whose functional capacity or motivation (or lack thereof) to improve may impact the accuracy of results of validated tools such as delirium, dementia, intellectual disabilities, and pervasive and specific development disorders
M1356Patients who died during the measurement period: M1356
M1356Patients who died during the measurement period: M1356
Numerator
Patients for whom a completed suicide safety plan is initiated, reviewed, or updated in collaboration between the patient and their clinician at the time the suicidal ideation behavior or risk is identified (concurrent or within 24 hours of index clinical encounter), during the measurement period.
Reporting Codes

Performance Met:

M1350Patients who had a completed suicide safety plan initiated, reviewed or updated in collaboration with their clinician (concurrent or within 24 hours) of the index clinical encounter

Performance Not Met:

M1353Patients who did not have a completed suicide safety plan initiated, reviewed or updated in collaboration with their clinician (concurrent or within 24 hours) of the index clinical encounter
Rate 2
Eligible Population
Eligible patients based on diagnosis codes
ANDDiagnosis for any mental, behavioral, or substance use disorder on the date of the index encounter (ICD- 10-CM)
ANDPatient encounter during the denominator identification period
ANDSuicidal Ideation and/or Behavior Symptoms based on the C-SSRS or equivalent assessment: M1352
ORSuicide risk based on their clinician's evaluation or a clinician-rated tool: M1355
Exclusions
M1479Patients whose functional capacity or motivation (or lack thereof) to improve may impact the accuracy of results of validated tools such as delirium, dementia, intellectual disabilities, and pervasive and specific development disorders
M1356Patients who died during the measurement period: M1356
M1356Patients who died during the measurement period: M1356
Reporting Codes
VBCA Insights

Why This Measure Matters

Any patient aged 12 or older with suicidal thoughts or behaviors needs a written safety plan created together with you—identifying triggers, coping strategies, people to contact, and means reduction. This measure ensures the plan is initiated, reviewed, or updated at the time the risk is identified or within 24 hours. Safety planning is evidence-based suicide prevention; it takes 15-20 minutes and has been shown to reduce suicide attempts. Make it part of your standard protocol whenever you assess suicide risk.

VBCA is a CMS-approved Qualified Clinical Data Registry (QCDR) that submits MIPS Measure 504 to the Quality Payment Program (QPP). Practices can report this measure as a MIPS Clinical Quality Measure (CQM) or through qualified registry submission.

🧮MIPS Score Simulator

Estimate only — actual CMS scoring may vary based on reporting method, data completeness, and annual rule updates.

%Benchmarks vary by collection type
💡 Tip: Enter your performance rate to compare MIPS points across all collection types. The same rate can score differently depending on how you submit.

2026 MIPS 504 Benchmarks

Historical CMS benchmark deciles for MIPS quality measure 504 by collection type. Your performance rate falls into a decile, which determines your measure points (3–10).

MIPS CQM
DecilePerformance Rate RangePoints

Clinical Context

Clinical Rationale

Suicide safety planning (SSP), which involves counseling the suicidal individual around reducing access to lethal means, teaching brief problem-solving and coping skills, and helping the individual increase social support and identify emergency contacts is effective and critical in suicide prevention as echoed in recent clinical practice guidelines and recommendations from the Joint Commission.

It has been identified as the best practice for suicide prevention by the American Foundation for Suicide Prevention and the Suicide Prevention Resource. In fact, this effective suicide prevention initiative has been found to be clinically useful and feasible by both suicidal individuals and clinicians, associated with reduction in suicidal behaviors.

Individuals with suicidal ideation and behaviors also report that the SSP helps them maintain their safety and increases the likelihood of them remaining in care.

Clinical Recommendations

Suicide safety plan is a brief intervention that involves working in collaboration with the patient, who is at risk for suicide, to identify and document a written list of warning signs of that the patient is becoming suicidal; coping strategies; sources of support; and means restrictions (Stanley et al., 2016). It must include the following 6 steps, where the provider helps the patient: Recognize the warning signs of the suicidal crisis.

Learn how to employ internal coping strategies without needing to contact another person. Understand the need for and benefits of socializing with family members or others who may offer distraction from the suicidal crisis. Contact family members or friends who may help them resolve the suicidal crisis. Contact mental health professionals or agencies.

Identify ways to make their environment safe (e.g., reduce their access to lethal means, such as firearms).

Implementation Notes

This measure contains two strata defined by two submission criteria. This measure produces two performance rates There are 2 Submission Criteria for this measure: 1) All patients for whom a suicide safety plan is initiated, reviewed, or updated (concurrent or within 24 hours of clinical encounter) AND 2) All patients for whom a suicide safety plan is initiated, reviewed, or updated in collaboration between the individual and their clinician at the time the suicidal ideation, behavior or risk is identified (concurrent or within 24 hours of clinical encounter) (i.

e., individuals who satisfy Numerator 1) AND reviewed and updated within 120 days after initiation This measure will be calculated with 2 performance rates: 1) Percentage of patients for whom a suicide safety plan is initiated, reviewed, or updated in collaboration between the patient and their clinician (concurrent or within 24 hours of clinical encounter) 2) Percentage of patients for whom a suicide safety plan is initiated, reviewed, or updated in collaboration between the individual and their clinician at the time the suicidal ideation, behavior or risk is identified (concurrent or within 24 hours of clinical encounter) AND reviewed and updated within 120 days after initiation.

For accountability reporting in the CMS MIPS program, the rate for Submission Criteria 2 is used for performance. For the purposes of MIPS, this patient-process measure is submitted a minimum of once per patient during the performance period. The most advantageous quality data code will be used if the measure is submitted more than once.

Frequently Asked Questions

Who is eligible for MIPS 504?

DENOMINATOR (CRITERIA 1): Patients aged 12 years and older with a mental and/or substance use disorder with suicidal ideation and/or behavior symptoms or suicide risk at a clinical encounter during the denominator identification period. Definitions: Suicidal ideation and/or behavior symptoms – Suicidal ideation and behavior should be assessed using a standardized assessment tool such as the Columbia Suicide Severity Rating Scale (C-SSRS) – ‘Screen Version’. The C-SSRS is a patient self-reported tool that enquires about wish for death, thoughts of suicide, suicidal thoughts with method without specific thoughts or intent, suicidal intent without and with specific plan, and suicide behavior. A “Yes” on the C-SSRS questions 1 or 2 indicates the need to initiate the Suicide Safety Plan. Other patient-reported assessment tools that qualify for this measure include but are not limited to: Patient Health Questionnaire (PHQ-9) – Item 9. The PHQ-9 is a routinely used scale in behavioral health and primary care. Item 9 of the instrument asks whether the patient has thoughts that they would be better off dead, or of hurting themselves. A “Yes” on PHQ-9 Item 9 indicates the need to initiate the Suicide Safety Plan. Suicide risk based on clinician's evaluation or a clinician-rated tool – A clinician may determine a patient at increased suicide risk by evaluation and clinical judgment or the use of a standardized tool, such as the Clinician Rating of Potential Suicide Risk (CRPSR). The CRPSR is a single item clinician-rated tool that was developed and tested during the DSM-5 Field Trials. The assessment tool includes a listing of risk factors for suicide and a description of a what very high-risk patient might look like. The clinician is asked to consider the list of risk factors and the description of a very high-risk patient in their clinical evaluation of the patient, and to rate the patient’s risk for suicide and the need for suicide prevention as part of the patient’s current clinical management. A non-zero score on the CRPSR indicates the need to initiate the Suicide Safety Plan. Other clinician rated assessment tools that qualify for this measure include but are not limited to: Suicide Assessment Five-step Evaluation & Triage (SAFE-T), SAFE-T Protocol with CSSRS (Columbia Risk & Protective Factors) Lifetime/Recent, CSSRS (Columbia Risk & Protective Factors) Lifetime/Recent. Denominator Identification Period – The period in which individuals can have an encounter at which suicidal thoughts or behaviors are found by a standardized assessment or screening tool OR a clinician determines increased suicide risk by evaluation or the results of a clinician-rated tool. The “denominator identification period” is the 12-month window starting 4 months prior to the measurement year and ending 8 months into the measurement year (September 1 of the previous year thru August 31 of the current year). Index Assessment – The clinical encounter when the patient first reports suicidal thoughts and/or behaviors OR is deemed at elevated suicide risk by their clinician is counted as the index assessment. If there are multiple qualifying assessments during the denominator identification period, the first qualifying assessment is counted as the index. DENOMINATOR (CRITERIA 2): Patients aged 12 years and older with a mental and/or substance use disorder with suicidal ideation and/or behavior symptoms or suicide risk at a clinical encounter during the denominator identification period. Definitions: Suicidal ideation and/or behavior symptoms – Suicidal ideation and behavior should be assessed using a standardized assessment tool such as the Columbia Suicide Severity Rating Scale (C-SSRS) – ‘Screen Version’. The C-SSRS is a patient self-reported tool that enquires about wish for death, thoughts of suicide, suicidal thoughts with method without specific thoughts or intent, suicidal intent without and with specific plan, and suicide behavior. A “Yes” on the C-SSRS questions 1 or 2 indicates the need to initiate the Suicide Safety Plan. Other patient-reported assessment tools that qualify for this measure include but are not limited to: Patient Health Questionnaire (PHQ-9) – Item 9. The PHQ-9 is a routinely used scale in behavioral health and primary care. Item 9 of the instrument asks whether the patient has thoughts that they would be better off dead, or of hurting themselves. A “Yes” on PHQ-9 Item 9 indicates the need to initiate the Suicide Safety Plan. Suicide risk based on clinician's evaluation or a clinician-rated tool – A clinician may determine a patient at increased suicide risk by evaluation and clinical judgment or the use of a standardized tool, such as the CRPSR. The Clinician Rating of Potential Suicide Risk (CRPSR) is a single item clinician-rated tool that was developed and tested during the DSM-5 Field Trials. The assessment tool includes a listing of risk factors for suicide and a description of a what very high-risk patient might look like. The clinician is asked to consider the list of risk factors and the description of a very high-risk patient in their clinical evaluation of the patient, and to rate the patient’s risk for suicide and the need for suicide prevention as part of the patient’s current clinical management. A non-zero score on the CRPSR indicates the need to initiate the Suicide Safety Plan. Other clinician rated assessment tools that qualify for this measure include but are not limited to: Suicide Assessment Five-step Evaluation & Triage (SAFE-T), SAFE-T Protocol with CSSRS (Columbia Risk & Protective Factors) Lifetime/Recent, CSSRS (Columbia Risk & Protective Factors) Lifetime/Recent. Denominator Identification Period – The period in which individuals can have an encounter at which suicidal thoughts or behaviors are found by a standardized assessment or screening tool OR a clinician determines increased suicide risk by evaluation or the results of a clinician-rated tool. The “denominator identification period” is the 12-month window starting 4 months prior to the measurement year and ending 8 months into the measurement year (September 1 of the previous year through August 31 of the current year). Index Assessment – The clinical encounter when the patient first reports suicidal thoughts and/or behaviors OR is deemed at elevated suicide risk by their clinician is counted as the “index assessment”. If there are multiple qualifying assessments during the denominator identification period, the first qualifying assessment is counted as the index.

Is MIPS 504 the same as MIPS 504?

Yes. CMS uses zero-padded three-digit Quality IDs (504) in official specifications, while clinicians often search for MIPS 504 or Quality ID 504 without the leading zero. Both refer to the same 2026 MIPS quality measure reported through the Quality Payment Program (QPP).

What codes do I submit for MIPS 504: Initiation, Review, and/or Update to Suicide Safety Plan for Individuals with Suicidal?

Submission codes: M1350 (Patients who had a completed suicide safety plan initiated, reviewed or updated in collaboration with their clinician (concurrent or within 24 hours) of the index clinical encounter); M1353 (Patients who did not have a completed suicide safety plan initiated, reviewed or updated in collaboration with their clinician (concurrent or within 24 hours) of the index clinical encounter)

How do I report MIPS Measure 504 in 2026?

MIPS Measure 504 (Quality ID 504) is reported through the Quality Payment Program (QPP) as a MIPS Clinical Quality Measure (CQM) via qualified registry, or Medicare Part B claims where applicable.

Is MIPS 504 a topped-out measure?

No, MIPS 504 is not topped out, meaning there is still meaningful performance variation across clinicians.

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