CMS2 / #134 — Depression screening and follow-up

Patients screened for depression on the date of the encounter or up to 14 days before, using an age-appropriate standardized tool, and, if the screen is positive, with a follow-up plan documented.

Denominator

• Age 12 or older at the start of the measurement period.
• At least one qualifying encounter (the measure has its own union of encounter value sets).

Finding the screen

The screening window runs from 14 days before the encounter to the encounter date (day precision).

Depression scores are the hardest data in this cookbook to find. Look in all of these:

• Observation with PHQ LOINC codes (for example PHQ-2 55758-7, PHQ-9 44261-6);
• QuestionnaireResponse items (the structured source on some EHRs, such as Elation);
• billed result codes for “screened positive / negative”;
• clinical notes — HTML tables in DocumentReference or Binary attachments, and PDF documents. Table layouts vary (some EHRs put scores in columns rather than rows).

Positive or negative

A screen is negative below these scores, positive at or above:

Tool	Negative below
PHQ-2	3
PHQ-9	10
EPDS	10
GDS (short form)	5
GDS (long form)	10
PSC-17 internalizing	5
CES-DC	15
CAT-MH	66

When there are several screens, the most recent governs; break ties toward positive.

Score or judgment?

The measure counts the result of the screen, positive or negative, which can be the clinician’s judgment or the institution’s standard rather than a strict score cut-off. QRDA I usually carries that judgment but not the PHQ-9 score. FHIR usually carries the score but may not carry the judgment. When FHIR has the judgment, use it. When it only has the score, apply the thresholds above, and expect some differences from the EHR’s own results. See Sources record different things.

Follow-up for a positive screen

Any of:

• a medication ordered at the visit, or an active antidepressant overlapping the period after the encounter (status=active, intent=order);
• a referral (ServiceRequest) or a follow-up procedure performed.

Filter out cancelled, revoked and entered-in-error statuses. When the adult and adolescent follow-up value sets overlap, look each one up separately so neither hides the other.

Exclusions and exceptions

• Exclusion: bipolar disorder (check which value set applies for the year).
• Exception: the patient declined screening — for example dataAbsentReason of asked-declined — within the same encounter window.