Percentage of patients aged 12 years and older screened for depression on the date of the encounter or 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 the eligible encounter
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
1.15 Denominator
All patients aged 12 years and older at the beginning of the measurement period with at least one eligible encounter during the measurement period
Exclusions
Exclusions
Denominator Exclusions Not Eligible – A patient is not eligible if one or more of the following conditions are documented during the encounter during the measurement period: -Patient has an active diagnosis of depression prior to any encounter during the measurement period -Patient has a diagnosed bipolar disorder prior to any encounter during the measurement period
Denominator Exceptions Patients with a Documented Reason for not Screening for Depression: -Patient refuses to participate -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 -Situations where the patient’s 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
Measure Record
Most Recent Endorsement Activity
Measure Retired and Endorsement Removed Behavioral Health and Substance Use Fall Cycle 2020
Initial Endorsement
Last Updated
Removal Date
Point of Contact
Steward Organization
Centers for Medicare & Medicaid Services
Steward POC email
Joel.Andress@cms.hhs.gov
Steward Organization Copyright
These measures were developed by Quality Insights of Pennsylvania as a special project under the Quality Insights´ Medicare Quality Improvement Organization (QIO) contract HHSM-500-2005-PA001C with the Centers for Medicare & Medicaid Services. These measures are in the public domain. Limited proprietary coding is contained in the measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. Quality Insights of Pennsylvania disclaims all liability for use or accuracy of any Current Procedural Terminology (CPT [R]) or other coding contained in the specifications. CPT® contained in the Measures specifications is copyright 2004- 2015 American Medical Association. All Rights Reserved. These performance measures are not clinical guidelines and do not establish a standard of medical care, and have not been tested for all potential applications.
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