Preventive Care and Screening: Screening for Depression and Follow-Up Plan CMS2v13

(2024) Electronic Clinical Quality Measures

Description

Percentage of patients aged 12 years and older 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 depression screening tool AND if positive, a follow-up plan is documented on the date of or up to two days after the date of the qualifying encounter. 

 Guidance

The intent of the measure is to screen for new cases of depression in patients who have never had a diagnosis of bipolar disorder. Patients who have ever been diagnosed with bipolar disorder prior to the qualifying encounter used to evaluate the numerator will be excluded from the measure regardless of whether the diagnosis is active or not.

A depression screen is completed on the date of the encounter or up to 14 calendar days prior to the date of the encounter using an age-appropriate standardized depression screening tool AND if positive, a follow-up plan must be documented on the date of or up to two calendar days after the date of the encounter, such as referral to a provider for additional evaluation, pharmacological interventions, or other interventions for the treatment of depression. An example to illustrate the follow-up plan documentation timing: if the encounter is on a Monday from 3-4 pm (day 0) and the patient screens positive, the clinician has through anytime on Wednesday (day 2) to complete follow-up plan documentation.

This measure does not require documentation of a specific score, just whether results of the normalized and validated depression screening tool used are considered positive or negative. Each standardized screening tool provides guidance on whether a particular score is considered positive for depression.

This eCQM is a patient-based measure. Depression screening is required once per measurement period, not at all encounters.

Screening Tools:

An age-appropriate, standardized, and validated depression screening tool must be used for numerator compliance.

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 by 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 qualifying encounter or up to 14 calendar days prior to the date of the qualifying encounter. 

The measure assesses the most recent depression screening completed either during the qualifying encounter or within the 14 calendar days prior to that encounter. Therefore, a clinician would not be able to complete another screening at the time of the encounter to count towards a follow-up, because that would serve as the most recent screening. In order to satisfy the follow-up requirement for a patient screening positively, the eligible clinician would need to provide one of the aforementioned follow-up actions, which does not include use of a standardized depression screening tool.

Follow-Up Plan:

The follow-up plan MUST still be provided for and discussed with the patient during the qualifying encounter used to evaluate the numerator. However, documentation of the follow-up plan can occur up to two calendar days after the qualifying encounter, in accordance with the policies of an eligible clinician or provider’s practice or health system. All services should be documented during, or as soon as practicable, after the qualifying encounter in order to maintain an accurate medical record.

The follow-up plan must be related to a positive depression screening, for example: "Patient referred for psychiatric evaluation due to positive depression screening."

Examples of a follow-up plan include but are not limited to: 

• Referral to a provider or program for further evaluation for depression, for example, referral to a psychiatrist, psychiatric nurse practitioner, psychologist, clinical 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 behavioral health evaluation, psychotherapy, pharmacological interventions, or additional treatment options

Should a patient screen positive for depression, a clinician should: 

• Only order pharmacological intervention when appropriate and after sufficient diagnostic evaluation. However, for the purposes of this measure, additional screening and assessment during the qualifying encounter will not qualify as a follow-up plan. 
• Opt to complete a suicide risk assessment when appropriate and based on individual patient characteristics. However, for the purposes of this measure, a suicide risk assessment or additional screening using a standardized tool will not qualify as a follow-up plan.

This version of the eCQM uses QDM version 5.6. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

 Initial Population

All patients aged 12 years and older at the beginning of the measurement period with at least one qualifying encounter during the measurement period 

Date of birth information can be entered in DrChrono in the patient chart under the Demographics tab with the Patient's Date of Birth. 

With A Qualifying Encounter During the Measurement Period

CPT Codes

59400, 59510, 59610, 59618, 90791, 90792, 90832, 90834, 90837, 92625, 96105, 96110, 96112, 96116, 96125, 96136, 96138, 96156, 96158, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 98966, 98967, 98968, 99078, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99401, 99402, 99403, 99424, 99441, 99442, 99443, 99483, 99484, 99491, 99492, 99493, 99384,, 99385, 99386, 99387, 99394, 99395, 99396, 99397

HPCS Codes

G0101, G0402, G0438, G0439, G0444

CPT and HCPCS codes can be entered into the billing section for the encounter.  Below is an example from the appointment window.

Denominator

Equals initial population. 

Denominator Exclusions

Patients who have ever been diagnosed with bipolar disorder at any time prior to the qualifying encounter.

Denominator Exceptions

Patient Reason(s) Patient refuses to participate in or complete the depression screening 

OR

Medical Reason(s)

Documentation of medical reason for not screening patient for depression (e.g., cognitive, functional, or motivational limitations that may impact accuracy of results; 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)

Numerator

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 or up to two days after the date of the qualifying encounter. 

You can enter the LOINC codes for depression screening in the CQMs tab of the patient's chart under the Risk Category/Assessment section. 

• Adolescent depression screening assessment LOINC Code 73831-0
• Adult depression screening assessment LOINC Code 73832-8

Click +New.

If the screening is positive, a follow-up plan needs to be documented.  One area to document this is in the patient's chart in the CQMs tab under the intervention section. 

 You can enter or search for the code.  Select ordered or performed and an appointment.  Click Create when finished. 

SNOMED Codes

If you prescribe a medication for depression, it will be documented when you complete the prescription.  

Medications can be prescribed in the patient's chart in the Send eRx tab.

Numerator Exclusions

Not applicable

Measure Information