Measure: CMS2

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

Measure Versions

eMeasure Code	Measure Year	Full Version Number	Title
CMS2v13	2024	13.1.000	Preventive Care and Screening: Screening for Depression and Follow-Up Plan
CMS2v12	2023	12	Preventive Care and Screening: Screening for Depression and Follow-Up Plan
CMS2v11	2022	11.0.000	Preventive Care and Screening: Screening for Depression and Follow-Up Plan
CMS2v10	2021	10.2.000	Preventive Care and Screening: Screening for Depression and Follow-Up Plan
CMS2v9	2020	9.1.000	Preventive Care and Screening: Screening for Depression and Follow-Up Plan
CMS2v8	2019	8.1.000	Preventive Care and Screening: Screening for Depression and Follow-Up Plan
CMS2v7	2018	7.1.000	Preventive Care and Screening: Screening for Depression and Follow-Up Plan
CMS2v6	2017	6.3.000	Preventive Care and Screening: Screening for Depression and Follow-Up Plan

Description

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.

Guidance

Patient Group Definitions

Group	Description	Instructions Links
Initial Population	All patients aged 12 years and older at the beginning of the measurement period with at least one qualifying encounter during the measurement period	Webchart Instructions
Denominator	Equals Initial Population	Webchart Instructions
Denominator Exclusions	Patients who have ever been diagnosed with depression or with bipolar disorder at any time prior to the qualifying encounter	Webchart Instructions
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	Webchart Instructions
Numerator Exclusions	Not Applicable	Webchart Instructions
Denominator Exceptions	Patient Reason(s) Patient refuses to participate OR Medical Reason(s) Documentation of medical reason for not screening patient for depression (e.g., cognitive, functional, or motivational limitations that may impact accuracy of results; 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)	Webchart Instructions

Details

Full eMeasure Code	eMeasure Identifier	Measure Year	Version	NQF #	GUID
CMS2v12	2	2023	12	N/A	9a031e24-3d9b-11e1-8634-00237d5bf174

Steward	Developer	Endorsed By
Centers for Medicare & Medicaid Services (CMS)	Mathematica	None

Scoring Method	Measure Type	Stratification	Risk Adjustment
Proportion	Process	None	None

Rate Aggregation

None

Improvement Notation

Higher score indicates better quality

Rationale

Clinical Recommendation Statement

Definition

Transmission Format

Applicable Value Sets

Category	Value Set	OID
Diagnosis	Bipolar Diagnosis	2.16.840.1.113883.3.600.450
Diagnosis	Depression diagnosis	2.16.840.1.113883.3.600.145
Encounter, Performed	Depression Screening Encounter Codes	2.16.840.1.113883.3.600.1916
Encounter, Performed	Physical Therapy Evaluation	2.16.840.1.113883.3.526.3.1022
Encounter, Performed	Telephone Visits	2.16.840.1.113883.3.464.1003.101.12.1080
Intervention, Order	Referral for Adolescent Depression	2.16.840.1.113883.3.526.3.1570
Intervention, Order	Referral for Adult Depression	2.16.840.1.113883.3.526.3.1571
Intervention, Performed	Follow Up for Adolescent Depression	2.16.840.1.113883.3.526.3.1569
Intervention, Performed	Follow Up for Adult Depression	2.16.840.1.113883.3.526.3.1568
Medication, Order	Adolescent Depression Medications	2.16.840.1.113883.3.526.3.1567
Medication, Order	Adult Depression Medications	2.16.840.1.113883.3.526.3.1566
Patient Characteristic Ethnicity	Ethnicity	2.16.840.1.114222.4.11.837
Patient Characteristic Payer	Payer	2.16.840.1.114222.4.11.3591
Patient Characteristic Race	Race	2.16.840.1.114222.4.11.836
Patient Characteristic Sex	ONC Administrative Sex	2.16.840.1.113762.1.4.1