Percentage of patients with depression or bipolar disorder with evidence of an initial assessment that includes an appraisal for alcohol or chemical substance use
Measure Specs
General Information
Numerator
Documented assessment for use of alcohol and chemical substance use; to include at least one of the following:
•Clinician documentation regarding presence or absence of alcohol and chemical substance use
•Patient completed history/assessment form that addresses alcohol and chemical substance use that is documented as being acknowledged by clinician performing the assessment
•Use of screening tools that address alcohol and chemical substance use
AND
Timeframe for chart documentation of the assessment for alcohol/chemical substance use must be present prior to, or concurrent with, the visit where the treatment plan is documented as being initiated
Denominator
UNIPOLAR DEPRESSION
Patients 18 years of age or older with an initial diagnosis or new presentation/episode of depression
AND
Documentation of a diagnosis of depression; to include at least one of the following:
• Codes 296.2x; 296.3x. 300.4 or 311 (ICD9CM or DSM-IV-TR) documented in body of chart, such as a pre-printed form completed by a clinician and/or codes documented in chart notes/forms such as a problem list.
OR
Diagnosis or Impression or working diagnosis documented in chart indicating depression
OR
Use of a screening/assessment tool for depression with a score or conclusion that patient is depressed and documentation that this information is used to establish or substantiate the diagnosis
BIPOLAR DISORDER
Patients 18 years of age or older with an initial or new episode of bipolar disorder
AND
Documentation of a diagnosis of bipolar disorder; to include at least one of the following:
• Codes 296.0x; 296.1x; 296.4x; 296.5x; 296.6x; 296.7; 296.80; 296.81; 296.82; 296.89; 301.13 documented in body of chart, such as a pre-printed form completed by a clinician and/or codes documented in chart notes/forms
OR
• Diagnosis or Impression or “working diagnosis” documented in chart indicating bipolar disorder
OR
• Use of a screening/assessment tool for bipolar disorder with a score or conclusion that patient has bipolar disorder and documentation that this information is used to establish or substantiate the diagnosis
Public Comments