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

Last updated: February 1, 2017

CMS Measure ID: CMS2v6
Version: 6
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 Population

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)
National Quality Strategy Domain: Community, Population and Public Health
Previous Version: Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan
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, 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

  • Updated Copyright.

    Section: Copyright

    Source: Annual Update

  • ​Added Patient Health Questionnaire (PHQ-9) and Pediatric Symptom Checklist (PSC-17) to Definition: Examples of depression screening tools for adolescents to clarify other options of standardized depression screening tools available for provider use.

    Section: Definition

    Source: JIRA (CQM-1533)

  • Changed term Clinical Depression to Depression because the term 'clinical' could reduce the sensitivity of screening.

    Section: Description

    Source: Measure Lead

  • Incremented eMeasure Version number.

    Section: eMeasure Version number

    Source: Annual Update

  • Changed term Clinical Depression to Depression because the term 'clinical' could reduce the sensitivity of screening.

    Section: Guidance

    Source: Measure Lead

  • Changed term Clinical Depression to Depression because the term 'clinical' could reduce the sensitivity of screening.

    Section: Numerator

    Source: Measure Lead

  • Updated to incorporate new literature.

    Section: Rationale

    Source: Expert Work Group Review

  • Changed title from Clinical Depression to Depression because the term 'clinical' could reduce the sensitivity of screening.

    Section: Title

    Source: Measure Lead

Logic

  • Updated logic to prevent a scenario where the case may be erroneously identified as a denominator exception rather than a denominator hit/numerator miss. This misidentification would occur when all of the following criteria were met: 1) patient has a qualified encounter and are excepted from the measure (refusal, medical reason) 2) patient has a qualified encounter later in the measurement period and are screened for depression 3) depression screen at second encounter is positive 4) follow-up is not documented. The revised logic for denominator exceptions requires that no depression screenings were performed during the measurement period and patient refusal or medical reason for not screening is documented during a qualifying encounter.

    Section: Denominator Exceptions

    Source: External Review

  • Replaced datatypes 'Diagnosis, Active; Diagnosis, Inactive; Diagnosis, Resolved' with the re-specified 'Diagnosis' datatype to conform to QDM 4.2 changes.

    Section: Denominator Exclusions

    Source: QDM Standards

  • Numerator logic has been updated to correct a situation where depression screenings outside of qualified encounters could impact numerator criteria. It is the intent of the measure to look for most recent screening during an encounter defined by the denominator criteria and to disregard screenings which do not take place during a qualified encounter.

    Section: Numerator

    Source: JIRA (CQM-1852)

  • Replaced datatypes 'Diagnosis, Active; Diagnosis, Inactive; Diagnosis, Resolved' with the re-specified 'Diagnosis' datatype to conform to QDM 4.2 changes.

    Section: QDM Data Elements

    Source: QDM Standards

Value Set

  • Value set Bipolar Diagnosis (2.16.840.1.113883.3.600.450): Added 1 ICD9CM code (296.52).

    Section: None

    Source: JIRA (CQM-1477)

  • Value set Depression medications - adult (2.16.840.1.113883.3.600.470): Added 1 RXNORM code (259197) and deleted 10 RXNORM codes (107078, 242345, 242637, 242715, 252718, 259993, 309671, 309672, 410062, 991200).

    Section: None

    Source: None

  • Value set Depression Screening Encounter Codes (2.16.840.1.113883.3.600.1916): Deleted 1 CPT code (90839).

    Section: None

    Source: None

  • Value set Depression diagnosis (2.16.840.1.113883.3.600.145): Added 3 ICD10CM codes (F32.89, F34.81, F34.89) and deleted 1 ICD10CM code (F32.8).

    Section: None

    Source: ICD-10 Addendum

External Resources