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

Compare Versions of: "Preventive Care and Screening: Screening for Depression and Follow-Up Plan"

The Compare function compares two years of the measure specifications found in the header of the measure's HTML. It does not include a comparison of any information in the body of the HTML, e.g., population criteria, Clinical Quality Language, or value sets.

Strikethrough text highlighted in red indicates information changed from the previous version. Text highlighted in green indicates information updated in the new eCQM version.

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Measure Information 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
CMS eCQM ID CMS2v11 CMS2v12 CMS2v13
NQF Number 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 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 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

Denominator Exclusions 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 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

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 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)
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

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
Telehealth Eligible Yes Yes Yes
Next Version No Version Available
Previous Version No Version Available
Notes

*There is a known issue on CMS2v13. See issue EKI-22 on the ONC eCQM Known Issues Dashboard for details.

Header

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated grammar, wording, and/or formatting to improve readability and consistency.

    Measure Section: Rationale

    Source of Change: Annual Update

  • Updated references.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Removed depression diagnosis exclusion based on recommendations from clinical experts.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Removed depression diagnosis exclusion based on recommendations from clinical experts.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Updated language from 'Patient refuses to participate' to 'Patient refuses to participate in or complete the depression screening' to clarify that the patient refusal exception is limited to refusal of the depression screening.

    Measure Section: Denominator Exceptions

    Source of Change: ONC Project Tracking System (JIRA): CQM-5351

Logic

  • Changed the definition name from 'History of Bipolar or Depression Diagnosis Before Qualifying Encounter' to 'History of Bipolar Diagnosis Before Qualifying Encounter' and revised the logic to remove a prior depression diagnosis from exclusion criteria based on recommendations from clinical experts.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Updated the timing precision in the 'Most Recent Adult Depression Screening Positive and Follow Up Provided' and 'Most Recent Adolescent Depression Screening Positive and Follow Up Provided' definitions to include that the authorDatetime of the follow-up intervention for a positive depression screen is 2 days or less on or after day of end of QualifyingEncounter to align with the measure intent that follow-up is documented during or up to 2 days after the qualifying encounter.

    Measure Section: Numerator

    Source of Change: Test Case Review

  • Updated the timing precision in the 'Most Recent Adult Depression Screening Positive and Follow Up Provided' and 'Most Recent Adolescent Depression Screening Positive and Follow Up Provided' definitions to include that the authorDatetime of the follow-up intervention for a positive depression screen is 2 days or less on or after day of end of QualifyingEncounter to align with the measure intent that follow-up is documented during or up to 2 days after the qualifying encounter.

    Measure Section: Definitions

    Source of Change: Test Case Review

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

    Measure Section: Definitions

    Source of Change: Standards/Technical Update

  • Changed the definition name from 'History of Bipolar or Depression Diagnosis Before Qualifying Encounter' to 'History of Bipolar Diagnosis Before Qualifying Encounter' and revised the logic to remove a prior depression diagnosis from exclusion criteria based on recommendations from clinical experts.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Added 'during the measurement period' to the 'Most Recent Adolescent Depression Screening Positive and Follow Up Provided' and 'Most Recent Adult Depression Screening Positive and Follow Up Provided' definitions to ensure that data collection of the follow-up plan occurs during the measurement period.

    Measure Section: Definitions

    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.

  • Value set Adolescent Depression Medications (2.16.840.1.113883.3.526.3.1567): Added 5 RxNorm codes (903873, 903879, 903884, 903887, 903891) based on review by technical experts, SMEs, and/or public feedback. Added 2 RxNorm codes (2591786, 2605950) based on terminology update.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Adult Depression Medications (2.16.840.1.113883.3.526.3.1566): Added 4 RxNorm codes (2591786, 2605950, 2605719, 2611260) based on terminology update. Deleted 2 RxNorm codes (1293413, 1945212) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Replaced value set Bipolar Diagnosis (2.16.840.1.113883.3.600.450) with value set Bipolar Disorder (2.16.840.1.113883.3.67.1.101.1.128) based on applicability of value set and/or OID.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Removed value set Depression Diagnosis (2.16.840.1.113883.3.600.145) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Encounter to Screen for Depression (2.16.840.1.113883.3.600.1916): Added 12 CPT codes based on review by technical experts, SMEs, and/or public feedback. Deleted 12 CPT codes based on terminology update. Added 2 HCPCS codes (G0270, G0271) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Replaced value set Patient Declined (2.16.840.1.113883.3.526.3.1582) with direct reference code SNOMED CT code (720834000) based on applicability of a single code to represent clinical data.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Payer (2.16.840.1.114222.4.11.3591): Added 5 SOP codes (1111, 1112, 142, 344, 141) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Referral for Adolescent Depression (2.16.840.1.113883.3.526.3.1570): Added 2 SNOMED CT codes (1186918003, 1186920000) based on terminology update. Deleted 2 SNOMED CT codes (306137002, 306294000) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Referral for Adult Depression (2.16.840.1.113883.3.526.3.1571): Added 2 SNOMED CT codes (1186918003, 1186920000) based on terminology update. Deleted 2 SNOMED CT codes (306137002, 306294000) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

Last Updated: Jan 22, 2024