CMS 2v8: Preventive Care and Screening: Screening for Depression and Follow-Up Plan

Measure: Percentage of patients aged 12 years and older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen
Measure Type High Priority Measure Scoring
Process No A higher percentage indicates better quality
Denominator All patients aged 12 years and older before the beginning of the measurement period with at least one eligible encounter during the measurement period
Numerator Patients screened for depression on the date of the encounter using an age appropriate standardized tool AND if positive, a follow-up plan is documented on the date of the positive screen
Denominator Exceptions

Patient Reason(s): Patient refuses to participate

OR

Medical Reason(s): Patient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient's health status

OR

Situations where the patient's functional capacity or motivation to improve may impact the accuracy of results of standardized depression assessment tools. For example: certain court appointed cases or cases of delirium

Denominator Exclusions Patients with an active diagnosis for depression or a diagnosis of bipolar disorder

Patients who meet the following criteria will be included in the denominator:

  • Age is ≥ 12 years at the beginning of the Measurement Period

    AND

  • Have at least one encounter during the Measurement Period finalized by the EC/EP

CPT: 59400, 59510, 59610, 59618, 90791, 90792, 90832, 90834, 90837, 92625, 96116, 96118, 96150, 96151, 97165, 97166, 97167, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99339, 99340, 99384, 99385, 99386, 99387, 99394, 99395, 99396, 99397, 99483, 99484, 99492, 99493

HCPCS: G0101, G0402, G0438, G0439, G0444

A patient will be counted as an exception for this measure if there is a medical reason they did not receive a depression screening or if the patient refused.

  1. Go to Encounter > Flowsheets/Labs > Standard Flowsheets
  2. Click Add New Flowsheet
  3. Select the appropriate Depression Screening flowsheet and click Add
  4. Click Add Column
  5. Select a value from the Patient exempt due to the following reason list
  6. Click OK to save

  1. Go to Encounter > Flowsheets/Labs > Standard Flowsheets
  2. Click Add New Flowsheet
  3. Select the PHQ-2 or PHQ-9 flowsheet and click Add
  4. Click Add Column
  5. Select the checkbox for Patient Declined Screening
  6. Click OK to save

Patients with an active diagnosis of depression or bipolar disorder will be excluded from the measure. Diagnoses are documented in the Assessment tab of an encounter. A comprehensive list of eligible depression and bipolar disorder diagnosis codes can be located here.

A patient will be counted in the numerator if they received a depression screening during the Measurement Period. If the result of the screening is Positive, the patient must receive a follow-up plan to be counted in the numerator.

A depression screening can be documented from the following standard flowsheets: Depression Screening Adult or Pediatric, PHQ-2, or PHQ-9.

  1. Go to Encounter > Flowsheets/Labs > Standard Flowsheets
  2. Click Add New Flowsheet
  3. Select the appropriate Depression Screening flowsheet and click Add
    1. Depression Screening – Pediatric is for patients aged ≥ 12 years and < 18 years
    2. Depression Screening – Adult is for patients aged ≥ 18 years
  4. Click Add Column
  5. Select a Date and Value for the screening
  6. Click OK to save

  1. Go to Encounter > Flowsheets/Labs > Standard Flowsheets
  2. Click Add New Flowsheet
  3. Select the PHQ-2 or PHQ-9 flowsheet and click Add
  4. Click Add Column
  5. Select a Value for all questions in the PHQ
  6. Click OK to save

If the result of the depression screening is Positive, additional evaluation for depression must be provided OR a suicide risk assessment must be performed OR the patient must be given a referral to a practitioner who is qualified to diagnose and treat depression OR the patient must be prescribed anti-depression medication.

A PHQ-2 score ≥ 3 will require a follow-up plan, and a PHQ-9 score ≥ 5 will require a follow-up plan.

From the Adult/Pediatric Depression Screening flowsheet, select Yes for the questions Did this patient receive additional evaluation?

From the Adult/Pediatric Depression Screening flowsheet, select Yes for the question Was a referral given to the patient?

From the Adult/Pediatric Depression Screening flowsheet, select a Date and a Value for the Suicide Risk Assessment

To prescribe a medication, go to Encounter > Medications > Manage/Prescribe Meds > Prescribe a Medication. A comprehensive list of eligible anti-depression medications can be located here.

A combination of any of these interventions will also count toward the numerator; however, the intervention(s) must be performed on the same day as the depression screening or no later than the following day

https://ecqi.healthit.gov/ecqm/ep/2019/cms002v8

 

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