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. 

Denominator Note: The intent of the measure is to screen for depression in patients who have never had a diagnosis of depression or bipolar disorder prior to the eligible encounter used to evaluate the numerator. Patients who have ever been diagnosed with depression or bipolar disorder will be excluded from the measure.

​

Denominator Exclusions: (G9717)

- Patients who have been diagnosed with depression.

OR

- Patients who have diagnosed with bipolar disorder

​

Denominator Exceptions: Patients with a Documented Reason for not Screening for Depression

- Patient refuses to participate

OR

- 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).

​

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 the eligible encounter.

​

Definitions: 

Screening: Completion of a clinical or diagnostic tool used to identify people at risk of developing or having a certain disease or condition, even in the absence of symptoms. 

Standardized Depression Screening Tool: A normalized and validated depression screening tool developed for the patient population in which it is being utilized.

​

Follow-Up Plan

Documented follow-up for a positive depression screening must include one or more of the following: 

• Referral to a provider for additional evaluation and assessment to formulate a follow-up plan for a positive depression screen

• Pharmacological interventions

• Other interventions or follow-up for the diagnosis or treatment of depression

Examples of a follow-up plan include but are not limited to:​

• Referral to a provider or program for further evaluation for depression, for example referral to a psychiatrist, psychologist, social worker, mental health counselor, or other mental health service such as family or group therapy, support group, depression management program, or other service for treatment of depression

• Other interventions designed to treat depression such as behavioral health evaluation, psychotherapy, pharmacological interventions, or additional treatment options

​

Numerator Instructions:

A depression screen is completed 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 must be documented on the date of the encounter, such as referral to a provider for additional evaluation, pharmacological interventions, or other interventions for the treatment of depression.

This is a patient-based measure. Depression screening is required once per measurement period, not at all encounters. An age-appropriate, standardized, and validated depression screening tool must be used for numerator compliance. The name of the age-appropriate standardized depression screening tool utilized must be documented in the medical record. This measure does not require documentation of a specific score, just whether results of the normalized and validated depression screening tool used are considered positive or negative. Each standardized screening tool provides guidance on whether a particular score is considered positive for depression. The depression screening must be reviewed and addressed by the provider on the date of the encounter. Positive pre-screening results indicating a patient is at high risk for self-harm should receive more urgent intervention as determined by the provider practice. The screening should occur during a qualifying encounter or up to 14 days prior to the date of the qualifying encounter.

The measure assesses the most recent depression screening completed either during the eligible encounter or within the 14 days prior to that encounter. Therefore, a clinician would not be able to complete another screening at the time of the encounter to count towards a follow-up, because that would serve as the most recent screening. In order to satisfy the follow-up requirement for a patient screening positively, the eligible clinician would need to provide one of the aforementioned follow-up actions, which does not include use of a standardized depression screening tool.

​

Should a patient screen positive for depression, a clinician should:​​

• Only order pharmacological intervention when appropriate and after sufficient diagnostic evaluation. However, for the purposes of this measure, additional screening and assessment during the qualifying encounter will not qualify as a follow-up plan.

• Opt to complete a suicide risk assessment when appropriate and based on individual patient characteristics. However, for the purposes of this measure, a suicide risk assessment or additional screening using a standardized tool, will not qualify as a follow-up plan.

​

Numerator Options:

Performance Met: Screening for depression is documented as being positive AND a follow-up plan is documented (G8431)

  OR

  Screening for depression is documented as negative, a follow-up plan is not required (G8510)

         OR

Denominator Exception: Screening for depression not completed, documented patient or medical reason (G8433)

OR

Performance Not Met: Depression screening not documented, reason not given (G8432)

          OR

          Screening for depression documented as positive, follow-up plan not documented, reason not given                  (G8511)