Overview

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.


Consult the CMS2v15 specification to verify that your QRDA-I documents use the required value sets and codes.


Improving Clinical Workflow

  • Enable reminders for overdue labs, follow-up visits, or depression screening

  • Update templates with the appropriate screenings according to your EMR documentation

  • Ensure data is entered into the EMR in the correct location and manner so that lab results and vitals are included in QRDA-I files


Key Points

  • Depression screening is required once per measurement period, not with all encounters

  • The depression screening can be performed on or up to 14 days prior to the qualifying encounter

    • The depression screening must be reviewed and addressed by the provider, filing the code, on the date of the encounter. Positive pre-screening results indicating a patient is at high risk for self-harm should receive more urgent intervention as determined by the provider practice.

    • The screening should occur during a qualifying encounter or up to 14 calendar days prior to the date of the qualifying encounter.

    • The follow-up plan documentation can be done on the date of or up to two days after the qualifying encounter

  • Only the most recent encounter where the patient was screened for depression should be used to determine numerator eligibility

  • If a depression screening is performed, the patient will meet the measure criteria if one of the following is true:

    • the result is negative

    • the result is positive with an acceptable follow-up plan documented

  • Once a patient is screened for depression and, if applicable, a follow-up plan is documented, no further depression screenings need to occur for the measurement period


Measure Components

Qualifying Encounter

  • Encounter, Performed: Encounter to Screen for Depression

    • templateId/@root=”2.16.840.1.113883.10.20.24.3.23” and templateId/@extension=”2021-08-01”

    • code/@code IN value set 2.16.840.1.113883.3.600.1916 

    • effectiveTime in measurement period

  • Encounter, Performed: Physical Therapy Evaluation

    • templateId/@root=”2.16.840.1.113883.10.20.24.3.23” and templateId/@extension=”2021-08-01”

    • code/@code IN value set 2.16.840.1.113883.3.526.3.1022

    • effectiveTime in measurement period

  • Encounter, Performed: Telephone Visits

    • templateId/@root=”2.16.840.1.113883.10.20.24.3.23” and templateId/@extension=”2021-08-01”

    • code/@code IN value set 2.16.840.1.113883.3.464.1003.101.12.1080

    • effectiveTime in measurement period

 

Depression Screening

  • Assessment, Performed: Adolescent depression screening assessment

    • templateId/@root=”2.16.840.1.113883.10.20.24.3.144” and templateId/@extension=”2021-08-01”

    • code/@code=”73831-0” and code/@codeSystem=”2.16.840.1.113883.6.1”

    • effectiveTime up to 14 days prior to qualifying encounter date

    • value/@code=”428171000124102” and value/@codeSystem=”2.16.840.1.113883.6.96” (Depression screening negative) or value/@code=”428181000124104” and value/@codeSystem=”2.16.840.1.113883.6.96” (Depression screening positive) 

  • Assessment, Performed: Adult depression screening assessment

    • templateId/@root=”2.16.840.1.113883.10.20.24.3.144” and templateId/@extension=”2021-08-01”

    • code/@code=”73832-8” and code/@codeSystem=”2.16.840.1.113883.6.1”

    • effectiveTime up to 14 days prior to qualifying encounter date

    • value/@code=”428171000124102” and value/@codeSystem=”2.16.840.1.113883.6.96” (Depression screening negative) or value/@code=”428181000124104” and value/@codeSystem=”2.16.840.1.113883.6.96” (Depression screening positive) 


Follow-Up Plan


If positive, a follow-up plan should be documented on the date or up to two days after the date of the qualifying encounter. Documented follow-up for a positive depression screening must include one or more of the following:

  • Referral to a provider for additional evaluation and assessment to formulate a follow-up plan for a positive depression screen

  • Pharmacological interventions (prescribed or active depression medication)

  • Other interventions or follow-up for the diagnosis or treatment of depression

Examples of a follow-up plan include but are not limited to: 

  • Referral to a provider or program for further evaluation for depression, for example, referral to a psychiatrist, psychiatric nurse practitioner, psychologist, clinical social worker, mental health counselor, or other mental health service such as family or group therapy, support group, depression management program, or other service for treatment of depression

  • Other interventions designed to treat depression such as behavioral health evaluation, psychotherapy, pharmacological interventions, or additional treatment options

Should a patient screen positive for depression, a clinician should:

  • Only order pharmacological intervention when appropriate and after sufficient diagnostic evaluation. However, for the purposes of this measure, additional screening and assessment during the qualifying encounter will not qualify as a follow-up plan.

  • Opt to complete a suicide risk assessment when appropriate and based on individual patient characteristics. However, for the purposes of this measure, a suicide risk assessment or additional screening using a standardized tool will not qualify as a follow-up plan.