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. Depression Screening 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. Document a Screening from the PHQ-2, PHQ-9, or Zung SDS Flowsheet Go to Encounter > Flowsheets/Labs > Standard or Chart > Flowsheets/Labs > StandardClick Add New FlowsheetSelect the PHQ-2 or PHQ-9 or Zung Self-Rating Depression Scale flowsheet and click AddClick Add ColumnSelect a Value for all questions in the PHQ or Zung SDS Click OK to save Document a Screening from the Adult/Adolescent Depression Screening Flowsheet Go to Encounter > Flowsheets/Labs > Standard or Chart > Flowsheets/Labs > StandardClick Add New FlowsheetSelect the appropriate Depression Screening flowsheet and click AddAdolescent Depression Screening is for patients aged ≥ 12 years and < 17 yearsAdult Depression Screening is for patients aged ≥ 18 yearsPatients whose age is 17 at the start of the Measurement Period may be screened using either the Adolescent or Adult depression screening flowsheetClick Add ColumnType the name of the Adult/Adolescent Screening Tool used in theValue fieldSelect a Depression Screening Tool ResultClick OK to save Follow-Up Plan for a Positive Finding 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 Document Referral Provided From the Adult/Adolescent Depression Screening flowsheet, select a Value from the Referral for Adult/Adolescent Depression to list. Note 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 Medication 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.

CMS 2v13: Preventive Care and Screening: Screening for Depression and Follow-Up Plan

Updated June 8, 2026 4 minute read

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

Denominator

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

Encounter Codes Eligible for Denominator

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

Denominator Exceptions

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.

Document an Exception from the Adult/Adolescent Depression Screening Flowsheet

Go to Encounter > Flowsheets/Labs > Standard or Chart > Flowsheets/Labs > Standard
Click Add New Flowsheet
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
Click Add Column
Select a Value from the Depression Screening Not Done Due to list
Click OK to save

Document an Exception from the PHQ-2, PHQ-9, or Zung SDS Flowsheet

Go to Encounter > Flowsheets/Labs > Standard or Chart > Flowsheets/Labs > Standard
Click Add New Flowsheet
Select the PHQ-2 or PHQ-9 or Zung Self-Rating Depression Scale flowsheet and click Add
Click Add Column
Select the checkbox for Patient Declined Screening
Click OK to save

Denominator Exclusions

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.

Numerator

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.

Depression Screening

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.

Document a Screening from the PHQ-2, PHQ-9, or Zung SDS Flowsheet

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

Document a Screening from the Adult/Adolescent Depression Screening Flowsheet

Go to Encounter > Flowsheets/Labs > Standard or Chart > Flowsheets/Labs > Standard
Click Add New Flowsheet
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
Click Add Column
Type the name of the Adult/Adolescent Screening Tool used in theValue field
Select a Depression Screening Tool Result
Click OK to save

Follow-Up Plan for a Positive Finding

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

Document Referral Provided

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

Note

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

Medication

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.

eCQI Reference

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

Return to 2024 eCQMs