Preventive Care and Screening: Screening for Depression and Follow-Up Plan

Measure Information	2021 Performance Period
CMS eCQM ID	CMS2v10
NQF Number	0418e
MIPS Quality ID	134
Description	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 the eligible encounter
Initial Population	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
Numerator Exclusions	Not Applicable
Denominator	Equals Initial Population
Denominator Exclusions	Patients who have been diagnosed with depression or with bipolar disorder
Denominator Exceptions	Patient Reason(s) Patient refuses to participate OR 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)
Steward	Centers for Medicare & Medicaid Services (CMS)
Measure Scoring	Proportion measure
Measure Type	Process measure
Improvement Notation	Higher score indicates better quality
Guidance	A depression screen is completed 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 must be documented on the date of the encounter, such as referral to a practitioner who is qualified to treat depression, pharmacological interventions or other interventions for the treatment of depression. This eCQM is a patient-based measure. Depression screening is required once per measurement period, not at all encounters. The intent of the measure is to screen for depression in patients who have never had a diagnosis of depression or bipolar disorder prior to the eligible encounter used to evaluate the numerator. Patients who have ever been diagnosed with depression or bipolar disorder will be excluded from the measure. Screening Tools: * An age-appropriate, standardized, and validated depression screening tool must be used for numerator compliance. * The name of the age-appropriate standardized depression screening tool utilized must be documented in the medical record. * The depression screening must be reviewed and addressed in the office of the provider, filing the code, on the date of the encounter. Positive pre-screening results indicating a patient is at high risk for self-harm should receive more urgent intervention as determined by the provider practice. * The screening should occur during a qualifying encounter or up to 14 days prior to the date of the qualifying encounter. * The measure assesses the most recent depression screening completed either during the eligible encounter or within the 14 days prior to that encounter. Therefore, a clinician would not be able to complete another screening at the time of the encounter to count towards a follow-up, because that would serve as the most recent screening. In order to satisfy the follow-up requirement for a patient screening positively, the eligible clinician would need to provide one of the aforementioned follow-up actions, which does not include use of a standardized depression screening tool. Follow-Up Plan: The follow-up plan must be related to a positive depression screening, for example: "Patient referred for psychiatric evaluation due to positive depression screening." Examples of a follow-up plan include but are not limited to: * Referral to a practitioner or program for further evaluation for depression, for example, referral to a psychiatrist, psychologist, social worker, mental health counselor, or other mental health service such as family or group therapy, support group, depression management program, or other service for treatment of depression * Other interventions designed to treat depression such as behavioral health evaluation, psychotherapy, pharmacological interventions, or additional treatment options Should a patient screen positive for depression, a clinician should opt to complete a suicide risk assessment when appropriate and based on individual patient characteristics. However, for the purposes of this measure, a suicide risk assessment or additional screening using a standardized tool will not qualify as a follow-up plan. This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM.
Telehealth Eligible	Yes
Next Version	CMS2v11
Previous Version	No Version Available

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Measure Information	2021 Performance Period	2022 Performance Period	2023 Performance Period	2024 Performance Period
Title	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Preventive Care and Screening: Screening for Depression and Follow-Up Plan
CMS eCQM ID	CMS2v10	CMS2v11	CMS2v12	CMS2v13
NQF Number	0418e	Not Applicable	Not Applicable	Not Applicable
Description	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 the eligible encounter	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 the eligible encounter	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	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
Initial Population	All patients aged 12 years and older at the beginning of the measurement period with at least one eligible encounter during the measurement period	All patients aged 12 years and older at the beginning of the measurement period with at least one eligible encounter during the measurement period	All patients aged 12 years and older at the beginning of the measurement period with at least one qualifying encounter during the measurement period	All patients aged 12 years and older at the beginning of the measurement period with at least one qualifying encounter during the measurement period
Denominator	Equals Initial Population	Equals Initial Population	Equals Initial Population	Equals Initial Population
Denominator Exclusions	Patients who have been diagnosed with depression or with bipolar disorder	Patients who have been diagnosed with depression or with bipolar disorder	Patients who have ever been diagnosed with depression or with bipolar disorder at any time prior to the qualifying encounter	Patients who have ever been diagnosed with bipolar disorder at any time prior to the qualifying encounter
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	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	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	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
Numerator Exclusions	Not Applicable	Not Applicable	Not Applicable	Not Applicable
Denominator Exceptions	Patient Reason(s) Patient refuses to participate OR 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)	Patient Reason(s) Patient refuses to participate OR 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)	Patient Reason(s) Patient refuses to participate OR 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)	Patient Reason(s) Patient refuses to participate in or complete the depression screening OR 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)
Measure Steward	Centers for Medicare & Medicaid Services (CMS)	Centers for Medicare & Medicaid Services (CMS)	Centers for Medicare & Medicaid Services (CMS)	Centers for Medicare & Medicaid Services (CMS)
Measure Scoring	Proportion measure	Proportion measure	Proportion measure	Proportion measure
Measure Type	Process measure	Process measure	Process measure	Process measure
Improvement Notation	Higher score indicates better quality	Higher score indicates better quality	Higher score indicates better quality	Higher score indicates better quality
Guidance	A depression screen is completed 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 must be documented on the date of the encounter, such as referral to a practitioner who is qualified to treat depression, pharmacological interventions or other interventions for the treatment of depression. This eCQM is a patient-based measure. Depression screening is required once per measurement period, not at all encounters. The intent of the measure is to screen for depression in patients who have never had a diagnosis of depression or bipolar disorder prior to the eligible encounter used to evaluate the numerator. Patients who have ever been diagnosed with depression or bipolar disorder will be excluded from the measure. Screening Tools: * An age-appropriate, standardized, and validated depression screening tool must be used for numerator compliance. * The name of the age-appropriate standardized depression screening tool utilized must be documented in the medical record. * The depression screening must be reviewed and addressed in the office of the provider, filing the code, on the date of the encounter. Positive pre-screening results indicating a patient is at high risk for self-harm should receive more urgent intervention as determined by the provider practice. * The screening should occur during a qualifying encounter or up to 14 days prior to the date of the qualifying encounter. * The measure assesses the most recent depression screening completed either during the eligible encounter or within the 14 days prior to that encounter. Therefore, a clinician would not be able to complete another screening at the time of the encounter to count towards a follow-up, because that would serve as the most recent screening. In order to satisfy the follow-up requirement for a patient screening positively, the eligible clinician would need to provide one of the aforementioned follow-up actions, which does not include use of a standardized depression screening tool. Follow-Up Plan: The follow-up plan must be related to a positive depression screening, for example: "Patient referred for psychiatric evaluation due to positive depression screening." Examples of a follow-up plan include but are not limited to: * Referral to a practitioner or program for further evaluation for depression, for example, referral to a psychiatrist, psychologist, social worker, mental health counselor, or other mental health service such as family or group therapy, support group, depression management program, or other service for treatment of depression * Other interventions designed to treat depression such as behavioral health evaluation, psychotherapy, pharmacological interventions, or additional treatment options Should a patient screen positive for depression, a clinician should opt to complete a suicide risk assessment when appropriate and based on individual patient characteristics. However, for the purposes of this measure, a suicide risk assessment or additional screening using a standardized tool will not qualify as a follow-up plan. This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM.	The intent of the measure is to screen for depression in patients who have never had a diagnosis of depression or bipolar disorder prior to the eligible encounter used to evaluate the numerator. Patients who have ever been diagnosed with depression or bipolar disorder will be excluded from the measure. A depression screen is completed 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 must be documented on the date of the encounter, such as referral to a provider for additional evaluation, pharmacological interventions, or other interventions for the treatment of depression. This measure does not require documentation of a specific score, just whether results of the normalized and validated depression screening tool used are considered positive or negative. Each standardized screening tool provides guidance on whether a particular score is considered positive for depression. This eCQM is a patient-based measure. Depression screening is required once per measurement period, not at all encounters. Screening Tools: * An age-appropriate, standardized, and validated depression screening tool must be used for numerator compliance. * The name of the age-appropriate standardized depression screening tool utilized must be documented in the medical record. * The depression screening must be reviewed and addressed by the provider, filing the code, on the date of the encounter. Positive pre-screening results indicating a patient is at high risk for self-harm should receive more urgent intervention as determined by the provider practice. * The screening should occur during a qualifying encounter or up to 14 days prior to the date of the qualifying encounter. * The measure assesses the most recent depression screening completed either during the eligible encounter or within the 14 days prior to that encounter. Therefore, a clinician would not be able to complete another screening at the time of the encounter to count towards a follow-up, because that would serve as the most recent screening. In order to satisfy the follow-up requirement for a patient screening positively, the eligible clinician would need to provide one of the aforementioned follow-up actions, which does not include use of a standardized depression screening tool. Follow-Up Plan: The follow-up plan must be related to a positive depression screening, for example: "Patient referred for psychiatric evaluation due to positive depression screening." Examples of a follow-up plan include but are not limited to: * Referral to a provider or program for further evaluation for depression, for example, referral to a psychiatrist, psychologist, social worker, mental health counselor, or other mental health service such as family or group therapy, support group, depression management program, or other service for treatment of depression * Other interventions designed to treat depression such as behavioral health evaluation, psychotherapy, pharmacological interventions, or additional treatment options Should a patient screen positive for depression, a clinician should: * Only order pharmacological intervention when appropriate and after sufficient diagnostic evaluation. However, for the purposes of this measure, additional screening and assessment during the qualifying encounter will not qualify as a follow-up plan. * Opt to complete a suicide risk assessment when appropriate and based on individual patient characteristics. However, for the purposes of this measure, a suicide risk assessment or additional screening using a standardized tool will not qualify as a follow-up plan. This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM.	The intent of the measure is to screen for new cases of depression in patients who have never had a diagnosis of depression or bipolar disorder. Patients who have ever been diagnosed with depression or bipolar disorder prior to the qualifying encounter used to evaluate the numerator will be excluded from the measure regardless of whether the diagnosis is active or not. A depression screen is completed on the date of the encounter or up to 14 calendar days prior to the date of the encounter using an age-appropriate standardized depression screening tool AND if positive, a follow-up plan must be documented on the date of or up to two calendar days after the date of the encounter, such as referral to a provider for additional evaluation, pharmacological interventions, or other interventions for the treatment of depression. An example to illustrate the follow-up plan documentation timing: if the encounter is on a Monday from 3-4 pm (day 0) and the patient screens positive, the clinician has through anytime on Wednesday (day 2) to complete follow-up plan documentation. This measure does not require documentation of a specific score, just whether results of the normalized and validated depression screening tool used are considered positive or negative. Each standardized screening tool provides guidance on whether a particular score is considered positive for depression. This eCQM is a patient-based measure. Depression screening is required once per measurement period, not at all encounters. Screening Tools: * An age-appropriate, standardized, and validated depression screening tool must be used for numerator compliance. * The name of the age-appropriate standardized depression screening tool utilized must be documented in the medical record. * The depression screening must be reviewed and addressed by the provider, filing the code, on the date of the encounter. Positive pre-screening results indicating a patient is at high risk for self-harm should receive more urgent intervention as determined by the provider practice. * The screening should occur during a qualifying encounter or up to 14 calendar days prior to the date of the qualifying encounter. * The measure assesses the most recent depression screening completed either during the qualifying encounter or within the 14 calendar days prior to that encounter. Therefore, a clinician would not be able to complete another screening at the time of the encounter to count towards a follow-up, because that would serve as the most recent screening. In order to satisfy the follow-up requirement for a patient screening positively, the eligible clinician would need to provide one of the aforementioned follow-up actions, which does not include use of a standardized depression screening tool. Follow-Up Plan: The follow-up plan MUST still be provided for and discussed with the patient during the qualifying encounter used to evaluate the numerator. However, documentation of the follow-up plan can occur up to two calendar days after the qualifying encounter, in accordance with the policies of an eligible clinician or provider’s practice or health system. All services should be documented during, or as soon as practicable, after the qualifying encounter in order to maintain an accurate medical record. The follow-up plan must be related to a positive depression screening, for example: "Patient referred for psychiatric evaluation due to positive depression screening." Examples of a follow-up plan include but are not limited to: * Referral to a provider or program for further evaluation for depression, for example, referral to a psychiatrist, psychiatric nurse practitioner, psychologist, clinical social worker, mental health counselor, or other mental health service such as family or group therapy, support group, depression management program, or other service for treatment of depression * Other interventions designed to treat depression such as behavioral health evaluation, psychotherapy, pharmacological interventions, or additional treatment options Should a patient screen positive for depression, a clinician should: * Only order pharmacological intervention when appropriate and after sufficient diagnostic evaluation. However, for the purposes of this measure, additional screening and assessment during the qualifying encounter will not qualify as a follow-up plan. * Opt to complete a suicide risk assessment when appropriate and based on individual patient characteristics. However, for the purposes of this measure, a suicide risk assessment or additional screening using a standardized tool will not qualify as a follow-up plan. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM.	The intent of the measure is to screen for new cases of depression in patients who have never had a diagnosis of bipolar disorder. Patients who have ever been diagnosed with bipolar disorder prior to the qualifying encounter used to evaluate the numerator will be excluded from the measure regardless of whether the diagnosis is active or not. A depression screen is completed on the date of the encounter or up to 14 calendar days prior to the date of the encounter using an age-appropriate standardized depression screening tool AND if positive, a follow-up plan must be documented on the date of or up to two calendar days after the date of the encounter, such as referral to a provider for additional evaluation, pharmacological interventions, or other interventions for the treatment of depression. An example to illustrate the follow-up plan documentation timing: if the encounter is on a Monday from 3-4 pm (day 0) and the patient screens positive, the clinician has through anytime on Wednesday (day 2) to complete follow-up plan documentation. This measure does not require documentation of a specific score, just whether results of the normalized and validated depression screening tool used are considered positive or negative. Each standardized screening tool provides guidance on whether a particular score is considered positive for depression. This eCQM is a patient-based measure. Depression screening is required once per measurement period, not at all encounters. Screening Tools: - An age-appropriate, standardized, and validated depression screening tool must be used for numerator compliance. - The name of the age-appropriate standardized depression screening tool utilized must be documented in the medical record. - The depression screening must be reviewed and addressed by the provider, filing the code, on the date of the encounter. Positive pre-screening results indicating a patient is at high risk for self-harm should receive more urgent intervention as determined by the provider practice. - The screening should occur during a qualifying encounter or up to 14 calendar days prior to the date of the qualifying encounter. - The measure assesses the most recent depression screening completed either during the qualifying encounter or within the 14 calendar days prior to that encounter. Therefore, a clinician would not be able to complete another screening at the time of the encounter to count towards a follow-up, because that would serve as the most recent screening. In order to satisfy the follow-up requirement for a patient screening positively, the eligible clinician would need to provide one of the aforementioned follow-up actions, which does not include use of a standardized depression screening tool. Follow-Up Plan: The follow-up plan MUST still be provided for and discussed with the patient during the qualifying encounter used to evaluate the numerator. However, documentation of the follow-up plan can occur up to two calendar days after the qualifying encounter, in accordance with the policies of an eligible clinician or provider’s practice or health system. All services should be documented during, or as soon as practicable, after the qualifying encounter in order to maintain an accurate medical record. The follow-up plan must be related to a positive depression screening, for example: "Patient referred for psychiatric evaluation due to positive depression screening." Examples of a follow-up plan include but are not limited to: - Referral to a provider or program for further evaluation for depression, for example, referral to a psychiatrist, psychiatric nurse practitioner, psychologist, clinical social worker, mental health counselor, or other mental health service such as family or group therapy, support group, depression management program, or other service for treatment of depression - Other interventions designed to treat depression such as behavioral health evaluation, psychotherapy, pharmacological interventions, or additional treatment options Should a patient screen positive for depression, a clinician should: - Only order pharmacological intervention when appropriate and after sufficient diagnostic evaluation. However, for the purposes of this measure, additional screening and assessment during the qualifying encounter will not qualify as a follow-up plan. - Opt to complete a suicide risk assessment when appropriate and based on individual patient characteristics. However, for the purposes of this measure, a suicide risk assessment or additional screening using a standardized tool will not qualify as a follow-up plan. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM.
MIPS Quality ID	134	134	134	134
Telehealth Eligible	Yes	Yes	Yes	Yes
Next Version	CMS2v11	CMS2v12	CMS2v13	No Version Available
Previous Version	No Version Available	CMS2v10	CMS2v11	CMS2v12

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Data Element Repository

Data Elements contained within CMS2v10

Value Sets

Value Sets to be used with CMS2v10

Release Notes

CMS2v10-TRN.xlsx

Header

Updated eCQM Version Number.

Measure Section: eCQM Version Number

Source of Change: Standards Update
Updated the measure developer field.

Measure Section: Measure Developer

Source of Change: Measure Lead
Revised description to improve alignment with measure intent and initial population language.

Measure Section: Description

Source of Change: Measure Lead
Updated copyright.

Measure Section: Copyright

Source of Change: Annual Update
Updated disclaimer.

Measure Section: Disclaimer

Source of Change: Standards Update
Revised rationale to align with updated guidelines and evidence.

Measure Section: Rationale

Source of Change: Measure Lead
Removed clinical recommendation statement from an outdated guideline.

Measure Section: Clinical Recommendation Statement

Source of Change: Measure Lead
Removed reference to outdated guideline.

Measure Section: Reference

Source of Change: Measure Lead
Updated references to align with American Psychological Association (APA) formatting.

Measure Section: Reference

Source of Change: Measure Lead
Removed guidance related to additional evaluation or assessment for depression and suicide risk assessment as appropriate follow-up. Added guidance about the importance of escalating patient care or certain circumstances which are not captured in the measure.

Measure Section: Guidance

Source of Change: Measure Lead
Added guidance about the intent of the denominator exclusions.

Measure Section: Guidance

Source of Change: Measure Lead
Added guidance to clarify the measure's use of the most recent depression screening.

Measure Section: Guidance

Source of Change: Measure Lead
Added text to identify the Quality Data Model (QDM) version used in the measure specification.

Measure Section: Guidance

Source of Change: Standards Update
Added text to indicate whether the measure is patient-based or episode-based.

Measure Section: Guidance

Source of Change: Standards Update
Removed guidance inconsistent with measure intent.

Measure Section: Guidance

Source of Change: Measure Lead
Revised existing guidance pertaining to using an age-appropriate depression screening tool.

Measure Section: Guidance

Source of Change: ONC Project Tracking System (Jira): CQM-3803
Revised guidance related to examples of appropriate follow-up plans.

Measure Section: Guidance

Source of Change: Measure Lead
Revised guidance to consolidate and more accurately reflect the intent of using a standardized age-appropriate depression screening tool.

Measure Section: Guidance

Source of Change: Measure Lead
Revised denominator exclusions language based upon subject matter experts' feedback to reflect that any patient with a current or historical diagnosis of bipolar disorder or depression should be excluded from the measure.

Measure Section: Denominator Exclusions

Source of Change: Measure Lead
Revised denominator exception language to follow a similar format as other eCQMs.

Measure Section: Denominator Exceptions

Source of Change: Measure Lead

Logic

Added new data element to allow for Physical Therapy Evaluation as an eligible encounter, per specialty society request.

Measure Section: Initial Population

Source of Change: Measure Lead
Revised denominator exclusions logic based upon subject matter experts' feedback to reflect that any patient with a current or historical diagnosis of bipolar disorder or depression should be excluded from the measure.

Measure Section: Denominator Exclusions

Source of Change: Measure Lead
Removed suicide risk assessment and additional evaluation or assessment for depression as appropriate follow-up options to meet the numerator based on subject matter expert input.

Measure Section: Numerator

Source of Change: Measure Lead
Revised numerator logic to allow providers to choose the age-appropriate tool to screen a patient who is 17 years old at the start of the measurement period for depression. This means patients seen when they are 17 years old of age can be screened using an adolescent depression screening tool, or patients seen after they turn 18 years of age during the measurement period can be screened using an adult depression screening tool.

Measure Section: Numerator

Source of Change: ONC Project Tracking System (Jira): CQM-3803
Added new data element to allow for Physical Therapy Evaluation as an eligible encounter, per specialty society request.

Measure Section: Definitions

Source of Change: Measure Lead
Updated the names of Clinical Quality Language (CQL) definitions, functions, and/or aliases for clarification and to align with the CQL Style Guide.

Measure Section: Definitions

Source of Change: Standards Update
Updated the names of CQL definitions, functions, and/or aliases for clarification and to align with the CQL Style Guide.

Measure Section: Functions

Source of Change: Standards Update
QDM v5.5 standards update: Added 'relevantDatetime' attribute to QDM datatypes. 'RelevantDatetime' indicates when the action occurred whereas 'authorDatetime' indicates when the action was recorded.

Measure Section: Multiple Sections

Source of Change: Standards Update
Revised CQL definition construction to reduce the overall complexity of the measure logic without changing the intent and/or application of data element. These revisions were intended to make the definition logic less complex, easier to understand, and more meaningful.

Measure Section: Multiple Sections

Source of Change: Measure Lead
Revised measure timings to improve alignment with the intent of the measure requirements.

Measure Section: Multiple Sections

Source of Change: Measure Lead
Updated CQL expression to conform with the HL7 Standard: Clinical Quality Language Specification, Release 1 STU 4 (CQL 1.4).

Measure Section: Multiple Sections

Source of Change: Standards Update
Updated CQL definition names and aliases used to more closely align with clinical concept intent or create consistency of naming across measures.

Measure Section: Multiple Sections

Source of Change: Measure Lead
Updated version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-5.0.000). Updated definitions and functions in the MAT Global Common Functions Library to align with standards changes, CQL Style Guide, and to include one new function related to calculating length of hospital stays with observation stays.

Measure Section: Multiple Sections

Source of Change: Standards Update

Value Set

The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.

Value set (2.16.840.1.113883.3.600.1916): Renamed to Encounter to Screen for Depression to align with best practices, based on expert review and/or public feedback.

Measure Section: Terminology

Source of Change: Annual Update
Value set Encounter to Screen for Depression (2.16.840.1.113883.3.600.1916): Added 2 CPT codes (96156, 96158) and deleted 2 CPT codes (96150, 96151) based on terminology update. Deleted 1 SNOMED CT code (32537008) based on terminology update.

Measure Section: Terminology

Source of Change: Annual Update
Replaced SNOMED CT value set Follow up for depression - adolescent (2.16.840.1.113883.3.600.467) with grouping value set Follow Up for Adolescent Depression (2.16.840.1.113883.3.526.3.1569) to align with best practices, based on expert review and/or public feedback.

Measure Section: Terminology

Source of Change: Annual Update
Replaced SNOMED CT value set Follow up for depression - adult (2.16.840.1.113883.3.600.468) with grouping value set Follow Up for Adult Depression (2.16.840.1.113883.3.526.3.1568) to align with best practices, based on expert review and/or public feedback.

Measure Section: Terminology

Source of Change: Annual Update
Replaced RxNorm value set Depression medications - adolescent (2.16.840.1.113883.3.600.469) with grouping value set Adolescent Depression Medications (2.16.840.1.113883.3.526.3.1567) to align with best practices, based on expert review and/or public feedback.

Measure Section: Terminology

Source of Change: Annual Update
Value set Adolescent Depression Medications (2.16.840.1.113883.3.526.3.1567): Deleted 3 RxNorm codes (199990, 248097, 248098) based on terminology update; codes are no longer prescribable.

Measure Section: Terminology

Source of Change: Annual Update
Replaced RxNorm value set Depression medications - adult (2.16.840.1.113883.3.600.470) with grouping value set Adult Depression Medications (2.16.840.1.113883.3.526.3.1566) to align with best practices, based on expert review and/or public feedback.

Measure Section: Terminology

Source of Change: Annual Update
Value set Adult Depression Medications (2.16.840.1.113883.3.526.3.1566): Deleted 3 RxNorm codes (857291, 857296, 857315) based on terminology update; codes are no longer prescribable.

Measure Section: Terminology

Source of Change: Annual Update
Replaced SNOMED CT value set Referral for Depression Adolescent (2.16.840.1.113883.3.600.537) with grouping value set Referral for Adolescent Depression (2.16.840.1.113883.3.526.3.1570) to align with best practices, based on expert review and/or public feedback.

Measure Section: Terminology

Source of Change: Annual Update
Value set Referral for Adolescent Depression (2.16.840.1.113883.3.526.3.1570): Deleted 4 SNOMED CT codes (305922005, 401174001, 429387009, 61801003) that do not align with data element intent.

Measure Section: Terminology

Source of Change: Annual Update
Replaced SNOMED CT value set Referral for Depression Adult (2.16.840.1.113883.3.600.538) with grouping value set Referral for Adult Depression (2.16.840.1.113883.3.526.3.1571) to align with best practices, based on expert review and/or public feedback.

Measure Section: Terminology

Source of Change: Annual Update
Value set Referral for Adult Depression (2.16.840.1.113883.3.526.3.1571): Deleted 5 SNOMED CT codes (103696004, 14129001, 401174001, 429387009, 61801003) that do not align with data element intent.

Measure Section: Terminology

Source of Change: Annual Update
Value set (2.16.840.1.113883.3.600.145): Renamed to Depression Diagnosis to align with best practices, based on expert review and/or public feedback.

Measure Section: Terminology

Source of Change: Annual Update
Replaced SNOMED CT value set Medical or Other Reason Not Done (2.16.840.1.113883.3.600.1.1502) with grouping value set Medical Reason (2.16.840.1.113883.3.526.3.1007) for harmonization purposes, based on expert review and/or public feedback.

Measure Section: Terminology

Source of Change: Annual Update
Value set Additional evaluation for depression - adolescent (2.16.840.1.113883.3.600.1542): Removed Additional evaluation for depression - adolescent based on expert review and/or public feedback.

Measure Section: Terminology

Source of Change: Measure Lead
Value set Additional evaluation for depression - adult (2.16.840.1.113883.3.600.1545): Removed Additional evaluation for depression - adult based on expert review and/or public feedback.

Measure Section: Terminology

Source of Change: Measure Lead
Value set Suicide Risk Assessment (2.16.840.1.113883.3.600.559): Removed Suicide Risk Assessment based on expert review and/or public feedback.

Measure Section: Terminology

Source of Change: Measure Lead
Replaced SNOMED CT value set Negative Depression Screening (2.16.840.1.113883.3.600.2451) with grouping value set Negative Depression Screening (2.16.840.1.113883.3.526.3.1564) to align with best practices, based on expert review and/or public feedback.

Measure Section: Terminology

Source of Change: Annual Update
Replaced SNOMED CT value set Positive Depression Screening (2.16.840.1.113883.3.600.2450) with grouping value set Positive Depression Screening (2.16.840.1.113883.3.526.3.1565) to align with best practices, based on expert review and/or public feedback.

Measure Section: Terminology

Source of Change: Annual Update
Value set Physical Therapy Evaluation (2.16.840.1.113883.3.526.3.1022): Added Physical Therapy Evaluation based on expert review and/or public feedback.

Measure Section: Terminology

Source of Change: Measure Lead
Replaced SNOMED CT value set Patient Reason refused (2.16.840.1.113883.3.600.791) with grouping value set Patient Declined (2.16.840.1.113883.3.526.3.1582) to align with best practices, based on expert review and/or public feedback.

Measure Section: Terminology

Source of Change: Annual Update