CMS2v7 – Preventive Care and Screening: Screening for Depression and Follow-Up Plan

All patients aged 12 years and older with at least one eligible encounter during the measurement period.
Eligible encounter is calculated through Visit codes and these codes are added through eSuperbills or charges.

– DENOMINATOR EXCLUSION

Patients with an active diagnosis for Depression or a diagnosis of Bipolar Disorder before the encounter.

– 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 EXCEPTIONS

Patient Reason(s)
Patient refuses to participate.

OR

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.

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.

For Denominator: 

All patients aged 12 years and older with at least one eligible encounter during the measurement period are included in denominator.
Initial population is calculated through Visit codes. These visits codes are added through eSuperbills or charges.
To record encounter, navigate to Patient > Provider Note > eSuperbill. The documentation of the first encounter takes place when one visit code gets attached with the patient’s eSuperbill/ charge.

For Numerator:

Patients screened for depression on the date of the encounter using an age appropriate standardized tool. For negative screening, no further action is required and in case of positive screening any one of the following must be documented on the date of positive screening.

• Additional evaluation for depression – adolescent/adult
• Referral for Depression Adolescent/adult
• Depression medications – adolescent/adult (These medications are prescribed))
• Follow-up for depression – adolescent/adult
• Suicide Risk Assessment

 1. Additional evaluation for depression – adolescent/adult:

To document depression screening, navigate to Patient > Clinical > Evaluations.
To learn more about How to Add Evaluations, click here.

2. Referral for Depression Adolescent/adult: 

In order to document a outgoing referral, user can navigate to  Patient > Clinical > Evaluations.

3. Depression medications – adolescent/adult (These medications are prescribed) 

For documenting medications for depression, navigate to Patient > Clinical > Medications. 

4.  Follow-up for depression – adolescent/adult:

To document a follow-up enounter, navigate to Patient > Clinical > Evaluations.

5. Suicide Risk Assessment:

To document Sucide Risk Assesment, navigate to  Patient > Clinical > Evaluations.

– DENOMINATOR EXCEPTION

Patient Reason(s)
Patient refuses to participate.

OR

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.

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.

To learn more about How to Document Denials and Refusals, click here.

– DENOMINATOR EXCLUSION

Patients with an active diagnosis for Depression or a diagnosis of Bipolar Disorder during measurement period.