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 ID NQF # Measure Type High Priority Measure? NQS Domain Data Submission Method(s)
134 0418 Process Yes Community/Population Health
Claims

Measure Description

Percentage of patients aged 12 years and older screened for depression on 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 positive screen

Instructions

This measure is to be submitted a minimum of once per performance period for patients seen during the performance period. The most recent quality-data code submitted will be used for performance calculation. This measure may be submitted by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding. The follow-up plan must be related to a positive depression screening, example: “Patient referred for psychiatric evaluation due to positive depression screening”.

NOTE: No notes for this Quality ID

Measure Submission

The listed denominator criteria is used to identify the intended patient population. The numerator quality-data codes included in this specification are used to submit the quality actions allowed by the measure. All measure-specific coding should be submitted on the claim(s) representing the eligible encounter.

Numerator

Patients screened for depression on 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

Numerator Instructions:

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 a follow-up plan is documented on the date of the positive screen. The name of the age appropriate standardized depression screening tool utilized must be documented in the medical record. The depression screening must be reviewed and addressed in the office of the provider filing the code on the
date of the encounter and the screening should occur during a qualified encounter.

Numerator Quality-Data Coding Options

Denominator Exclusion: G9717:

Depression Screening or Follow-Up Plan not Documented, Patient not Eligible

Documentation stating the patient has an active diagnosis of depression or has a diagnosed bipolar disorder, therefore screening or follow-up not required

Denominator Exception: G8433:

Screening for Depression not Completed, Documented Reason

Screening for depression not completed, documented reason

Performance Met: G8431:

Screening for Depression Documented as Positive, AND Follow-Up Plan Documented

Screening for depression is documented as beingpositive AND a follow-up plan is documented

Performance Met: G8510:

Screening for Depression Documented as Negative, Follow-Up Plan not Required

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

Performance Not Met: G8432:
Screening for Depression not Documented, Reason not Given

Depression screening not documented, reason not given

Performance Not Met: G8511:
Screening for Depression Documented as Positive, Follow-Up Plan not Documented, Reason not
Given

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

Numerator Note:

Data not available

Denominator

All patients aged 12 years and older before the beginning of the measurement period with at least one eligible encounter during the measurement period

Eligible cases are determined and must be reported, if either of the following conditions

Option 1 – Denominator Criteria (Eligible Cases):

Patients aged ≥ 12 years on date of encounter

AND

Patient encounter during the performance period (CPT or HCPCS): 59400, 59510, 59610, 59618, 90791, 90792, 90832, 90834, 90837, 92625, 96116, 96118, 96150, 96151, 97165, 97166, 97167, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99384*, 99385*, 99386*, 99387*, 99394*, 99395*, 99396*, 99397*, G0101, G0402, G0438, G0439, G0444, G0502, G0503, G0504, G0505, G0507

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