CMS2v14 Preventative Care and Screening: Screening for Depression and Follow-Up Plan

Percentage of patients aged 12 years and older screened for depression on the date of the encounter or 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 doc

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

Screenings and follow up can be counted in several ways. Any of the following screenings along with the appropriate follow up actions will cause a patient to be counted in the numerator.

Clinical Decision Support: The clinician completes one of the following CDS rules:

• Screening for Depression in Adolescents aged 12 to 18 years
• Screening for Depression in Adults
  • The CDS Rule MUST include the following text in the Results/Comments of the rule: "depression screening with standardized tool done".
    • Note: Completing the Decision Support rules counts as screening and follow-up.

Tracked Data & PHQ-9: If you enter depression screenings as tracked data, or if PHQ-9 screenings are saved there, you'll need to ensure you take two steps: one, that the data is saved in tracked data, and two, that you indicate follow-up was completed if the screening was positive.

• Screening: The depression screening score should be saved in Tracked Data. Follow these steps to enter the score:
  • From the patient’s chart, select “Summary Sheet” tab at the top of the chart
  • The “Tracked Data” section will be on the right of the page. Click “Add/Edit”
  • Enter either “PHQ9” or “PHQ-9” into the Item
  • Enter the Value (Note: a score of 10 or higher is considered a positive screen)
  • Enter the date collected
  • Select “Move Data To Grid” and then click “Ok”
  • Select “Save and Close”
• Follow up plan: If the screening is positive, follow up is required in the form of recording that a follow up will take place, referring the patient to another provider for depression, or if the patient is on depression medication. Follow up will be counted as completed if any of the following is done:
  • Encounter text: The clinician recorded in the Plan or Assessment of the Most Recent Encounter any of the following phrases:
    • Depression follow up plan
    • Suicide risk assessed
    • Suicide assessment
    • Suicide screening
  • Referral: The clinician created a referral for the patient to a mental health professional.
    • In the Orders screen, select the "Referral" tab
    • Select the provider who you are referring the patient to
      • Note: The provider's specialty must include either the term "Behavioral Health" or "Psych" (the specialty displays in parentheses when you're selecting the clinician)
    • In the comment field, you should include any of the following phrases to identify the referral has to do with their depression screening:
      • "depression follow up"
      • "referred for depression"
    • Select either "Save Order" or "Send Order Message" to save the order.
  • Medication: The clinician recorded the patient as taking a depression medication.
    • Note: the clinician does not have to be the prescribing provider. Listing the medication in the patient's Current Medication list is sufficient

Screening noted in the encounter: You can also record the screening in the patient's encounter as text, after which you'll need to ensure a follow-up plan is documented if the screen was positive.

• Screening: The depression screening should be indicated in the Plan or Assessment of the chart using either of the following phrases:
  • Depression screening with standardized tool done: positive
  • Depression screening with standardized tool done: negative
• Follow up plan: If the screening is positive, follow up is required. Follow up will be counted as completed if any of the following is done:
  • Noted in the Encounter: The clinician recorded in the Plan or Assessment of the Most Recent Encounter any of the following phrases:
    • Depression follow up plan
    • Suicide risk assessed
    • Suicide assessment
    • Suicide screening

• • Referral: The clinician created a referral for the patient to a mental health professional.
    • In the Orders screen, select the "Referral" tab
    • Select the provider who you are referring the patient to
      • Note: The provider's specialty must include either the term "Behavioral Health" or "Psych" (the specialty displays in parentheses when you're selecting the clinician)
    • In the comment field, you should include any of the following phrases to identify the referral has to do with their depression screening:
      • "depression follow up"
      • "referred for depression"
    • Select either "Save Order" or "Send Order Message" to save the order.

• • Medication: The clinician recorded the patient as taking a depression medication.
    • Note: the clinician does not have to be the prescribing provider. Listing the medication in the patient's Current Medication list is sufficient

Denominator

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

• Note: A qualifying encounter is recorded by CPT code (example: 99213) being entered into Amazing Charts. This needs to be completed, even if the practice does not bill out of Amazing Charts. 

Denominator Exclusion

A patient who meets the criteria to be in the denominator will be excluded from the denominator if they have ever been diagnosed with bipolar disorder at any time prior to the qualifying encounter.

Denominator Exceptions

A patient will be marked as an exception for any of the following scenarios:

Refuses: Patient refuses to participate in or complete the depression screening

• In the assessment or plan section, add one of the following phrases
  • refuses depression screening
  • refuses to complete depression screening

Medical Reason(s): 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. In the assessment or plan section, add any of the following phrases:

• Urgent Situation. No Depression screening given
• Emergent Situation. No Depression screening given
• Medical contraindication indicated. No depression screening given

Cognitive Capacity: Situations where the patient's cognitive capacity, functional capacity or motivation to improve may impact the accuracy of results of standardized depression assessment tools.

• Patent has an active diagnosis of any of the following:
  • F05 (Delirium due to known physiological condition)
  • R41.0 (Disorientation, unspecified)