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Kareo Help Center

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

Updated: 08/19/2020
Views: 1314

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.

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.
  • Patient’s age is calculated based on the patient’s Date of Birth, which is entered when you created the patient’s account.
  • Create a note detailing the patient’s office visit.
Denominator Exclusions:
  • If "Depression" or "Bipolar" is documented in the Problem List, 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".
  • 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 clinical 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 positive screen.
  • 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:
  • Complete the note and make sure to include an E/M Codes or CPT/HCPCS Codes on the Superbill.
    Note: Select "Not Completed" for Depression Screening & Follow-up (Age 18+): Standardized adolescent screening tool used in the Care Checklist when the follow up plan was not completed by the provider.
  • Sign the note.

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

Guidance: A follow-up plan can be documented in the Plan section of a visit note, however the corresponding measures in the Care Checklist must still be completed.

A depression screen is completed on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, either additional evaluation for depression, suicide risk assessment, referral to a practitioner who is qualified to diagnose and treat depression, pharmacological interventions, or other interventions or follow-up for the diagnosis or treatment of depression is documented on the date of the positive screen.
Quality ID: 134
CMS Measure ID: CMS2
Measure type: Process