CMS2v9 – Preventive Care and Screening: Screening for Depression and Follow-Up Plan

All patients aged 12 years or older at the start of the measurement period. And also if a qualifying encounter for depression screening exists for the patient.

– 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 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 eligible encounter.

– 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 cognitive capacity, 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 visit 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. Here, the code 59400 has been used that is for routine obstetric care.

For Numerator:

Patients screened for depression on the date of the encounter using an age appropriate standardized tool. Use following workflow to document depression screening:

Patient > Clinical > Evaluations

Select Adolescent depression screening for patients between the age range of 12 to 17 or Adult depression screening for patients aged over 17.

• Additional evaluation for depression – adolescent/adult
• Referral for Depression Adolescent/adult
• Pharmacologic Depression Treatment – adolescent/adult (Prescribed Medications)
• Follow-up for depression – adolescent/adult
• Suicide Risk Assessment

If the result of depression screening is negative then the patient will be included in the numerator without any further action.

If the result of depression screening is Positive, then 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
• Pharmacologic Depression Treatment – adolescent/adult (Prescribed Medications)
• 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. Evaluation can be added using relevant evaluation codes. In this case, the evaluation i.e. Assessment for Bipolar Disorder is added using the code 429441000124107.
To learn more about How to Add Evaluations, click here.

2. Referral for Depression Adolescent/adult: 

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

3. Pharmacologic Depression Treatment – adolescent/adult (Prescribed Medications) 

For documenting medications for depression, navigate to Patient > Provider Notes > Prescriptions. Medication list includes:

• Fluoxetine
• Doxepin Hydrochloride
• lamotrigine
• vilazodone hydrochloride
• 24 HR lamotrigine
• Nefazodone hydrochloride
• Desipramine Hydrochloride
• Maprotiline Hydrochloride
• Amoxapine
• Nortriptyline
• Lamotrigine

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

To document a follow-up encounter, navigate to Patient > Clinical > Evaluations. To add ‘Emotional Support Education’, the code 385725001 is used.

5. Suicide Risk Assessment:

To document Suicide Risk Assessment, navigate to  Patient > Clinical > Evaluations. In this case, the code ‘225337009’ has been used to add ‘Suicide Risk Assessment’ evaluation.

– 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 cognitive capacity, 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.