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CMS Measure ID:
Version:
8
NQF Number:
418
Performance/Reporting Period
2019
Description:

Percentage of patients aged 12 years and older screened for depression on 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 positive screen.

Data Elements contained within the eCQM + Expand all

Direct Reference Code

Constrained to 'Adolescent depression screening assessment' LOINC code

QDM Datatype and Definition (QDM Version 5.3)

Assessment, Performed

Data elements that meet criteria using this datatype should document completion of the assessment indicated by the QDM category and its corresponding value set.

A QDM Known Issue has been identified related to this datatype. To see this QDM known Issue, please click here.

Timing: The time the assessment is completed; Author dateTime.

Direct Reference Code

Constrained to 'Adult depression screening assessment' LOINC code

QDM Datatype and Definition (QDM Version 5.3)

Assessment, Performed

Data elements that meet criteria using this datatype should document completion of the assessment indicated by the QDM category and its corresponding value set.

A QDM Known Issue has been identified related to this datatype. To see this QDM known Issue, please click here.

Timing: The time the assessment is completed; Author dateTime.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent diagnoses of bipolar disorder.
Data Element Scope: This value set may use the Quality Data Model (QDM) category or attribute related to Diagnosis.
Inclusion Criteria: Includes only relevant concepts associated with mild to severe cases, brief episodes, or chronic disorders, which would indicate that there is a current diagnosis of bipolar disorder documented by the healthcare provider.
Exclusion Criteria: No exclusions.

Constrained to codes in the Diagnosis: Bipolar Diagnosis value set (2.16.840.1.113883.3.600.450)

QDM Datatype and Definition (QDM Version 5.3)

Diagnosis

Data elements that meet criteria using this datatype should document the Condition/Diagnosis/Problem and its corresponding value set. The onset dateTime corresponds to the implicit start dateTime of the datatype and the abatement dateTime corresponds to the implicit stop dateTime of the datatype. If the abatement dateTime is not present, then the diagnosis is considered to still be active. When this datatype is used with timing relationships, the criterion is looking for an active diagnosis for the time frame indicated by the timing relationships.

Timing: The Prevalence Period references the time from the onset date to the abatement date.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent a current diagnosis of a depressed state or actual depressive disorder whether recurrent, chronic, or diagnosed as moderate, major, or severe.
Data Element Scope: This value set may use the Quality Data Model (QDM) category or attribute related to Diagnosis.
Inclusion Criteria: Includes only relevant concepts associated with depression diagnoses as well as depression as indicated as depressed mood or features, a single episode, or type of psychosis, or a reaction as related to depression.
Exclusion Criteria: No exclusions.

Constrained to codes in the Diagnosis: Depression diagnosis value set (2.16.840.1.113883.3.600.145)

QDM Datatype and Definition (QDM Version 5.3)

Diagnosis

Data elements that meet criteria using this datatype should document the Condition/Diagnosis/Problem and its corresponding value set. The onset dateTime corresponds to the implicit start dateTime of the datatype and the abatement dateTime corresponds to the implicit stop dateTime of the datatype. If the abatement dateTime is not present, then the diagnosis is considered to still be active. When this datatype is used with timing relationships, the criterion is looking for an active diagnosis for the time frame indicated by the timing relationships.

Timing: The Prevalence Period references the time from the onset date to the abatement date.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts in which a depression screen could be assessed and documented through an exam, assessment, interview or evaluation.
Data Element Scope: This value set may use the Quality Data Model (QDM) category or attribute related to Encounter.
Inclusion Criteria: Includes only relevant concepts associated with wellness visits, annual visits, therapy evaluations, or primary or specialist physician office visits where a depression screen could be conducted.
Exclusion Criteria: No exclusions.

Constrained to codes in the Encounter, Performed: Depression Screening Encounter Codes value set (2.16.840.1.113883.3.600.1916)

QDM Datatype and Definition (QDM Version 5.3)

Encounter, Performed

Data elements that meet criteria using this datatype should document that the encounter indicated by the QDM category and its corresponding value set is in progress or has been completed.

Timing: The Relevant Period addresses:

  • startTime – the time the encounter began (admission time)
  • stopTime – the time the encounter ended (discharge time)

The Author dateTime addresses when an Encounter is documented. Documentation can occur at the beginning, during, at the end or subsequent to the end of an Encounter. The Author dateTime should be used only if the Relevant Period cannot be obtained.

The Location Period is an attribute of the attribute facility location addresses:

  • startTime - the time the patient arrived at the location;
  • stopTime - the time the patient departed from the location

 

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent appropriate referrals specific to the child and adolescent age group for depression management.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Intervention.
Inclusion Criteria: Includes only relevant concepts associated with appropriate referrals as specific to the child and adolescent age group for depression management.
Exclusion Criteria: No exclusions.

Constrained to codes in the Intervention, Order: Referral for Depression Adolescent value set (2.16.840.1.113883.3.600.537)

QDM Datatype and Definition (QDM Version 5.3)

Intervention, Order

Data elements that meet criteria using this datatype should document a request to perform the intervention indicated by the QDM category and its corresponding value set.

Timing: The time the order is signed; Author dateTime

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent appropriate referrals specific to the adult age group for depression management.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Intervention.
Inclusion Criteria: Includes only relevant concepts associated with appropriate referrals as specific to the adult age group for depression management.
Exclusion Criteria: No exclusions.

Constrained to codes in the Intervention, Order: Referral for Depression Adult value set (2.16.840.1.113883.3.600.538)

QDM Datatype and Definition (QDM Version 5.3)

Intervention, Order

Data elements that meet criteria using this datatype should document a request to perform the intervention indicated by the QDM category and its corresponding value set.

Timing: The time the order is signed; Author dateTime

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent interventions and procedures where an adolescent patient received additional evaluation to determine the presence of depression.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Intervention or Procedure.
Inclusion Criteria: Includes only relevant concepts associated with psychiatric interview and evaluations used to determine the presence of depression, bipolar, or other mental health diagnoses.
Exclusion Criteria: No exclusions.

Constrained to codes in the Intervention, Performed: Additional evaluation for depression - adolescent value set (2.16.840.1.113883.3.600.1542)

QDM Datatype and Definition (QDM Version 5.3)

Intervention, Performed

Data elements that meet criteria using this datatype should document the completion of the intervention indicated by the QDM category and its corresponding value set.

Timing: The Relevant Period addresses:

  • startTime – the time the intervention begins
  • stopTime – the time the intervention ends

NOTE - timing refers to a single instance of an intervention. If a measure seeks to evaluate multiple interventions over a period of time, the measure developer should use CQL logic to represent the query request.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent interventions and procedures where an adult patient received additional evaluation to determine the presence of depression.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Intervention or Procedure.
Inclusion Criteria: Includes only relevant concepts associated with psychiatric interview and evaluation for testamentary capacity, rehabilitation, criminal responsibility, bipolar disorder and mental status.
Exclusion Criteria: No exclusions.

Constrained to codes in the Intervention, Performed: Additional evaluation for depression - adult value set (2.16.840.1.113883.3.600.1545)

QDM Datatype and Definition (QDM Version 5.3)

Intervention, Performed

Data elements that meet criteria using this datatype should document the completion of the intervention indicated by the QDM category and its corresponding value set.

Timing: The Relevant Period addresses:

  • startTime – the time the intervention begins
  • stopTime – the time the intervention ends

NOTE - timing refers to a single instance of an intervention. If a measure seeks to evaluate multiple interventions over a period of time, the measure developer should use CQL logic to represent the query request.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent follow-up plans used to document a plan is in place for the treatment of depression that specifically pertains to the adolescent population.
Data Element Scope: This value set may use the Quality Data Model (QDM) category or attribute related to Intervention.
Inclusion Criteria: Includes only relevant concepts associated with emotional and coping support as well as mental health management in an attempt to follow up on previously evaluated and diagnosed depression or depressive disorder in the adolescent population.
Exclusion Criteria: No exclusions.

Constrained to codes in the Intervention, Performed: Follow-up for depression - adolescent value set (2.16.840.1.113883.3.600.467)

QDM Datatype and Definition (QDM Version 5.3)

Intervention, Performed

Data elements that meet criteria using this datatype should document the completion of the intervention indicated by the QDM category and its corresponding value set.

Timing: The Relevant Period addresses:

  • startTime – the time the intervention begins
  • stopTime – the time the intervention ends

NOTE - timing refers to a single instance of an intervention. If a measure seeks to evaluate multiple interventions over a period of time, the measure developer should use CQL logic to represent the query request.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent follow-up plans used to document a plan is in place for the treatment of depression specifically pertaining to the adult population.
Data Element Scope: This value set may use the Quality Data Model (QDM) category or attribute related to Intervention.
Inclusion Criteria: Includes only relevant concepts associated with emotional and coping support as well as mental health management in an attempt to follow up on previously evaluated and diagnosed depression or depressive disorder in the adult population.
Exclusion Criteria: No exclusions.

Constrained to codes in the Intervention, Performed: Follow-up for depression - adult value set (2.16.840.1.113883.3.600.468)

QDM Datatype and Definition (QDM Version 5.3)

Intervention, Performed

Data elements that meet criteria using this datatype should document the completion of the intervention indicated by the QDM category and its corresponding value set.

Timing: The Relevant Period addresses:

  • startTime – the time the intervention begins
  • stopTime – the time the intervention ends

NOTE - timing refers to a single instance of an intervention. If a measure seeks to evaluate multiple interventions over a period of time, the measure developer should use CQL logic to represent the query request.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent suicide risk assessments and the Beck depression inventory.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Assessment or Intervention.
Inclusion Criteria: Includes only relevant concepts associated with suicide risk assessment and the Beck depression inventory.
Exclusion Criteria: No exclusions.

Constrained to codes in the Intervention, Performed: Suicide Risk Assessment value set (2.16.840.1.113883.3.600.559)

QDM Datatype and Definition (QDM Version 5.3)

Intervention, Performed

Data elements that meet criteria using this datatype should document the completion of the intervention indicated by the QDM category and its corresponding value set.

Timing: The Relevant Period addresses:

  • startTime – the time the intervention begins
  • stopTime – the time the intervention ends

NOTE - timing refers to a single instance of an intervention. If a measure seeks to evaluate multiple interventions over a period of time, the measure developer should use CQL logic to represent the query request.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent medications that are commonly used to treat adolescent depression.
Data Element Scope: This value set may use the Quality Data Model (QDM) category or attribute related to Medication.
Inclusion Criteria: Includes only relevant concepts associated with antidepressant medications as well as other recommended depressive management medications, specific to the child and adolescent age group, for depression management.
Exclusion Criteria: Excludes medications that are not commonly used in the treatment of depression in the child and adolescent age group.

Constrained to codes in the Medication, Order: Depression medications - adolescent value set (2.16.840.1.113883.3.600.469)

QDM Datatype and Definition (QDM Version 5.3)

Medication, Order

Data elements that meet criteria using this datatype should document a request to a pharmacy to provide the medication indicated by the QDM category and its corresponding value set.

Timing: The Author dateTime is the time the order is signed.

Timing: The Relevant Period addresses:

  • startTime - when the first administration of the medication is expected. The first administration may be expected at the time of the order or at a specified future date (i.e., the active time for the order); such information should be identified in the medication order. If the startTime is not specified in the order, the startTime defaults to the Author dateTime (the time the order is signed).
  • stopTime - when the medication supply provided by the medication order is expected to be completed, including all fulfillments covered by the number of refills.

Note that when calculating cumulative medication duration, the stopTime may be present directly in the medication order. If the stopTime is not available, the duration in days is the difference between the Relevant Period start and stop times multiplied by (1 + the number of refills).

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent medications that are commonly used to treat adult depression.
Data Element Scope: This value set may use the Quality Data Model (QDM) category or attribute related to Medication.
Inclusion Criteria: Includes only relevant concepts associated with antidepressant medications as well as other recommended depressive management medications, specific to the adult age group, for depression management.
Exclusion Criteria: Excludes medications that are not commonly used in the treatment of depression in the adult age group.

Constrained to codes in the Medication, Order: Depression medications - adult value set (2.16.840.1.113883.3.600.470)

QDM Datatype and Definition (QDM Version 5.3)

Medication, Order

Data elements that meet criteria using this datatype should document a request to a pharmacy to provide the medication indicated by the QDM category and its corresponding value set.

Timing: The Author dateTime is the time the order is signed.

Timing: The Relevant Period addresses:

  • startTime - when the first administration of the medication is expected. The first administration may be expected at the time of the order or at a specified future date (i.e., the active time for the order); such information should be identified in the medication order. If the startTime is not specified in the order, the startTime defaults to the Author dateTime (the time the order is signed).
  • stopTime - when the medication supply provided by the medication order is expected to be completed, including all fulfillments covered by the number of refills.

Note that when calculating cumulative medication duration, the stopTime may be present directly in the medication order. If the stopTime is not available, the duration in days is the difference between the Relevant Period start and stop times multiplied by (1 + the number of refills).

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent whether the patient is Hispanic or not; ethnicity category defined by the Centers for Disease Control and Prevention and National Center for Health Statistics.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Patient Characteristic Ethnicity.
Inclusion Criteria: Includes only relevant concepts associated with ethnicity defined as Hispanic or Latino, or Not Hispanic or Latino.
Exclusion Criteria: No exclusions.

Constrained to codes in the Patient Characteristic Ethnicity: Ethnicity value set (2.16.840.1.114222.4.11.837)

QDM Datatype and Definition (QDM Version 5.3)

Patient Characteristic Ethnicity

Data elements that meet criteria using this datatype should document that the patient has one or more of the ethnicities indicated by the QDM category and its corresponding value set.

Timing: Ethnicity does not have a specific timing. Measures using Patient Characteristic, Ethnicity should address the most recent entry in the clinical record.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent categories of types of health care payor entities as defined by the US Public Health Data Consortium SOP code system.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Patient Characteristic Payer.
Inclusion Criteria: Includes only relevant concepts associated with payer codes in the code system.
Exclusion Criteria: No exclusions.

Constrained to codes in the Patient Characteristic Payer: Payer value set (2.16.840.1.114222.4.11.3591)

QDM Datatype and Definition (QDM Version 5.3)

Patient Characteristic Payer

Data elements that meet criteria using this datatype should document that the patient has one or more of the payers indicated by the QDM category and its corresponding value set.

Timing: The Relevant Period addresses:

  • startTime – the first day of insurance coverage with the referenced payer
  • stopTime – the last day of insurance coverage with the referenced payer

 

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent the general race category reported by the patient - subject may have more than one; defined by the Centers for Disease Control and Prevention and National Center for Health Statistics.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Patient Characteristic Race.
Inclusion Criteria: Includes only relevant concepts associated with the following race categories: American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander, Other Race, White.
Exclusion Criteria: No exclusions.

Constrained to codes in the Patient Characteristic Race: Race value set (2.16.840.1.114222.4.11.836)

QDM Datatype and Definition (QDM Version 5.3)

Patient Characteristic Race

Data elements that meet criteria using this datatype should document the patient’s race.

Timing: Race does not have a specific timing. Measures using Patient Characteristic, Race should address the most recent entry in the clinical record.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent gender identity restricted to only male and female used in administrative situations requiring a restriction to these two categories.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Patient Characteristic Sex.
Inclusion Criteria: Includes relevant concepts associated with gender concepts for male and female only.
Exclusion Criteria: Excludes any gender identity that is not male or female.

Constrained to codes in the Patient Characteristic Sex: ONC Administrative Sex value set (2.16.840.1.113762.1.4.1)

QDM Datatype and Definition (QDM Version 5.3)

Patient Characteristic Sex

Data elements that meet criteria using this datatype should document that the patient's sex matches the QDM category and its corresponding value set.

Timing: Birth (administrative) sex does not have a specific timing.