Measure ID: MIPS 505|Suicide Prevention|2026 Performance Year

2026 MIPS Measure #505: Reduction in Suicidal Ideation or Behavior Symptoms

The percentage of patients aged 18 years and older with a mental and/or substance use disorder AND suicidal thoughts, behaviors or risk symptoms who demonstrated a reduction in suicidal ideation and/or behavior symptoms based on results from the Columbia-Suicide Severity Rating Scale 'Screen Version' or 'Since Last Visit' (C-SSRS), within 120 days after an index assessment.

Patient-Reported Outcome-Based Performance Measure (PRO-PM) – High PrioritySuicide PreventionMental HealthPatient-Reported Outcomes
Measure ID:MIPS 505 (Quality ID 505)
Collection:MIPS CQM
Topped Out:No
View CMS Spec ↗

Measure Specification

Eligible Population
Patients aged 18 years and older on the date of the index encounter during the denominator identification period
ANDDiagnosis for any mental, behavioral, or substance use disorder on the date of the index encounter during the denominator identification period
ANDPatient encounter during the denominator identification period
ANDSuicidal Ideation and/or Behavior Symptoms based on the C-SSRS: M1360
ORSuicide risk based on their clinician's evaluation or a clinician-rated tool: M1361
ANDIndex Assessment during the denominator period when the suicidal ideation and/or behavior symptoms or increased suicide risk by clinician determination occurs AND a non-zero C-SSRS score is obtained: M1359
Exclusions
M1480Patients 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
M1362Patients who died during the measurement period: M1362
Numerator
Patients who demonstrated a reduction in suicidal ideation and/or behavior symptoms as demonstrated by results of a follow-up assessment using the C-SSRS within 120 days after the index assessment during the measurement period.
Reporting Codes

Performance Met:

M1357Patients who had a reduction in suicidal ideation and/or behavior upon follow-up assessment within 120 days of index assessment

Performance Not Met:

M1358Patients who did not have a reduction in suicidal ideation and/or behavior upon follow-up assessment within 120 days of index assessment
M1363Patients who did not have a follow-up assessment within 120 days of the index assessment
VBCA Insights

Why This Measure Matters

For patients with mental health or substance use disorders who have suicidal thoughts, this outcome measure tracks whether their suicidal ideation actually improves. Administer the Columbia Suicide Severity Rating Scale at baseline and again within 120 days, looking for a score reduction. As with any symptom-focused treatment, the goal is measurable improvement. Close monitoring of suicidal symptoms is essential to detecting worsening and adjusting treatment rapidly.

VBCA is a CMS-approved Qualified Clinical Data Registry (QCDR) that submits MIPS Measure 505 to the Quality Payment Program (QPP). Practices can report this measure as a MIPS Clinical Quality Measure (CQM) or through qualified registry submission.

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Related Measures

Patient-Reported Outcomes
MIPS 191: Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract SurgeryMIPS 217: Functional Status Change for Patients with Knee ImpairmentsMIPS 218: Functional Status Change for Patients with Hip ImpairmentsMIPS 219: Functional Status Change for Patients with Lower Leg, Foot or Ankle ImpairmentsMIPS 220: Functional Status Change for Patients with Low Back ImpairmentsMIPS 221: Functional Status Change for Patients with Shoulder ImpairmentsMIPS 222: Functional Status Change for Patients with Elbow, Wrist or Hand ImpairmentsMIPS 303: Cataracts: Improvement in Patient’s Visual Function within 90 Days Following CataractMIPS 420: Varicose Vein Treatment with Saphenous Ablation: Outcome SurveyMIPS 459: Back Pain After Lumbar SurgeryMIPS 461: Leg Pain After Lumbar SurgeryMIPS 470: Functional Status After Primary Total Knee ReplacementMIPS 471: Functional Status After Lumbar SurgeryMIPS 478: Functional Status Change for Patients with Neck ImpairmentsMIPS 483: Person-Centered Primary Care Measure Patient Reported OutcomeMIPS 485: Psoriasis – Improvement in Patient-Reported Itch SeverityMIPS 486: Dermatitis – Improvement in Patient-Reported Itch Severity

Clinical Rationale

Mental and substance use disorders are among the 25 leading causes of years lived with disability and contribute significantly to the global burden of disease. Specifically, 19% of U.S. adults (46.6 million individuals aged 18 and older) have a mental illness and 7.6% (18.7 million individuals aged 18 and older) have a substance use- disorder. Mental and substance use disorders often co-occur with about 8.

5 million adults aged 18 and older in the US having both conditions. Individuals with mental and/or substance use disorders are at high risk for suicide - a leading cause of death in the US and a preventable cause of lost lives. For the past 20 years death by suicide has increased significantly with more than 40,000 Americans dying by suicide each year and reaching over 47,000 in 2018.

Adding alarm to this issue is the even greater number of Americans who attempt suicide each year (i.e., 20 to 25 times more than the number of suicide) and the resulting health consequences including the group’s 2-4 times increased risk for dying by suicide. An even greater proportion of Americans (~100X) have serious thoughts of suicide. This measure encourages the provision of evidence-based care to individuals presenting to a number of health professionals across a variety of settings for the assessment and care of their mental or substance use disorders.

More specifically, the proposed measure aims to avert or reduce the risk of suicide and associated outcome (i.e., suicide attempts) in this population that is at high risk for suicide and suicide attempts. The measure emphasizes patient- centered quality care, which is important for combating these prevalent and preventable outcomes that affect thousands of Americans each year.

Clinical Recommendations

Suicidal ideation and behavior should be assessed using the Columbia-Suicide Severity Rating Scale 'Screen Version' or the 'Since Last Visit' version of the C-SSRS (CSSR, 2008). The C-SSRS is a patient self-reported tool that asks 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.

The C-SSRS “score” for the current measure is the sum of all the Yes/No items (Yes = 1, No = 0) if using the ‘Screen Version’ or intensity of ideation if using the ‘Since Last Visit’ version. A non-zero on questions 1 or 2 of either C-SSRS version qualifies as at risk. C-SSRS ‘Screen Version’ available at: https://www.cms.gov/files/document/cssrs-screen-version-instrument.

pdf C-SSRS ‘Since Last Visit’ available at: https://cssrs.columbia.

Implementation Notes

This measure contains one strata defined by a single submission criteria. This measure produces a single performance rate. For the purposes of MIPS implementation, this patient-periodic measure is submitted a minimum of once per patient per timeframe specified by the measure during the performance period. The most advantageous quality data code will be used if the measure is submitted more than once.

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