2026 MIPS Measure #504: Initiation, Review, And/Or Update To Suicide Safety Plan For Individuals With Suicidal Thoughts, Behavior, Or Suicide Risk

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.

This measure is to be submitted a minimum of once per performance period for patients with mental and/or substance use disorder AND suicidal thoughts, behaviors, or risk symptoms who are seen during the performance period. This measure is intended to reflect the quality of services provided for patients with suicidal ideation or behavior symptoms or are at increased risk (based on clinician’s evaluation) with whom a suicide safety plan is initiated, reviewed, or updated within 24 hours of clinical encounter and within 120 days after initiation. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who provided the measurespecific denominator coding.

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

NOTE: Patient encounters for this measure conducted via telehealth (including but not limited to encounters coded with GQ, GT, 95, POS 02, POS 10) are allowable. Please note that effective January 1, 2025, while a measure may be denoted as telehealth eligible, specific denominator codes within the encounter may no longer be eligible due to changes outlined in the CY 2024 PFS Final Rule List of Medicare Telehealth Services.

Measure Submission Type:
Measure data may be submitted by individual MIPS eligible clinicians, groups, or third-party intermediaries. The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions as allowed by the measure. The quality data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third-party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third-party intermediaries that utilize Medicare Part B claims data. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.

THERE ARE TWO 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

SUICIDE SAFETY PLAN MEASURE – DENOMINATOR (SUBMISSION CRITERIA) ONLY – SUMMARY:

SUBMISSION CRITERIA 1 – SUICIDE SAFETY PLAN INITIATED, REVIEWED, OR UPDATED (CONCURRENT OR WITHIN 24 HOURS):
- Denominator: 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
- Denominator Identification Period: 12-month window starting 4 months prior to the measurement year and ending 8 months into the measurement year (September 1 of previous year thru August 31 of current year)
- Index Assessment: The clinical encounter when the patient first reports suicidal thoughts and/or behaviors OR is deemed at elevated suicide risk
- Qualifying Assessment: Suicidal ideation/behavior symptoms based on C-SSRS or equivalent (M1352) OR suicide risk based on clinician's evaluation or clinician-rated tool (M1355)
- Exclusions: Patients whose functional capacity or motivation may impact accuracy of results (delirium, dementia, intellectual disabilities, pervasive/specific development disorders) – M1479; Patients who died during measurement period – M1356

SUBMISSION CRITERIA 2 – SUICIDE SAFETY PLAN INITIATED, REVIEWED, OR UPDATED CONCURRENT WITH INDEX ASSESSMENT AND WITHIN 120 DAYS AFTER INITIATION:
- Denominator: 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
- Denominator Identification Period: 12-month window starting 4 months prior to the measurement year and ending 8 months into the measurement year (September 1 of previous year thru August 31 of current year)
- Index Assessment: The clinical encounter when the patient first reports suicidal thoughts and/or behaviors OR is deemed at elevated suicide risk
- Qualifying Assessment: Suicidal ideation/behavior symptoms based on C-SSRS or equivalent (M1352) OR suicide risk based on clinician's evaluation or clinician-rated tool (M1355)
- Measurement Period: 16-month period, starting 4 months prior to the previous performance period through the 12 months of the current performance period
- Exclusions: Patients whose functional capacity or motivation may impact accuracy of results (delirium, dementia, intellectual disabilities, pervasive/specific development disorders) – M1479; Patients who died during measurement period – M1356

KEY TAKEAWAYS:
1. Both criteria use the same denominator population (age ?12, mental/substance use disorder, suicidal ideation/behavior/risk)
2. Both use the same denominator identification period (Sept 1 previous year – Aug 31 current year)
3. Both use the same qualifying assessments (M1352 or M1355)
4. Both use the same exclusions (M1479 – accuracy impact, M1356 – death)
5. Criteria 1: Safety plan initiated/reviewed/updated concurrent or within 24 hours of index encounter
6. Criteria 2: Safety plan initiated/reviewed/updated concurrent or within 24 hours AND reviewed/updated within 120 days after initiation
7. Index Assessment = first qualifying assessment during denominator identification period

SUICIDE SAFETY PLAN MEASURE – DENOMINATOR CRITERIA (ELIGIBLE CASES) – BOTH SUBMISSION CRITERIA:

SUBMISSION CRITERIA 1 – SAFETY PLAN INITIATED, REVIEWED, OR UPDATED (CONCURRENT OR ?24 HOURS):
- Patients aged ? 12 years on the date of the index encounter
- Diagnosis for any mental, behavioral, or substance use disorder on the date of the index encounter (ICD-10-CM: F10.10–F99 – see full list)
- Patient encounter during the denominator identification period using eligible CPT codes:
90791, 90792, 90832, 90834, 90837, 90839, 90845, 90847, 90849, 90853, 90865, 90875*, 90876*, 90880, 90901, 90912, 96112, 96116, 96125, 96127, 96130, 96132, 96136, 96138, 96146, 98000–98016, 99202–99215, 99211, 99242*–99245*, 99401*–99404*, 99406, 99407, 99408*–99409*, 99421–99423, 99492–99493, 99484, G0323, G0556–G0558, G0560
- Suicidal Ideation and/or Behavior Symptoms based on C-SSRS or equivalent assessment: M1352
OR
- Suicide risk based on clinician's evaluation or a clinician-rated tool: M1355
- EXCLUDE: Patients whose functional capacity or motivation may impact accuracy of results (delirium, dementia, intellectual disabilities, pervasive/specific development disorders) – M1479
- EXCLUDE: Patients who died during the measurement period – M1356

SUBMISSION CRITERIA 2 – SAFETY PLAN INITIATED, REVIEWED, OR UPDATED (?24 HOURS) + REVIEWED/UPDATED WITHIN 120 DAYS:
- Patients aged ? 12 years on the date of the index encounter
- Diagnosis for any mental, behavioral, or substance use disorder on the date of the index encounter (ICD-10-CM: F10.10–F99 – see full list)
- Patient encounter during the denominator identification period using eligible CPT codes:
90791, 90792, 90832, 90834, 90837, 90839, 90845, 90847, 90849, 90853, 90865, 90875*, 90876*, 90880, 90901, 90912, 96112, 96116, 96125, 96127, 96130, 96132, 96136, 96138, 96146, 98000–98016, 99202–99215, 99211, 99242*–99245*, 99401*–99404*, 99406, 99407, 99408*–99409*, 99421–99423, 99492–99493, 99484, G0323, G0556–G0558, G0560
- Suicidal Ideation and/or Behavior Symptoms based on C-SSRS or equivalent assessment: M1352
OR
- Suicide risk based on clinician's evaluation or a clinician-rated tool: M1355
- EXCLUDE: Patients whose functional capacity or motivation may impact accuracy of results (delirium, dementia, intellectual disabilities, pervasive/specific development disorders) – M1479
- EXCLUDE: Patients who died during the measurement period – M1356

KEY TAKEAWAYS:
1. Both criteria use the SAME eligible cases (identical denominator criteria)
2. Both require age ?12, mental/substance use disorder diagnosis, and qualifying encounter during denominator identification period
3. Both require suicidal ideation/behavior symptoms (M1352) OR suicide risk by clinician evaluation (M1355)
4. Both use the same exclusions (M1479 – accuracy impact, M1356 – death)
5. The difference between Criteria 1 and 2 is in the NUMERATOR (timing of safety plan review/update), NOT the denominator
6. Denominator Identification Period: September 1 of previous year thru August 31 of current year
7. Index Assessment: First qualifying encounter during denominator identification period

SUICIDE SAFETY PLAN MEASURE – NUMERATOR (SUBMISSION CRITERIA) ONLY – BOTH CRITERIA:

SUBMISSION CRITERIA 1 – SAFETY PLAN INITIATED, REVIEWED, OR UPDATED (CONCURRENT OR ?24 HOURS):
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 the index clinical encounter), during the measurement period.

Definition:
Suicide Safety Plan – A brief intervention that involves the patient with suicidal ideation, behavior, or risk and their clinician working in collaboration to identify and document:
- A written list of warning signs
- Internal coping strategies the patient can use to stay safe without involving others
- Sources of support (including access to professional services)
- Ways to make their environment safe

SUBMISSION CRITERIA 2 – SAFETY PLAN INITIATED, REVIEWED, OR UPDATED (?24 HOURS) + REVIEWED/UPDATED WITHIN 120 DAYS:
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 the index clinical encounter after initiation.

Definition:
Suicide Safety Plan – A brief intervention that involves the patient with suicidal ideation, behavior, or risk and their clinician working in collaboration to identify and document:
- A written list of warning signs
- Internal coping strategies the patient can use to stay safe without involving others
- Sources of support (including access to professional services)
- Ways to make their environment safe

Measurement Period – A 16-month period, starting 4 months prior to the previous performance period through the 12 months of the current performance period.

KEY TAKEAWAYS:
1. Criteria 1: Safety plan must be initiated, reviewed, or updated within 24 hours of index encounter
2. Criteria 2: Safety plan must be initiated, reviewed, or updated within 24 hours AND reviewed/updated within 120 days after initiation
3. Both require collaboration between patient and clinician
4. Both require completion of the safety plan (all 4 components: warning signs, coping strategies, sources of support, environmental safety)
5. Criteria 2 has a longer measurement period (16 months vs. standard performance period)
6. The index encounter is when suicidal ideation/behavior/risk is first identified

SUICIDE SAFETY PLAN MEASURE – NUMERATOR OPTIONS – BOTH SUBMISSION CRITERIA:

SUBMISSION CRITERIA 1 – SAFETY PLAN INITIATED, REVIEWED, OR UPDATED (CONCURRENT OR ?24 HOURS):
- M1350: Performance Met – 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: Performance Not Met – 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

SUBMISSION CRITERIA 2 – SAFETY PLAN INITIATED, REVIEWED, OR UPDATED (?24 HOURS) + REVIEWED/UPDATED WITHIN 120 DAYS:
- M1351: Performance Met – Patients who had a suicide safety plan initiated, reviewed, or updated AND reviewed and updated in collaboration with the patient and their clinician concurrent or within 24 hours of clinical encounter and within 120 days after initiation
- M1354: Performance Not Met – Patients who did not have a suicide safety plan initiated, reviewed, or updated OR reviewed and updated in collaboration with the patient and their clinician concurrent or within 24 hours of clinical encounter and within 120 days after initiation

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 (Stanley et al., 2016). It has been identified as the best practice for suicide prevention by the American Foundation for Suicide Prevention and the Suicide Prevention Resource (Action Alliance, 2018). 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 (Brodsky et a., 2018). 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 (Stanley et al., 2016).

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)