CMS 2 - Preventive Care and Screening: Screening for Depression and Follow-up Plan

Overview

CMS2v9 (2020)
CMS2v10 (2021)
CMS2v11 (2022)

Identifiers

CMS eCQM ID	NQF eCQM ID	NQF	MIPS Quality ID
CMS2v11	–	–	134

*MIE only supports data collection and reporting using eCQM specifications

Definitions

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 the eligible encounter.
Initial Patient Population	All patients aged 12 years and older at the beginning of the measurement period with at least one eligible encounter during the measurement period.
Denominator	Equals Initial Population.
Denominator Exclusions	Patients who have been diagnosed with depression or with bipolar disorder.
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 the eligible encounter.
Numerator Exclusions	Patient Reason(s) Patient refuses to participate 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)
Denominator Exceptions	–

Additional Information

Measure Type	Process measure
Measure Scoring	Proportion measure
Granularity	Patient
Improvement Notation	Higher score indicates better quality
Domain	Community/Population Health

Clinical Instructions

Ensure all 12+ year-old patients are screened for depression during or within the 14 days prior to an eligible encounter during the measurement period. Use the preferred Preventive Care section or the alternate Test and Procedures section of the Visit encounter to order and perform the age appropriate depression screening. Any patient with a positive screening requires a follow-up plan documented during the current encounter.  Additionally, an adult or adolescent depression screening document with an appropriate LOINC code will also be counted.  Perform the following steps to document a depression screening.

Preferred Workflow

1. While documenting the Visit encounter, record the procedure, as appropriate
2. Open the Preventive Care section
3. Add the Depression Screening to the exam
   1. For patients under 18, use the Adolescent Depression Screening
   2. For patients 18+, use the Adult Depression Screening
4. Click Add to Exam
5. Open the Depression Screening section
6. Complete the questions
7. Close the section
8. If the PHQ9 Calculation in the Depression Screening indicates the patient is positive for depression, order depression follow-up
   1. Open the Preventive Care section
   2. Open the Depression Follow-up picklist
   3. Order the appropriate follow-up items(s) for the patient OR
   4. E-prescribe an antidepressant medication
9. Continue documenting the encounter, as appropriate
10. When completed, Close and Archive the encounter

Alternate Workflow

1. While documenting the Visit encounter, record the procedure, as appropriate
2. Open the Tests and Procedures section
3. Search for Depression Screening in the autocomplete
   1. For patients under 18, use the Adolescent Depression Screening
   2. For patients 18+, use the Adult Depression Screening
4. Click Add to Exam
5. Open the Depression Screening section
6. Complete the questions
7. Close the section
8. If the PHQ9 Calculation in the Depression Screening indicates the patient is positive for depression, order depression follow-up
   1. Order the appropriate follow-up items(s) for the patient OR
   2. E-prescribe an antidepressant medication
9. Continue documenting the encounter, as appropriate
10. When completed, Close and Archive the encounter

Evidence

Initial Patient Population

Name	Value Set
Encounter, Performed: Encounter to Screen for Depression	2.16.840.1.113883.3.600.1916
Encounter, Performed: Physical Therapy Evaluation	2.16.840.1.113883.3.526.3.1022

Denominator Exclusions

Name	Value Set
Diagnosis: Bipolar Diagnosis	2.16.840.1.113883.3.600.450
Diagnosis: Depression Diagnosis	2.16.840.1.113883.3.600.145

Numerator

Name	Value Set
Assessment, Performed: Adolescent depression screening assessment	LOINC Code 73831-0
Assessment, Performed: Adult depression screening assessment	LOINC Code 73832-8
Intervention, Order: Referral for Adolescent Depression	2.16.840.1.113883.3.526.3.1570
Intervention, Order: Referral for Adult Depression	2.16.840.1.113883.3.526.3.1571
Intervention, Performed: Follow Up for Adolescent Depression	2.16.840.1.113883.3.526.3.1569
Intervention, Performed: Follow Up for Adult Depression	2.16.840.1.113883.3.526.3.1568
Medication, Order: Adolescent Depression Medications	2.16.840.1.113883.3.526.3.1567
Medication, Order: Adult Depression Medications	2.16.840.1.113883.3.526.3.1566

Denominator Exceptions

Name	Value Set
Assessment, Not Performed: Adolescent depression screening assessment	LOINC Code 73831-0
Assessment, Not Performed: Adult depression screening assessment	LOINC Code 73832-8

Source(s)

eCQI CMS2