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

Last updated: May 9, 2019

CMS Measure ID: CMS2v9
Version: 9
NQF Number: 418e
Measure Description:

Percentage of patients aged 12 years and older screened for depression on the date of the encounter or 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 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 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)

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 cognitive capacity, 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:
Measure Scoring: Proportion
Measure Type: Process
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, 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 eligible encounter.

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. 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 qualified encounter or up to 14 days prior to the date of the qualifying 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 eCQMinfo-icon version number.

    Measure Section: eCQM Version number

    Source of Change: Measure Lead

  • Added 'e' to NQFinfo-icon number.

    Measure Section: NQF Number

    Source of Change: Standards Update

  • Updated description statement to include depression screenings performed 14 days prior to the encounter to allow alternative methods of depression screenings, such as pre-screenings within EHRsinfo-icon, to more closely align with the measure intent.

    Measure Section: Description

    Source of Change: Measure Lead

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated rationale statement to reflect current literature, and to align with clinical guideline recommendations and Healthy People 2020.

    Measure Section: Rationale

    Source of Change: Expert Work Group Review

  • Updated references to align with American Psychological Association (APA) style.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Updated references.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Added guidance statements for: 1) Timing of the qualified depression screening encounter, and 2) Follow-up for positive pre-screening results to provide clarity and more closely align with the measure intent.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Updated numeratorinfo-icon statement to include depression screenings performed 14 days prior to the encounter to allow alternative methods of depression screenings, such as pre-screenings within EHRs, to more closely align with the measure intent.

    Measure Section: Numerator

    Source of Change: Measure Lead

  • Added denominator exceptionsinfo-icon statement for situations where a patient's cognitive capacity, functional capacity or motivation to improve may impact the accuracy of results of standardized depression assessment tools to align with American College of Physicians recommendation.

    Measure Section: Denominator Exceptions

    Source of Change: Expert Work Group Review

  • Updated parenthetical citations to align with American Psychological Association (APA) style.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

Logic

  • Replaced 'Intervention, Performed' with 'Assessment, Performed' to align with Quality Data Model (QDM)info-icon v5.4 changes.

    Measure Section: Initial Populationinfo-icon

    Source of Change: Measure Lead

  • Updated numerator logic to include depression screenings performed 14 days prior to the encounter to allow alternative methods of depression screenings, such as pre-screenings within EHRs, to more closely align with the measure intent.

    Measure Section: Numerator

    Source of Change: Measure Lead

  • Replaced 'Intervention, Performed' with 'Assessment, Performed' to align with Quality Data Model (QDM) v5.4 changes.

    Measure Section: Numerator

    Source of Change: Measure Lead

  • Replaced 'Intervention, Performed' with 'Assessment, Performed' to align with Quality Data Model (QDM) v5.4 changes.

    Measure Section: Denominator Exceptions

    Source of Change: Measure Lead

  • Updated the names of Clinical Quality Language (CQL)info-icon definitions, functions, and/or aliases for clarification and to align with CQL Style Guideinfo-icon.

    Measure Section: Definitions and Functions

    Source of Change: Standards Update

  • Updated Clinical Quality Language (CQL) expression to conform with the HL7info-icon Standard: Clinical Quality Language Specificationinfo-icon, Release 1 STUinfo-icon 3 (CQL 1.3).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated definitions and functions in the Measure Authoring Tool (MATinfo-icon) Global Common Functions Library to align with standards changes, Clinical Quality Language (CQL) Style Guide, and to include two new functions related to calculating hospital stays.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-4.0.000).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

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 Depression Screening Encounter Codes (2.16.840.1.113883.3.600.1916): Added 11 CPT codes (96105, 96110, 96112, 96125, 96136, 96138, 99078, 99401, 99402, 99403, 99404) and deleted 1 CPT code (96118). Deleted 10 SNOMED CT codes (108250004, 252592009, 274803000, 30346009, 37894004, 277404009, 43362002, 48423005, 67533008, 91573000).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Bipolar Diagnosis (2.16.840.1.113883.3.600.450): Deleted 2 SNOMED CT codes (191632009, 61771000119106).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Depression medications - adolescent (2.16.840.1.113883.3.600.469): Added 40 RxNorm codes.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Depression medications - adult (2.16.840.1.113883.3.600.470): Deleted 2 RxNorm codes (199820, 313497).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Direct reference code for Birth date (LOINC Code (21112-8)) now displayed in Human Readable.

    Measure Section: Terminology

    Source of Change: Annual Update

  • ​Removed code systeminfo-icon versions from direct reference codes. Please refer to Appendix A of the Electronic Clinical Quality Measureinfo-icon Logic and Implementation Guidance document for a list of code system versions used in the eCQM specificationsinfo-icon for 2020 reporting/performance.

    Measure Section: Terminology

    Source of Change: Standards Update

  • Standardized purpose statement language in value sets across eCQMsinfo-icon. Value set purpose statements are visible in the Value Set Authority Center (VSAC) as well as the downloadable eCQM value set files.

    Measure Section: Terminology

    Source of Change: Measure Lead

External Resources