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

Updated: 06/13/2023|Views: 2673

CMS 2 / Quality ID #134

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.

Denominator:  All patients aged 12 years and older at the beginning of the measurement period with at least one qualifying encounter during the measurement period.
  • Patient’s age is calculated based on the patient’s Date of Birth, which was entered when you created the patient’s account.
  • Create a note detailing the patient’s office visit.
Denominator Exclusions: Patients who have ever been diagnosed with depression or with bipolar disorder at any time prior to the qualifying encounter.
  • If "Depression" or "Bipolar Disorder" is documented under Problems with a Start Date, these patients will be excluded from the denominator.
Denominator Exceptions: Indicate in the Care Checklist if there was a medical reason or patient refused to complete the screening. These patients will be marked as "Excepted".
  1. Patient Reason(s): Patient refuses to participate
  2. Medical Reason(s):  Patient is in an emergent situation.
  • On the date of service, click on Care Checklist from within the note. Select "Excepted" for Depression Screening & Follow-up (Age 18+): Standardized adolescent screening tool used.
  • Select the appropriate reason for not completing the screening: Patient Noncompliance, Medication Contraindication, or Refusal of Treatment by Patient (situation).
  • If patient agrees to be screened, but refuses a follow-up plan, select "Excepted" for Depression Screening & Follow-up (Age 18+): Positive screening, follow-up plan provided.
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.
  • On the date of service, click on Care Checklist from within the note.
  • Select "Completed" for Depression Screening & Follow-up (Age 18+): Standardized adolescent screening tool used.
  • Select Positive Screening or Negative Screening from the drop-down.
  • If positive screening, select "Completed" for Depression Screening & Follow-up (Age 18+): Positive screening, follow-up plan provided.
Office Visit Documentation:

Once all steps have been completed, the measure will be added to the Quality Measures Report.

Measure type: Process
High Priority Measure: No
Telehealth Eligible: Yes