CQM Measure CMS2v6 Preventive Care and Screening: Screening for Clinical Depression and Follow Up Plan

CQM Measure CMS2v6 Preventive Care and Screening: Screening for Clinical Depression and Follow Up Plan

NQS Domain: Population/Public Health

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.

Denominator Logic

Patient was >= 12 years old on or before the start of measurement period.

AND Patient had one or more appointment scheduled during measurement period, with CPT code [90791, 90792, 90832, 90834, 90837, 92625, 96116, 96118, 96150, 96151, 97003, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99384, 99385, 99386, 99387, 99394, 99395, 99396, 99397] or HCPCS code [G0101, G0402, G0438, G0439, G0444] entered.

Exclusions Logic:

Patient had active patient problem Depression diagnosis (CQM ValueSet: 2.16.840.1.113883.3.600.145) or Bipolar Diagnosis (CQM ValueSet: 2.16.840.1.113883.3.600.450) recorded during measurement period.

Numerator Logic

OR: Patient had Risk Category/Assessment record Adolescent Depression Screening (CQM ValueSet: 2.16.840.1.113883.3.600.2452) with result Negative Depression Screening recorded during measurement period.

OR: Patient had Risk Category/Assessment record Adult Depression Screening (CQM ValueSet: 2.16.840.1.113883.3.600.2449) with result Negative Depression Screening recorded during measurement period

OR:
        OR: Patient had Intervention Referral for Depression Adolescent (CQM ValueSet: 2.16.840.1.113883.3.600.537) ordered.
        OR: Patient had Intervention Referral for Depression Adult (CQM ValueSet: 2.16.840.1.113883.3.600.538) ordered.
    
    OR: Patient had Intervention Follow-up for depression-adolescent (CQM ValueSet: 2.16.840.1.113883.3.600.467) performed.

        
OR: Patient had Intervention Follow-up for depression-adult (CQM ValueSet: 2.16.840.1.113883.3.600.478) performed.

        OR: Patient had Intervention Additional evaluation for depression-adolescent (CQM ValueSet: 2.16.840.1.113883.3.600.1542) performed.
        OR: Patient had Intervention Additional evaluation for depression-adult (CQM ValueSet: 2.16.840.1.113883.3.600.1545) performed.
        OR: Patient had Medication Additional evaluation for depression-adolescent (2.16.840.1.113883.3.600.469) ordered.
        OR: Patient had Medication Additional evaluation for depression-adult (2.16.840.1.113883.3.600.470) ordered.
        OR: Patient had CPT code 3085F recorded.
        <= 1 day after the first Risk Category/Assessment record Adolescent Depression Screening (CQM ValueSet: 2.16.840.1.113883.3.600.2452) or Adult Depression Screening (CQM ValueSet: 2.16.840.1.113883.3.600.2449) record during measurement period.

For more information, please visit the CMS website here.

How To (Website)

Step 1: Access the patient's record, and click CQMs

Step 2: To create an intervention, Click “New” in the “Intervention” section

Step 3: To create a risk category/assessment, Click “New” in the “Risk Category/Assessment” section