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

General eCQM Information

CMS Measure ID CMS2v10
NQF Number 0418e
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

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
Denominator Statement

Equals Initial Population

Denominator Exclusions

Patients who have been diagnosed with depression or with bipolar disorder

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

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)
Domain Community/Population Health
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.

Quality ID 134
Meaningful Measure Prevention, Treatment, and Management of Mental Health
Telehealth Eligible Yes
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Release Notes

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

Last Updated: May 05, 2021