CMS 2v13: 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 up to 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 or up to two days after the date of the qualifying 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 qualifying 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 or up to two days after the date of the qualifying encounter
Denominator Exceptions

  • Patient Reason(s): Patient refuses to participate

  • Medical Reason(s): Documentation of medical reason for not screening patient for depression (e.g., cognitive, functional, or motivational limitations that may impact accuracy of results; 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)
Denominator Exclusions Patients who have ever been diagnosed with bipolar disorder at any time prior to the qualifying encounter

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

CPT: 59400, 59510, 59610, 59618, 90791, 90792, 90832, 90834, 90837, 92625, 96105, 96110, 96112, 96116, 96125, 96136, 96138, 96156, 96158, 97165, 97166, 97167, 97802, 97803, 99078, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99384, 99385, 99386, 99387, 99394, 99395, 99396, 99397, 99401, 99402, 99403, 99404, 99424, 99483, 99484, 99491, 99492, 99493, 97161, 97162, 97163, 97164, 99441, 99442, 99443, 98966, 98967, 98968

HCPCS: G0101, G0402, G0438, G0439, G0444, G0270, G0271

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 or Chart > Flowsheets/Labs > Standard
  2. Click Add New Flowsheet
  3. Select the appropriate Depression Screening flowsheet and click Add
    • Adolescent Depression Screening is for patients aged ≥ 12 years and < 17 years
    • Adult Depression Screening is for patients aged ≥ 18 years
    • Patients whose age is 17 at the start of the Measurement Period may be screened using either the Adolescent or Adult depression screening flowsheet
  4. Click Add Column
  5. Select a Value from the Depression Screening Not Done Due to list
  6. Click OK to save

  1. Go to Encounter > Flowsheets/Labs > Standard or Chart > Flowsheets/Labs > Standard
  2. Click Add New Flowsheet
  3. Select the PHQ-2 or PHQ-9 or Zung Self-Rating Depression Scale 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 or resolved (historical) diagnosis of 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 diagnosis codes for bipolar disorder 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 or up to two days after the date the eligible encounter for the patient to be counted in the numerator.

A depression screening can be documented from the following standard flowsheets: Adult Depression Screening, Adolescent Depression Screening, PHQ-2, PHQ-9, or Zung Self-Rating Depression Scale.

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

  1. Go to Encounter > Flowsheets/Labs > Standard or Chart > Flowsheets/Labs > Standard
  2. Click Add New Flowsheet
  3. Select the appropriate Depression Screening flowsheet and click Add
    • Adolescent Depression Screening is for patients aged ≥ 12 years and < 17 years
    • Adult Depression Screening is for patients aged ≥ 18 years
    • Patients whose age is 17 at the start of the Measurement Period may be screened using either the Adolescent or Adult depression screening flowsheet
  4. Click Add Column
  5. Type the name of the Adult/Adolescent Screening Tool used in theValue field
  6. Select a Depression Screening Tool Result
  7. Click OK to save

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

  • 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; a PHQ-9 score ≥ 5 will require a follow-up plan; a Zung SDS score > 49 will require a follow-up plan

From the Adult/Adolescent Depression Screening flowsheet, select a Value from the Referral for Adult/Adolescent Depression to list.

This action does not create a referral in Sevocity. Referrals are created from the Referrals tab in the chart or from the Orders/Referrals tab in an encounter

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

https://ecqi.healthit.gov/ecqm/ec/2024/cms0002v13

 

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