| Valid Data Submission Method(s) | Measure Type | High Priority Measure? | NQS Domain | Specialty Measure Sets |
|---|---|---|---|---|
| Claims, EHR, CMS Web Interface, Registry | Process | No | Community/Population Health | Internal Medicine, Mental/Behavioral Health, General Practice/Family Medicine, Pediatrics |
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
Instruction
This measure is to be reported a minimum of once per performance period for patients seen during the performance period. This measure may be reported by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding. The follow-up plan must be related to a positive depression screening, example: “Patient referred for psychiatric evaluation due to positive depression screening”.
Denominator
All patients aged 12 years and older
Denominator Criteria (Eligible Cases):
Patients aged ≥ 12 years on date of encounter
AND
Patient encounter during the performance period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 92625, 96116, 96118, 96150, 96151, 97165, 97166, 97167, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, G0101, G0402, G0438, G0439, G0444
AND NOT
DENOMINATOR EXCLUSION:
Documentation stating the patient has an active diagnosis of depression or has a diagnosed bipolar disorder, therefore screening or follow-up not required: G9717
Numerator
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 Instructions: 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.
Definitions:
Screening – Completion of a clinical or diagnostic tool used to identify people at risk of developing or having a certain disease or condition, even in the absence of symptoms.
Standardized Depression Screening Tool – A normalized and validated depression screening tool developed for the patient population in which it is being utilized. The name of the age appropriate standardized depression screening tool utilized must be documented in the medical record.
Examples of depression screening tools include but are not limited to:
- Adolescent Screening Tools (12-17 years)
Patient Health Questionnaire for Adolescents (PHQ-A), Beck Depression Inventory-Primary Care Version (BDI-PC), Mood Feeling Questionnaire (MFQ), Center for Epidemiologic Studies Depression Scale (CES-D), Patient Health Questionnaire (PHQ-9), Pediatric Symptom Checklist (PSC-17), and PRIME MD-PHQ2 - Adult Screening Tools (18 years and older)
Patient Health Questionnaire (PHQ-9), Beck Depression Inventory (BDI or BDI-II), Center for Epidemiologic Studies Depression Scale (CES-D), Depression Scale (DEPS), Duke Anxiety- Depression Scale (DADS), Geriatric Depression Scale (GDS), Cornell Scale Screening, and PRIME MD-PHQ2
Follow-Up Plan – Documented follow-up for a positive depression screening must include one or more of the following:
- Additional evaluation for depression
- Suicide Risk Assessment
- Referral to a practitioner who is qualified to diagnose and treat depression
- Pharmacological interventions
- Other interventions or follow-up for the diagnosis or treatment of depression
Not Eligible for Depression Screening or Follow-Up Plan (Denominator Exclusion) –
- Patient has an active diagnosis of Depression
- Patient has a diagnosed Bipolar Disorder
Patients with a Documented Reason for not Screening for Depression (Denominator Exception) –
One or more of the following conditions are documented:
- Patient refuses to participate
- 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
- 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
Numerator Options:
Performance Met: Screening for depression is documented as being positive AND a follow-up plan is documented (G8431)
OR
Performance Met: Screening for depression is documented as negative, a follow-up plan is not required (G8510)
OR
Denominator Exception: Screening for depression not completed, documented reason (G8433)
OR
Performance Not Met: Depression screening not documented, reason not given (G8432)
OR
Performance Not Met: Screening for depression documented as positive, follow-up plan not documented, reason not given (G8511)