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
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