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

Last updated: October 11, 2018

CMS Measure ID: CMS2v8
Version: 8
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 at 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 & Medicaid Services (CMS)
Domain: Community/Population Health
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.

Depression screening is required once per measurement period, not at all encounters; this is patient based and not an encounter based measure.

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

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.

Examples of a follow-up plan include but are not limited to:

* Additional evaluation or assessment for depression such as psychiatric interview, psychiatric evaluation, or assessment for bipolar disorder

* Completion of any Suicide Risk Assessment such as Beck Depression Inventory or Beck Hopelessness Scale

* 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 psychotherapy, pharmacological interventions, or additional treatment options

* 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.

Quality ID: 134
Meaningful Measure: Prevention, Treatment, and Management of Mental Health

Specifications

Release Notes

Header

  • Updated Version Number.

    Measure Section: eMeasure Version number

    Source of Change: Measure Lead

  • Updated Copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated Disclaimer.

    Measure Section: Disclaimer

    Source of Change: Measure Lead

  • Updated rationale to include information from more current source.

    Measure Section: Rationale

    Source of Change: Expert Work Group

  • Updated reference updated to include information from more current source.

    Measure Section: Reference

    Source of Change: Expert Work Group

  • Added 'or assessment' to the definition of Follow-Up Plan to allow for use of additional assessment tools.

    Measure Section: Definition

    Source of Change: JIRA (CQMinfo-icon-2194)

  • Updated the definitions section to add two standardized and validated screening tools to the example screening tool list.

    Measure Section: Definition

    Source of Change: Expert Work Group

  • Added the statement 'Depression screening is required once per measurement period, not all encounters; this is patient based and not an encounter based measure' to clarify the assessment frequency.

    Measure Section: Guidance

    Source of Change: Expert Work Group

  • Updated guidance related to standardized depression screening tools.

    Measure Section: Guidance

    Source of Change: Expert Work Group

  • Added examples of a follow-up plan to the guidance section based on expert recommendations.

    Measure Section: Guidance

    Source of Change: Expert Work Group

  • Replaced 'before the beginning of' with 'at the beginning of' to better align with CQLinfo-icon logic.

    Measure Section: Initial Populationinfo-icon

    Source of Change: Measure Lead

Logic

  • Updated logic expressed using CQL to address an encounter issue resulting in an unexpected exclusion of cases.

    Measure Section: Denominatorinfo-icon Exclusions

    Source of Change: JIRA (CQM-2574)

  • Changed 'Procedure performed' to 'Intervention performed' to harmonize the representation of the data elements within other measures.

    Measure Section: Numeratorinfo-icon

    Source of Change: JIRA (CQM-2752)

  • Revised logic for timing of follow-up interventions to better align with the measure intent.

    Measure Section: Numerator

    Source of Change: QDMinfo-icon Standards

  • Added supplemental timing attributes to most datatypes in QDM 5.3 to facilitate accurate retrieval of time related information within CQL logic. Timing attributes now include a time interval, such as prevalence period or relevant period, and/or actual time of documentation with Author Datetime. Relevant period is the general method to describe start and stop times for datatypes. Prevalence period is used for some datatypes to more accurately define onset and abatement times.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Assigned cardinality to each attribute to be more explicit in guiding specificationinfo-icon and implementation of QDM data elements. Cardinality refers to the number of instances of the attribute that can be included in the measure description. Cardinality for most attributes is 0.. 1 (i.e., can occur up to 1 time), but some attributes have a cardinality of 0.. * (i.e., can occur multiple times).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • CQL libraries contain sets of CQL definitions, or CQL expression statements. A context statement, patient or population, can now be used in a CQL library to clearly establish how the subsequent list of CQL expressions will be interpreted. A 'Population' context will interpret the CQL expression with reference to the entire population of the item being counted, patients or encounters. A 'Patient' context will interpret the CQL expression with reference to a single patient. Context statements are not required, but one or more context statements may be used within a library to help clarify how the CQL expressions will be interpreted. Patient context is the default if none is specified.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Replaced measure-defined definitions with similar definitions and functions from CQL shared libraries for consistency across measures.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated measure logic from Quality Data Model (QDM)-based logic to Clinical Quality Language (CQL)-based logic. Information on CQL can be found at the eCQI Resource centerinfo-icon (https://ecqi.healthit.gov/cql). Information about specific versions of the new standards in use for CMS reporting periods can be found at the eCQI Resource Center (https://ecqi.healthit.gov/ecqm-tools-key-resources). Switching from QDM to CQL brings with it many changes, as well as enhanced expression capability, but only those changes with significant impact will be outlined in technical release notes. For example, in the case of timing operators, changes may only be summarized if those changes impact the measure calculation.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

Value Setinfo-icon

The VSAC 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): Deleted 1 SNOMEDCT code (428161000124109).

    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): Deleted 1 SNOMEDCT code (428151000124107).

    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 25 CPT codes and deleted 5 HCPC codes (G0502, G0503, G0504, G0505, G0507).

    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 11 SNOMEDCT codes (108313002, 1555005, 15558000, 18512000, 229065009, 75516001, 76168009, 28868002, 304891004, 405780009, 81294000).

    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 11 SNOMEDCT codes (108313002, 1555005, 15558000, 18512000, 229065009, 75516001, 76168009, 28868002, 304891004, 405780009, 81294000).

    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 (454331000124109).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Depression medications - adult (2.16.840.1.113883.3.600.470): Deleted 3 RXNORM codes (730440, 730441, 730442).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Payer (2.16.840.1.114222.4.11.3591): Added 11 SOP codes (299, 32127, 32128, 391, 517, 524, 614, 621, 622, 623, 629) and deleted 3 SOP codes (63, 64, 69).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Replaced LOINC single code value sets with direct referenced codes. A direct referenced code is a single concept code that is used to describe a clinical element directly within the logic. The use of direct referenced codes replaces the need for single code value sets. Measures using other code systems in single value sets may optionally transition to direct referenced codes.

    Measure Section: QDM Data Elements

    Source of Change: Standards Update

  • Value set Depression diagnosis (2.16.840.1.113883.3.600.145): Added 2 ICD10CM codes (F53.0, F53.1) and deleted 1 ICD10CM code (F53).

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

  • Value set Payer (2.16.840.1.114222.4.11.3591): Deleted 1 SOP code (24).

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

  • Value set Depression medications - adult (2.16.840.1.113883.3.600.470): Deleted 1 RXNORM code (245373).

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

External Resources