CMS 2v9: 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 or 14 days prior to 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 eligible encounter
Measure Type High Priority Measure Scoring
Process No A higher percentage indicates better quality
Denominator All patients aged 12 years and older at 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 or up to 14 days prior to 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 eligible encounter
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 cognitive capacity, 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 eligible encounter during the Measurement Period finalized by the EC/EP

CPT: 59400, 59510, 59610, 59618, 90791, 90792, 90832, 90834, 90837, 92625, 96105, 96110, 96112, 96116, 96125, 96136, 96138, 96150, 96151, 97165, 97166, 97167, 99078, 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, 99401, 99402, 99403, 99404, 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. The diagnosis must be documented prior to the eligible encounter date.

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 on the same day as their eligible encounter or in the 14 days prior to the encounter.

  • If the result of the screening is Positive, a follow-up plan must be documented on the day of the eligible encounter for the patient to be counted in the numerator.

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

  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
  1. Go to Encounter > Flowsheets/Labs > Standard Flowsheets
  2. Click Add New Flowsheet
  3. Select the appropriate Depression Screening flowsheet and click Add
    • Depression Screening – Pediatric is for patients aged ≥ 12 years and < 18 years
    • 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

The name of the screening tool should be documented in the encounter in which it was used

If the result of the depression screening is Positive, at least one of the following actions must be performed and documented:

  • Additional evaluation for depression
  • Suicide risk assessment
  • Referral to a practitioner who is qualified to diagnose and treat depression
  • Prescription for 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 > New Prescription. A comprehensive list of eligible anti-depression medications can be located here.

https://ecqi.healthit.gov/ecqm/ep/2020/cms002v9

 

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