Skip to main content

​
Measure Details

The percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event.

​
Measure Parameters

Numerator: Adolescent patients 12 to 17 years of age and adult patients 18 years of age and older who achieved remission at twelve months as demonstrated by the most recent twelve month (+/- 60 days) PHQ-9 or PHQ-9M score of less than five. Denominator: Adolescent patients 12 to 17 years of age and adult patients 18 years of age and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 or PHQ-9M score greater than nine during the index event. Patients may be assessed using PHQ-9 or PHQ-9M on the same date or up to 7 days prior to the encounter (index event). Exceptions:
  • Exclude patients who died before the end of the measurement period.
  • Exclude patients who are in hospice or palliative care for any part of the measurement period.
  • Exclude patients with a diagnosis of bipolar disorder any time prior to the end of the measure assessment period.
  • Exclude patients with a diagnosis of personality disorder emotionally labile any time prior to the end of the measure assessment period.
  • Exclude patients with a diagnosis of schizophrenia or psychotic disorder any time prior to the end of the measure assessment period.
  • Exclude patients with a diagnosis of pervasive developmental disorder any time prior to the end of the measure assessment period.

​
Elation Workflows

The automated clinical reminders for this measure are currently unavailable - which means you won’t receive an alert in the patient’s visit note when a depression screening needs to be performed. Review the denominator definition carefully so that you can independently identify when a depression screening is necessary.To address this measure, follow the exact instructions below to appropriately add patients to the denominator, numerator, exclusion, and/or exception.When asked to apply a Document Tag, make sure you select one that was created by Elation, and not by a user in your practice. Patients who are accounted for correctly with the workflows below will automatically appear in your CQM report.Once the automated clinical reminders and optimized workflows are available later this year, we will update the instructions below to reflect these changes.

​
Meeting requirements

If the patient is 12 years and older AND if a diagnosis of depression or dysthymia is recorded in their Problem List:
  1. Document a Depression Screening:
  2. Go to the Psych section of the Clinical Profile and then click “add special”.
  3. Select “Depression (PHQ-9 Questionnaire)”.
  4. Complete the questionnaire with the patient.
  5. Document a patient encounter for the 2025 calendar year and make sure the visit note has one of the following CPT or HCPCS Codes: CMS159v13 - Visit Codes.

​
Measure calculations

Denominator Criteria If the patient is 12 years and older by November 1, 2023,
  1. Check if they have a signed visit note in their chart with a date between between November 1, 2023 to October 31, 2024 where the visit note has one of the following CPT or HCPCS Codes: CMS159v13 - Visit Codes.
  2. Check and see if the patient had a PHQ-9 Score greater than 9 documented in their Clinical Profile within 7 days prior to the visit note date from step #1 AND if a diagnosis of depression or dysthymia was recorded in their Problem List with a start date less than or equal to the visit note date from step #1. Click here for a list of ICD-10 codes for depression and dysthymia that will be counted towards the Denominator criteria.
If step #1 and #2 are true then the patient will be included in the measure’s Denominator- proceed to step #3. Numerator Criteria
  1. Calculate if your current encounter is within 10-14 months of the date from step #1 - if so proceed to step #4.
  2. Document a patient encounter for the 2025 calendar year and make sure the visit note has one of the following CPT or HCPCS Codes: CMS159v13 - Visit Codes.
  3. Document a follow-up Depression Screening:
  4. Go to the Psych section of the Clinical Profile and then click “add special”.
  5. Select “Depression (PHQ-9 Questionnaire)”.
  6. Complete the questionnaire with the patient.
  7. If the result is less than or equal to 4, the patient will automatically be included in the measure’s Numerator and no further action is needed.
  8. If the result is greater than or equal to 5, the patient does not meet the Numerator requirements and will not be included in the Numerator. Proceed with the instructions in the [CMS2v14] Preventive Care and Screening: Screening for Depression and Follow-Up Plan article.

​
Documenting Exceptions

To exclude patients who died before the end of the measurement period.Record the patient’s deceased status in their chart: Click on the patient’s name to open their demographics. • Go to the “Notes & Chart Management” section. • Select ‘Deceased’ in the “Status” field. • Enter the deceased date. • Click “Save” to save your changes to their demographics.
Exclude patients who are in hospice or palliative care for any part of the measurement period.Add the following Document Tag to the visit note: EXCLUSION: IP Discharge Status to Health Care Facility for Hospice Care
Exclude patients with a diagnosis of bipolar disorder any time prior to the end of the measure assessment period.Document a diagnosis of bipolar disorder in the patient’s Problem List with a start date prior to the end of 2025. Click here for a list of mental health disorders that meet this Denominator exception.
Exclude patients with a diagnosis of personality disorder emotionally labile any time prior to the end of the measure assessment period.Document a diagnosis of personality disorder emotionally labile in the patient’s Problem List with a start date prior to the end of 2025. Click here for a list of mental health disorders that meet this Denominator exception.
Exclude patients with a diagnosis of schizophrenia or psychotic disorder any time prior to the end of the measure assessment period.Document a diagnosis of schizophrenia or psychotic disorder in the patient’s Problem List with a start date prior to the end of 2025. Click here for a list of mental health disorders that meet this Denominator exception.
Exclude patients with a diagnosis of pervasive developmental disorder any time prior to the end of the measure assessment period.Document a diagnosis of pervasive developmental disorder in the patient’s Problem List with a start date prior to the end of 2025. Click here for a list of mental health disorders that meet this Denominator exception.

​
Measure Information

Depression is a common and treatable mental disorder. During 2013-2016, 8.1% of American adults age 20 and over had depression in a given 2 week period. Women (10.4%) were almost twice as likely as men (5.5%) to have had depression. The prevalence of depression among adults decreased as family income levels increased. About 80% of adults with depression reported at least some difficulty with work, home, or social activities because of their depression symptoms (Brody, Pratt, and Hughes, 2018). Depression is a risk factor for development of chronic illnesses such as diabetes and coronary heart disease and adversely affects the course, complications and management of chronic medical illness. Both maladaptive health risk behaviors and psychobiological factors associated with depression may explain depression’s negative effect on outcomes of chronic illness (Katon, 2011). Reference: Measure information from CMS

​
Frequently Asked Questions

How can I enter a PHQ-9 result from last year to count toward this measure’s Denominator?
To document a past PHQ-9 result, enter it in the Psych section of the patient’s Clinical Profile in the exact format shown below:
  • Depression: PHQ-9 Score: X (MM/DD/YYYY)
For example, a PHQ-9 evaluation performed on May 1, 2024 with a score of 11 will look like:
  • Depression: PHQ-9 Score: 11 (05/01/2024)
Do I need to reference the PHQ-9 result in the visit note for it to count towards the Numerator?
No, you do not need to reference any PHQ-9 results in visit notes for it to count towards the Numerator. By default, the measure will look for the score and the date of the evaluation in the Psych section of the patient’s Clinical Profile.