CMS2v13 – Preventive Care and Screening: Screening for Depression and Follow-Up Plan

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

In this case, a qualifying visit includes any of the following:

• Encounter to Screen for Depression
• Physical Therapy Evaluation
• Telephone Visits

– 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.

A follow up for depression can include:

• Medication for Adolescent/Adult Depression
• Referral for Adolescent/Adult Depression
• Follow up for Adolescent/Adult Depression

Note: The follow-up plan should be documented on the date of or up to two days after the date of the positive screening for depression.

– DENOMINATOR EXCLUSION

Patients who have ever been diagnosed with depression or with bipolar disorder at any time prior to the qualifying encounter

– DENOMINATOR EXCEPTIONS

• Patient refuses to participate.
• Documentation of medical reason for not screening patient for depression.

For Denominator: 

To record an encounter, navigate to Patient > Provider Note > Create Superbill. Under the ‘Procedure- CPTs’ heading, enter the encounter code.

For Numerator:

• To document the result of a depression screening, navigate to Patient > Provider Note > Evaluations. Click ‘Add’ and search for ‘Adolescent/Adult depression screening assessment’. From the ‘Status’ dropdown, select ‘Performed’ and from the ‘Result’ dropdown, select the relevant positive or negative result. Then click ‘Save & Accept’ or ‘Sign & Accept’.

• Alternatively, users can fill out one of the assessment forms below to document the negative or positive depression screening result of a patient. Navigate to Patient > Provider Note > Assessments. Click ‘Add’ and from the ‘Questionnaire’ drop-down select the relevant assessment and then click ‘Search’.
  • PHQ-A (Patient Health Questionnaire-A)
  • MFQ (Mood Feelings Questionnaire)
  • PHQ-9 (Patient Health Questionnaire-9)
  • PHQ-2 (Patient Health Questionnaire-2)

Once the assessment form is complete, click ‘Save’. Depending on the score calculated, the patient is considered as screened positive or negative for depression.

• To order an intervention (referral or follow-up), use the workflow Patient > Provider Note > Evaluations. Click ‘Add’ and search for either a referral or follow up intervention. From the ‘Status’ dropdown, select ‘Ordered’, then click ‘Save & Accept’ or ‘Sign & Accept’.

• Medication can be ordered via Patient > Provider Note > Prescriptions. Click ‘Add’ and search for the relevant medication. Add the prescription details and then click ‘Prescribe’.

For Denominator Exception:

• To document patient or medical reasons for refusing depression screening, head over to Patient > Provider Note > Evaluations. Click ‘Add’ and search for the screening. From the ‘Status’ drop-down select ‘Not Performed’ and from the ‘Reason’ drop-down select the relevant reason.

For Denominator Exclusion:

• The bipolar disorder diagnosis can be recorded using the workflow Patient > Provider Note > Diagnoses. Click ‘Add’ and search for the relevant diagnosis. Fill out the details as needed and once done, click ‘Save’. Then click ‘Accept’ to add the diagnosis to the provider note.