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

Last updated: May 17, 2016

CMS Measure ID: CMS2v5
Version: 5
NQF Number: 0418
Measure Description:

Percentage of patients aged 12 years and older screened for clinical 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 Population

Denominator Exclusions:

Patients with an active diagnosis for Depression or a diagnosis of Bipolar Disorder

Numerator Statement:

Patients screened for clinical 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
National Quality Strategy Domain: Community, Population and Public Health
Next Version: Preventive Care and Screening: Screening for Depression and Follow-Up Plan
Previous Version: Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan
Measure Score: Proportion
Improvement Notation:

Higher score indicates better quality.

Guidance:

A clinical depression screen is completed 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.

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 and encounter must occur on the same date
  • 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.

Specifications

Release Notes

Header

  • Copyright updated.
  • Disclaimer updated.
  • eMeasure version number incremented.

Logic

  • Introduced function 'satisfies all' to specify that qualifying events must meet all conditions from a set of conditions or 'satisfies any' to specify that qualifying events must meet at least one condition from a set of conditions to streamline expression logic.
  • Introduced the new timing operator 'overlaps' to replace two lines of logic (AND/AND NOT) or to enforce when an event or set of events occur to meet the measure intent.
  • Replaced 'ORs' with 'Union of' operator to provide a mechanism for specifying that qualifying event(s) must be a member of at least one of the data elements being unioned (if appropriate for measure intent).
  • Replaced 'Patient Characteristic Birthdate' with 'Age at' operator.
  • The top level logical operator for the Numerator Exclusions, Denominator Exclusions, Denominator Exceptions, and Measure Population Exclusions defaults to 'OR'.
  • Updated Denominator Exclusion logic such that the exclusion criteria is described in relation to 'Occurrence A of Encounter...' rather than 'Occurrence A of Risk Category Assessment...'. 
  • Updated Numerator logic with the requirement that 'Occurrence A of Risk Category Assessment... (result: 'Depression Screening Result')' starts during 'Occurrence A of Encounter...'.

Value Sets

  • Replaced value use Medical reason contraindicated (OID 2.16.840.1.113883.3.600.792) with value set Medical or Other reason not done (OID 2.16.840.1.113883.3.600.1.1502).
  • Value set Additional evaluation for depression - adolescent (OID 2.16.840.1.113883.3.600.1542): Added 1 SNOMED code (428161000124109).
  • Value set Additional evaluation for depression - adult (OID 2.16.840.1.113883.3.600.1545): Added 1 SNOMED code (428151000124107).
  • Value set Depression diagnosis (OID 2.16.840.1.113883.3.600.145): Added 2 ICD9CM codes (296.20, 296.30).
  • Value set Depression Screening Denominator Encounter Codes (OID 2.16.840.1.113883.3.600.1916): Updated value set name from 'Depression Screening Denominator Encounter Codes New' to 'Depression Screening Encounter Codes'; Added 8 CPT codes (99384, 99385, 99386, 99387, 99394, 99395, 99396,99397).

External Resources