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

General eCQM Information

CMS Measure ID CMS2v11
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 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 Type Process
Improvement Notation

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 (https://ecqi.healthit.gov/qdm) for more information on the QDM.

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

Release Notes

Header

  • Updated the eCQM version number.

    Measure Section: eCQM Version Number

    Source of Change: Annual Update

  • ​Removed NQF number and notation of endorsement from measure header because this measure is no longer endorsed by NQF.

    Measure Section: NQF Number

    Source of Change: Measure Lead

  • Updated Measure Developer.

    Measure Section: Measure Developer

    Source of Change: Measure Lead

  • ​Removed NQF number and notation of endorsement from measure header because this measure is no longer endorsed by NQF.

    Measure Section: Endorsed By

    Source of Change: Measure Lead

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated disclaimer.

    Measure Section: Disclaimer

    Source of Change: Annual Update

  • Updated the rationale to align with current evidence based on published literature.

    Measure Section: Rationale

    Source of Change: Measure Lead

  • Added the 2019 United States Preventative Services Task Force recommendation statement about perinatal depression to ensure measure includes updated evidence and clinical guidelines.

    Measure Section: Clinical Recommendation Statement

    Source of Change: Expert Work Group Review

  • Updated references.

    Measure Section: Reference

    Source of Change: Annual Update

  • Updated the language in the list of numerator-compliant follow-up plans to ensure patients receive clinically appropriate treatment based on the recommendations from clinical experts.

    Measure Section: Definition

    Source of Change: Expert Work Group Review

  • Added a new guidance statement to clarify measure instructions regarding the appropriateness of pharmacological intervention.

    Measure Section: Guidance

    Source of Change: Expert Work Group Review

  • Added guidance statement that a specific depression screening score is not required to calculate the measure for clarity and to align with guidance from the PREV-12 modality.

    Measure Section: Guidance

    Source of Change: Measure Lead

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

    Measure Section: Guidance

    Source of Change: Annual Update

  • Removed language related to setting.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Updated existing guidance to reflect the language changes to the list of numerator-compliant follow-up plans in the Definition section.

    Measure Section: Guidance

    Source of Change: Expert Work Group Review

Logic

  • 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: Multiple Sections

    Source of Change: Standards Update

  • Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-6.2.000). Updated the 'Inpatient Encounter' definition to include a 'day of' timing clarification. Added the following timing functions: Normalize Interval, Has Start, Has End, Latest, Latest Of, Earliest, and Earliest Of. Please see individual measure details for application of specific timing functions.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Added new NormalizeInterval function to timing attributes to decrease implementation burden due to variable use of timing attributes for select QDM data types. The NormalizeInterval function was applied, where applicable, for the following data elements: Assessment, Performed; Device, Applied; Diagnostic Study, Performed; Intervention, Performed; Laboratory Test, Performed; Medication, Administered; Medication, Dispensed; Physical Exam, Performed; Procedure, Performed; Substance, Administered.

    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 Encounter to Screen for Depression (2.16.840.1.113883.3.600.1916): Deleted 1 CPT code (99201) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Bipolar Diagnosis (2.16.840.1.113883.3.600.450): Added 7 ICD-9-CM codes (296.50, 296.51, 296.53, 296.54, 296.55, 296.56, 296.89) based on review by technical experts, SMEs, and/or public feedback. Added 1 ICD-10-CM code (F31.0) 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): Deleted 6 ICD-10-CM codes (O90.6, O99.340, O99.341, O99.342, O99.343, O99.345) based on review by technical experts, SMEs, and/or public feedback. Added 1 ICD-9-CM code (296.35) based on review by technical experts, SMEs, and/or public feedback. Added 3 SNOMED CT codes (191604000, 10811121000119102, 133121000119109) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Replaced value sets Negative Depression Screening (2.16.840.1.113883.3.526.3.1564) and Positive Depression Screening (2.16.840.1.113883.3.526.3.1565) with direct reference codes SNOMED CT codes (428171000124102, 428181000124104) based on applicability of a single code to represent clinical data.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Adult Depression Medications (2.16.840.1.113883.3.526.3.1566): Added 1 RxNorm code (616402) based on review by technical experts, SMEs, and/or public feedback. Deleted 3 RxNorm codes (251200, 794947, 199283) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Adolescent Depression Medications (2.16.840.1.113883.3.526.3.1567): Deleted 2 RxNorm codes (251200, 794947) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Follow Up for Adult Depression (2.16.840.1.113883.3.526.3.1568): Added 1 SNOMED CT code (228557008) based on terminology update. Deleted 1 SNOMED CT code (304891004) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Follow Up for Adolescent Depression (2.16.840.1.113883.3.526.3.1569): Added 1 SNOMED CT code (228557008) based on terminology update. Deleted 1 SNOMED CT code (304891004) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

Last Updated: Jul 08, 2021