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

Measure Information 2023 Performance Period
CMS Measure ID CMS2v12
NQF Number Not Applicable
Measure 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 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 qualifying encounter during the measurement period

Denominator Statement

Equals Initial Population

Denominator Exclusions

Patients who have ever been diagnosed with depression or with bipolar disorder at any time prior to the qualifying encounter

Numerator Statement

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

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)

Measure Steward Centers for Medicare & Medicaid Services (CMS)
Quality Domain Community/Population Health
Measure Scoring Proportion measure
Measure Type Process measure
Improvement Notation

Higher score indicates better quality

Guidance

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.

MIPS Quality ID 134
Meaningful Measure Prevention, Treatment, and Management of Mental Health
Telehealth Eligible Yes
Next Version No Version Available
Previous Version

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Measure Information 2021 Performance Period 2022 Performance Period 2023 Performance Period
CMS Measure ID CMS2v10 CMS2v11 CMS2v12
NQF Number 0418e Not Applicable Not Applicable
Measure 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

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

Denominator Statement

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
Numerator Statement

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

Numerator Exclusions

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)

Measure Steward Centers for Medicare & Medicaid Services (CMS) Centers for Medicare & Medicaid Services (CMS) Centers for Medicare & Medicaid Services (CMS)
Quality Domain Community/Population Health Community/Population Health Community/Population Health
Measure Scoring Proportion measure Proportion measure Proportion measure
Measure Type Process measure Process measure Process measure
Improvement Notation

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 (https://ecqi.healthit.gov/qdm) 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.

MIPS Quality ID 134 134 134
Meaningful Measure Prevention, Treatment, and Management of Mental Health Prevention, Treatment, and Management of Mental Health Prevention, Treatment, and Management of Mental Health
Telehealth Eligible Yes Yes Yes
Next Version CMS2v11 CMS2v12 No Version Available
Previous Version No Version Available

Release Notes

Header

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Added the 2018 American College of Obstetricians and Gynecologists recommendation statement about perinatal depression to ensure the measure includes updated evidence and clinical guidelines.

    Measure Section: Clinical Recommendation Statement

    Source of Change: Measure Lead

  • Added 'Psychiatric Nurse Practitioners' and replaced 'social worker' with 'clinical social worker' to improve alignment with measure intent and clarify appropriate follow-up providers after a positive depression screen.

    Measure Section: Guidance

    Source of Change: Expert Work Group Review

  • Revised existing guidance to clarify that the depression screening can take place up to 14 CALENDAR days prior to the date of the qualifying encounter in order to maintain consistency with the level of specificity included in the guidance.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Revised existing language to improve alignment with measure intent and clarify that patients who have ever been diagnosed with depression or bipolar disorder should be excluded from the measure.

    Measure Section: Guidance

    Source of Change: ONC Project Tracking System (JIRA): CQM-4608

  • Updated version number of the Quality Data Model (QDM) used in the measure specification to v5.6.

    Measure Section: Guidance

    Source of Change: Standards/Technical Update

  • Revised existing language to improve alignment with measure intent and clarify that patients who have ever been diagnosed with depression or bipolar disorder should be excluded from the measure.

    Measure Section: Denominator Exclusions

    Source of Change: ONC Project Tracking System (JIRA): CQM-4608

  • Made minor updates to grammar, wording, and formatting to improve readability and consistency.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Added new and revised existing language to allow a grace period of up to two calendar days after the qualifying encounter for provider documentation of a follow-up plan in order to allow flexibility based on feedback from implementers about clinical workflows.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

Logic

  • Added the Telephone Visits (2.16.840.1.113883.3.464.1003.101.12.1080) value set to the 'Qualifying Encounter During Measurement Period' definition to improve alignment with measure intent and expand eligible telehealth encounters to meet denominator criteria.

    Measure Section: Definitions

    Source of Change: ONC Project Tracking System (JIRA): CQM-5039

  • Added logic to mulitple definitions to allow providers to document a follow-up plan on the day of or up to two calendar days after the qualifying encounter in order to allow flexibility based on feedback from implementers about clinical workflows.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Updated the version of the Quality Data Model (QDM) to 5.6 and Clinical Quality Language (CQL) to 1.5.

    Measure Section: Multiple Sections

    Source of Change: Standards/Technical Update

  • Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library to v7.0.000.

    Measure Section: Multiple Sections

    Source of Change: Standards/Technical Update

  • Updated the names of CQL definitions, functions, and/or aliases for clarification and to align with the CQL Style Guide.

    Measure Section: Multiple Sections

    Source of Change: Standards/Technical Update

  • Replaced the Global.CalendarAgeInYearsAt function with the native CQL function AgeInYearsAt to take advantage of existing CQL features and increase human readability. As a result of this change, the LOINC code 21112-8 is no longer required and has been removed from the Terminology section of the human readable specification.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

Value set

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

  • Added value set Telephone Visits (2.16.840.1.113883.3.464.1003.101.12.1080) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Physical Therapy Evaluation (2.16.840.1.113883.3.526.3.1022): Added 6 SNOMED CT codes (410158009, 410160006, 183326003, 410159001, 424203006, 424291000) based on review by technical experts, SMEs, and/or public feedback. Added 1 CPT code (97164) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Adolescent Depression Medications (2.16.840.1.113883.3.526.3.1567): Added 7 RxNorm codes (403969, 403970, 403971, 403972, 721787, 251201, 410584) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Adult Depression Medications (2.16.840.1.113883.3.526.3.1566): Added 21 RxNorm codes based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Bipolar Diagnosis (2.16.840.1.113883.3.600.450): Added 9 ICD-10-CM codes (F30.10, F30.11, F30.12, F30.13, F30.2, F30.3, F30.4, F30.8, F30.9) based on review by technical experts, SMEs, and/or public feedback. Added 2 ICD-9-CM codes (296.81, 296.82) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Depression Diagnosis (2.16.840.1.113883.3.600.145): Added 1 ICD-10-CM code (F32.A) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Medical Reason (2.16.840.1.113883.3.526.3.1007): Deleted 1 SNOMED CT code (397745006) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Referral for Adolescent Depression (2.16.840.1.113883.3.526.3.1570): Deleted 1 SNOMED CT code (183851006) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Referral for Adult Depression (2.16.840.1.113883.3.526.3.1571): Deleted 1 SNOMED CT code (305922005) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Removed direct reference code LOINC code (21112-8) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

Last Updated: May 04, 2022