download chevron-down chevron-right chevron-with-circle-down chevron-with-circle-up check circle-with-minus circle-with-plus export help-with-circle inbox link mail old-phone star-outlined star user v-card close close close Back to top
Top

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

Last updated: May 3, 2018

CMS Measure ID: CMS2v7
Version: 7
NQF Number: 0418
Measure 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

Initial Patient Population:

All patients aged 12 years and older before the beginning of the measurement period with at least one eligible encounter during the measurement period

Denominator Statement:

Equals Initial Populationinfo-icon

Denominator Exclusions:

Patients with an active diagnosis for depression or a diagnosis of bipolar disorder

Numerator Statement:

Patients screened for depression on 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 positive screen

Numerator Exclusions:

Not Applicable

Denominator Exceptions:

Patient Reason(s)

Patient refuses to participate

OR

Medical Reason(s)

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

OR

Situations where the patient's functional capacity or motivation to improve may impact the accuracy of results of standardized depression assessment tools. For example: certain court appointed cases or cases of delirium

Measure Steward: Centers for Medicare and Medicaid Services (CMS)
Domain: Community/Population Health
Next Version:
Previous Version:
Improvement Notation:

Higher score indicates better quality

Guidance:

A depression screen is completed on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, either additional evaluation for depression, suicide risk assessment, referral to a practitioner who is qualified to diagnose and treat depression, pharmacological interventions, or other interventions or follow-up for the diagnosis or treatment of depression is documented on the date of the positive screen.

Screening Tools:

* 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

* The screening should occur during a qualified encounter

* Standardized Depression Screening Tools should be normalized and validated for the age appropriate patient population in which they are used and must be documented in the medical record

Follow-Up Plan:

* The follow-up plan must be related to a positive depression screening, example: Patient referred for psychiatric evaluation due to positive depression screening.

* Pharmacologic treatment for depression is often indicated during pregnancy and/or lactation. Review and discussion of the risks of untreated versus treated depression is advised. Consideration of each patient's prior disease and treatment history, along with the risk profiles for individual pharmacologic agents, is important when selecting pharmacologic therapy with the greatest likelihood of treatment effect.

Notes: Value Set content updated Sept 2017

Specifications

Release Notes

Header

  • ​Incremented eMeasure Version number.

    Measure Section: eMeasure Version number

    Source of Change: Measure Lead

  • Modified Measure Developerinfo-icon name from 'Quality Insights of Pennsylvania' to 'Quality Insights.'.

    Measure Section: Measure Developer

    Source of Change: Measure Lead

  • ​Updated Copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • ​​Updated Rationale.

    Measure Section: Rationale

    Source of Change: Measure Lead

  • Updated Clinical Recommendation Statement to align with clinical guidelines.

    Measure Section: Clinical Recommendation Statement

    Source of Change: Expert Work Group Review

  • Updated References.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Revised the example list of screening tools to include additional example tools, including perinatal screening tools, to align with the clinical guideline recommendations.

    Measure Section: Definition

    Source of Change: Expert Work Group Review

  • Updated Guidance.

    Measure Section: Guidance

    Source of Change: Measure Lead

Logic

  • Replaced 'Risk Category Assessment' datatype with 'Assessment, Performed' datatype to conform with QDMinfo-icon 4.3 changes.

    Measure Section: Numeratorinfo-icon

    Source of Change: QDM Standards

  • Replaced 'Risk Category Assessment' datatype with 'Assessment, Performed' datatype to conform with QDM 4.3 changes.

    Measure Section: Denominator Exceptionsinfo-icon

    Source of Change: QDM Standards

Value Setinfo-icon

The VSACinfo-icon is the source of truth for the value set content, please visit the VSAC for downloads of current value setsinfo-icon.

  • Value set Additional evaluation for depression - adolescent (2.16.840.1.113883.3.600.1542): Added 1 SNOMEDCT code (429441000124107).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Additional evaluation for depression - adult (2.16.840.1.113883.3.600.1545): Added 1 SNOMEDCT code (429441000124107).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Depression Screening Encounter Codes (2.16.840.1.113883.3.600.1916): Added 4 CPT codes (59400, 59510, 59610, 59618).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Bipolar Diagnosis (2.16.840.1.113883.3.600.450): Added 15 ICD9CM codes. Added 20 ICD10CM codes. Added 5 SNOMEDCT codes (133091000119105, 23741000119105, 261000119107, 271000119101, 61771000119106).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Follow-up for depression - adolescent (2.16.840.1.113883.3.600.467): Added 2 SNOMEDCT codes (386472008, 76740001).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Follow-up for depression - adult (2.16.840.1.113883.3.600.468): Added 2 SNOMEDCT codes (386472008, 76740001).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Referral for Depression Adult (2.16.840.1.113883.3.600.538): Added 3 SNOMEDCT codes (703978000, 710914003, 711281004).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Suicide Risk Assessment (2.16.840.1.113883.3.600.559): Added 1 SNOMEDCT code (446765009).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Depression diagnosis (2.16.840.1.113883.3.600.145): Added 10 ICD10CM codes (F33.40, F33.41, F33.8, F53, O90.6, O99.340, O99.341, O99.342, O99.343, O99.345).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Depression medications - adult (2.16.840.1.113883.3.600.470): Added 37 RXNORM codes and deleted 53 RXNORM codes.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Depression Screening Encounter Codes (2.16.840.1.113883.3.600.1916): Added 3 CPT codes (97165, 97166, 97167) and deleted 1 CPT code (97003). Added 5 HCPCS codes (G0502, G0503, G0504, G0505, G0507).

    Measure Section: QDM Data Elements

    Source of Change: 2018 Addendum

  • Value set Depression medications - adolescent (2.16.840.1.113883.3.600.469): Deleted 1 RXNORM code (803293).

    Measure Section: QDM Data Elements

    Source of Change: 2018 Addendum

  • Value set Suicide Risk Assessment (2.16.840.1.113883.3.600.559): Added 1 SNOMEDCT code (717317000).

    Measure Section: QDM Data Elements

    Source of Change: 2018 Addendum

  • Value set Depression medications - adult (2.16.840.1.113883.3.600.470): Deleted 1 RXNORM code (803293).

    Measure Section: QDM Data Elements

    Source of Change: 2018 Addendum

External Resources