eCQM: Preventive Care and Screening: Screening for Depression and Follow-Up Plan (CMS 2v6)

eCQM:

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

CMS ID:

CMS 2v6

NQF Number:

0418

NQS Domain:

Community/Population Health

Measure Type:

Process

MIPS High Priority Measure:

No

Eligible for Quality Programs:

  • Merit-Based Incentive Payment System (MIPS)
  • Medicaid EHR Incentive Program (Meaningful Use)

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.

  • 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.
  • Denominator: All patients aged 12 years and older before the beginning of the measurement period with at least one eligible encounter (defined as a signed chart note with an encounter type of Office Visit) during the measurement period.

    • Denominator Exclusions: Patients with an active diagnosis for Depression or a diagnosis of Bipolar Disorder.

    • Denominator Exceptions:

      • Patient Reason: Patient refuses to participate,

      • Medical Reasons: 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, OR

      • 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.

Performance Benchmark for MIPS: 72.64%
For further benchmarks and details on how this measure will be scored within the Quality performance category of MIPS, please click
here.

Practice Fusion Suggested Workflow
Practice Fusion suggests the following workflow to help ensure that you are able to meet the requirements of this measure within the Practice Fusion EHR.

  1. For all patients age 12 and older, complete a depression screening for the patient on the date of the Office Visit encounter (refer to Table 1 for examples of appropriate depression screening tools)

  2. Document that the depression screening was completed using the suggested workflow in Table 2.

  3. If the patient’s screening is positive, document an appropriate follow-up for the patient in the same encounter using the suggested workflows in Table 2. Examples of appropriate follow-up plans include:

    1. Referral for depression

    2. Additional evaluation for depression

    3. Follow-up for depression

    4. Medication for depression

    5. Suicide risk assessment

Table 1: Examples of Depression Screening Tools for CMS 2v6

Age Category

Screening Tool Examples

Adolescent
12-17 years of age

  • 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)
  • PRIME MD-PHQ-2

Adult
18 years of age 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 (SDS)
  • Cornell Scale Screening
  • PRIME MD-PHQ-2
Table 2: Practice Fusion Suggested Workflows for CMS 2v6

Data Element

Practice Fusion Suggested Workflow

Depression screening

  • In the Screenings/Interventions/Assessments section of the encounter, search for “Adolescent depression screening assessment” (LOINC 73831-0) or “Adult depression screening assessment” (LOINC 73832-8) and select the appropriate item.

  • Record and save the following information in the modal window that opens:

    • Status: Performed

    • Result: Depression Screening Negative OR
      Depression Screening Positive

    • Start Date: If the screening was performed on the same date of service as the encounter in which it is recorded in the Screenings/Interventions/Assessments section, a start or end date should not be entered for the screening. (See Graphic 1 for example.) 

Referral for depression
(Adult and adolescent)

  • In the Screenings/Interventions/Assessments section of the encounter, search for the applicable referral being sent and select the item. Examples include:

    • Referral to mental health worker (procedure) (SNOMED CT 183583007)

    • Referral to psychiatry service (procedure) (SNOMED CT 183524004)

    • Referral for mental health counseling (procedure) (SNOMED CT 306227000)

  • Record and save the following information in the modal window that opens:

    • Status: Ordered

    • Start Date: If the referral was made on the same date of service as the encounter in which it is recorded in the Screenings/Interventions/Assessments section, a start or end date should not be entered for the referral. (See Graphic 1 for example.) 

Additional evaluation for depression
(Adult and adolescent)

  • In the Screenings/Interventions/Assessments section of the encounter, search for the applicable evaluation  and select the item. Examples include:

    • Psychiatric interview and evaluation (procedure) (SNOMED CT 10197000)

    • Evaluation of psychiatric state of patient (procedure) (SNOMED CT 90407005)

  • Record and save the following information in the modal window that opens:

    • Status: Performed

    • Start Date:If the evaluation was performed on the same date of service as the encounter in which it is recorded in the Screenings/Interventions/Assessments section, a start or end date should not be entered for the procedure. (See Graphic 1 for example.) 

Follow-up for depression
(Adult and adolescent)

  • In the Screenings/Interventions/Assessments section of the encounter, search for an applicable follow-up and select the item. Examples include:

    • Coping support assessment (procedure) (SNOMED CT 385721005)

    • Emotional support assessment (procedure) (SNOMED CT 385725001)

  • Record and save the following information in the modal window that opens:

    • Status: Performed

    • Start Date: If the procedure was performed on the same date of service as the encounter in which it is recorded in the Screenings/Interventions/Assessments section, a start or end date should not be entered for the procedure. (See Graphic 1 for example.) 

Medication for depression
Adult

  • In the Medications or Plan section of the encounter, order an applicable medication for depression, ensuring that a valid start date has been assigned. Examples of applicable medications include:

    • Folic Acid 5 MG Oral Tablet (RXNORM 199318)

    • Paroxetine 20 MG Oral Tablet (RXNORM 314199)

Medication for depression
Adolescent

  • In the Medications or Plan section of the encounter, order an applicable medication for depression, ensuring that a valid start date has been assigned. Examples of applicable medications include:

    • Fluoxetine 60 MG Oral Tablet (RXNORM 1190110)

    • Fluoxetine 15 MG Oral Tablet (RXNORM 803293)

Suicide Risk Assessment
Adult
or Adolescent

  • In the Screenings/Interventions/Assessments section of the encounter, search for “Suicide risk assessment (procedure)” (SNOMED CT 225337009) and select the item.

  • Record and save the following information in the modal window that opens:

    • Status: Performed

    • Result: As applicable

    • Start Date: If the assessment was performed on the same date of service as the encounter in which it is recorded in the Screenings/Interventions/Assessments section, a start or end date should not be entered for the assessment. (See Graphic 1 for example.) 

Graphic 1: Example of data elements recorded in Screenings/Interventions/Assessments


To access a complete list of qualifying procedures, screenings and medications, visit the
United States Health Information Knowledgebase (USHIK). This site is produced by the Agency for Healthcare Research and Quality (AHRQ) in partnership with CMS and the National Library of Medicine (NLM). A free Unified Medical Language System® (UMLS) license, available from NLM, is required to access USHIK.

Additional Measure Information

  • This 2016 measure version has been updated from the previous 2015 version specifications, incorporating the following change:

    • Added PHQ-9 and PSC-17 to Definition as examples of depression screening tools for adolescents to clarify other options of standardized depression screening tools available for provider use.

    • Changed term Clinical Depression to Depression in the measure description, guidance, and title because the term "clinical" could reduce the sensitivity of the screening,

    • Updated logic to prevent a scenario where the case may be erroneously identified as a denominator exception rather than a denom hit/num miss. See tech release notes for full scenario.

    • Numerator logic updated to correct a situation where depression screenings outside of qualified encounters could impact numerator criteria.

  • To be recognized for the denominator exclusion, the patient must have an active diagnosis of depression or bipolar disorder recorded in his or her chart.

  • To be recognized for the denominator exception, please refer to the suggested workflow below in Table 3.

  • 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 on the date of the encounter and the screening and encounter must occur on the same date.

Table 3: Practice Fusion Suggested Workflow for CMS 2v6 Denominator Exceptions

Exception Criteria

Practice Fusion Suggested Workflow

Patient Reason: Patient Refused

  • In the Screenings/Interventions/Assessments section of the encounter, search for either “Adult depression screening assessment” (LOINC 73832-8) or “Adolescent depression screening assessment” (LOINC 73831-0) as applicable and select the item.

  • Record and save the following information in the modal window that opens:

    • Status: Not Performed

    • Reason: Refusal of treatment by patient

    • Start Date: If the screening was performed on the same date of service as the encounter in which it is recorded in the Screenings/Interventions/Assessments section, a start or end date should not be entered for the screening.

Medical or Other Reason Not Done

  • In the Screenings/Interventions/Assessments section of the encounter, search for either “Adult depression screening assessment” (LOINC 73832-8) or “Adolescent depression screening assessment” (LOINC 73831-0) as applicable and select the item.

  • Record and save the following information in the modal window that opens:

    • Status: Not Performed

    • Reason: Medical contraindication, Procedure contraindicated, OR Treatment not tolerated

    • Start Date: If the screening was performed on the same date of service as the encounter in which it is recorded in the Screenings/Interventions/Assessments section, a start or end date should not be entered for the screening.

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