| 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 |
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/EP
Encounter Codes Eligible for Denominator
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
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/Pediatric Depression Screening Flowsheet
- Go to Encounter > Flowsheets/Labs > Standard Flowsheets
- Click Add New Flowsheet
- Select the appropriate Depression Screening flowsheet and click Add
- Click Add Column
- Select a value from the Patient exempt due to the following reason list
- Click OK to save
Document an Exception from the PHQ-2 or PHQ-9 Flowsheet
- Go to Encounter > Flowsheets/Labs > Standard Flowsheets
- Click Add New Flowsheet
- Select the PHQ-2 or PHQ-9 flowsheet and click Add
- Click Add Column
- Select the checkbox for Patient Declined Screening
- Click OK to save
Denominator Exclusions
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.
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 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: Depression Screening Adult, Depression Screening Pediatric, PHQ-2, or PHQ-9.
Document a Screening from the PHQ-2 or PHQ-9 Flowsheet
- Go to Encounter > Flowsheets/Labs > Standard Flowsheets
- Click Add New Flowsheet
- Select the PHQ-2 or PHQ-9 flowsheet and click Add
- Click Add Column
- Select a Value for all questions in the PHQ
- Click OK to save
Document a Screening from the Adult/Pediatric Depression Screening Flowsheet
- Go to Encounter > Flowsheets/Labs > Standard Flowsheets
- Click Add New Flowsheet
- 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
- Click Add Column
- Select a Date and Value for the screening
- Click OK to save
Sevocity Best Practice
The name of the screening tool should be documented in the encounter in which it was used
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:
- 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.
Document Additional Evaluation for Depression Provided
From the Adult/Pediatric Depression Screening flowsheet, select Yes for the questions Did this patient receive additional evaluation?
Document Referral Provided
From the Adult/Pediatric Depression Screening flowsheet, select Yes for the question Was a referral given to the patient?
Document Suicide Risk Assessment Performed
From the Adult/Pediatric Depression Screening flowsheet, select a Date and a Value for the Suicide Risk Assessment
Medication
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.
eCQI Reference
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