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

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## Overview [CMS2v13](https://medicalcodify.com/eh/?f=layoutnouser&func=&name=RXDBmain&showresult=CMS2v13&showresulttype=Measure&module=&tabmodule=&searchterm=cms2) (2024) [CMS2v12](https://medicalcodify.com/eh/?f=layoutnouser&func=&name=RXDBmain&showresult=CMS2v12&showresulttype=Measure&module=&tabmodule=&searchterm=cms2) (2023) [CMS2v11](https://medicalcodify.com/eh/?f=layoutnouser&func=&name=RXDBmain&showresult=CMS2v11&showresulttype=Measure&module=&tabmodule=&searchterm=cms2) (2022) ### Identifiers
CMS eCQM ID NQF eCQM ID NQF MIPS Quality ID
CMS2v13 – – 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 or up to two days after the date of the qualifying encounter
Initial Patient 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
Denominator Equals Initial Population.
Denominator Exclusions Patients who have ever been diagnosed with bipolar disorder at any time prior to the qualifying encounter
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
Numerator Exclusions 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)
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
Telehealth Eligible Yes
## 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. Encounter eligibility is determined based on the billing codes linked to the encounter in WebChart EHR. Use the preferred Test and Procedures section or the alternate Preventive Care section of the Visit encounter to order and perform an age appropriate depression screening. Any patient with a positive screening requires a follow-up plan documented during the current encounter.  Perform the following steps to document a depression screening. ### Numerator Compliance #### Preferred Workflow 1. While documenting the Visit encounter, open the Tests and Procedures section 2. Search for Depression Screening in the autocomplete * For patients under 18, use the Adolescent Depression Screening LOINC 73831-0 * For patients 18+, use the Adult Depression Screening LOINC 73832-8 3. Click Add to Exam 4. Open the Depression Screening section 5. Complete the questions a. Select either Positive for Depression (SNOMEDCT: 428181000124104) or Negative for Depression (SNOMEDCT: 428171000124102) b. If selecting Positive for Depression, select an appropriate Adult or Adolescent Depression Follow-up Item 6. Close the section 7. If the Depression Screening indicates the patient is positive for depression, the appropriate follow-up should be recorded * Order the appropriate follow-up items(s) for the patient as selected in the Depression Screening OR * E-prescribe an antidepressant medication 8. Continue documenting the encounter, as appropriate 9. When completed, Close and Archive the encounter #### Alternate Workflow 1. While documenting the Visit encounter, open the Preventive Care section 2. Add the Depression Screening to the exam * For patients under 18, use the Adolescent Depression Screening LOINC 73831-0 * For patients 18+, use the Adult Depression Screening LOINC 73832-8 3. Click Add to Exam 4. Open the Depression Screening section 5. Complete the questions a. Select either Positive for Depression (SNOMEDCT: 428181000124104) or Negative for Depression (SNOMEDCT: 428171000124102) b. If selecting Positive for Depression, select an appropriate Adult or Adolescent Depression Follow-up Item 6. Close the section 7. If the Depression Screening indicates the patient is positive for depression, the appropriate follow-up should be recorded * Open the Preventive Care section * Open the Depression Follow-up picklist * Order the appropriate follow-up items(s) for the patient OR * E-prescribe an antidepressant medication 8. Continue documenting the encounter, as appropriate 9. When completed, Close and Archive the encounter ### Denominator Exclusion Compliance #### Preferred Workflow 1. While documenting the encounter, record an active Bipolar diagnosis * Use the Smart Plan section quick lists to record the condition OR * Use the Past Medical History section quick lists to record the condition OR * Use the Symptoms/Diagnosis section quick lists to record the condition 2. Continue documenting the encounter, as appropriate 3. 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
Encounter, Performed: Telephone Visits 2.16.840.1.113883.3.464.1003.101.12.1080
### Denominator Exclusions
Name Value Set
Diagnosis: Bipolar Diagnosis 2.16.840.1.113883.3.600.450
### Numerator
Name Value Set
Assessment, Performed: Adolescent depression screening assessment LOINC Code 73831-0
Assessment, Performed: Adult depression screening assessment LOINC Code 73832-8
Depression screening positive (finding) SNOMEDCT Code 428181000124104
Depression screening negative (finding) SNOMEDCT Code 428171000124102
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
Depression screening declined (situation) SNOMEDCT Code 720834000
## Source(s) [eCQI CMS2](https://ecqi.healthit.gov/ecqm/ec/2024/cms0002v13?qt-tabs_measure=measure-information) ## Revision History
Date Description
07/24/2024 Updated for the 2024 reporting period
05/11/2022 Updated for the 2022 reporting period
06/18/2021 Updated for the 2021 reporting period
02/27/2020 Initial document creation

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Published: July 25, 2024