Contents
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
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.
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).
- 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
| 1 |
Click Address in the Depression Screening Follow-Up is Due reminder at the top of the visit note draft.
- This reminder will automatically appear if ALL of the following denominator requirements are met:
- Patient is 12 years of age or older at the time of visit.
- Patient has a signed visit note in their chart dated within the past 12 months (plus or minus 60 days) that includes a qualifying CMS159v13 - Visit Code.
- Patient has an active diagnosis of major depression or dysthymia in their Problem List with a start date equal to or prior to the date of the visit note in Step b.
- Patient has a PHQ-9 score greater than 9 documented in their Clinical Profile within 7 days prior to the date of the visit note in Step b.
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| 2 | To immediately meet the numerator requirements by administering a PHQ-9 Screening click Launch PHQ-9 Questionnaire. |
| 3 | Complete the PHQ-9 Questionnaire with the patient and click Save. |
| 4 | If the PHQ-9 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. |
| 5 | If the PHQ-9 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 [CMS2v15] Preventive Care and Screening: Screening for Depression and Follow-Up Plan (MIPS 2026) article for follow-up plan options. |
Documenting exclusions/exceptions
Some exclusions/exceptions can be documented by clicking Address in the Depression Screening Follow-Up is Due reminder at the top of the visit note draft and selecting the appropriate exclusion.
For other exclusions/exceptions and other ways to document them see:
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Exclusion/exception
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Step(s)
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Exclude patients who died before the end of the measurement period.
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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.
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Exclude patients who are in hospice or palliative care for any part of the measurement period.
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Click + Tag at the bottom of the visit note draft and add the following document tag - EXCLUSION: IP Discharge Status to Health Care Facility for Hospice Care.
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Exclude patients with a diagnosis of bipolar disorder any time prior to the end of the measure assessment period.
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Add a diagnosis of bipolar disorder in the patient’s Problem List or visit note with a start date prior to December 31, 2026.
Click here for a list of mental health disorders that meet this Denominator exception.
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Exclude patients with a diagnosis of personality disorder emotionally labile any time prior to the end of the measure assessment period.
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Add a diagnosis of personality disorder emotionally labile in the patient’s Problem List or visit note with a start date prior to December 31, 2026.
Click here for a list of mental health disorders that meet this Denominator exception.
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Exclude patients with a diagnosis of schizophrenia or psychotic disorder any time prior to the end of the measure assessment period.
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Add a diagnosis of schizophrenia or psychotic disorder in the patient’s Problem List or visit note with a start date prior December 31, 2026.
Click here for a list of mental health disorders that meet this Denominator exception.
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Exclude patients with a diagnosis of pervasive developmental disorder any time prior to the end of the measure assessment period.
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Add a diagnosis of pervasive developmental disorder in the patient’s Problem List or visit note with a start date prior December 31, 2026.
Click here for a list of mental health disorders that meet this Denominator exception.
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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
Which ICD-10 codes for major depression or dysthymia are counted towards the Denominator criteria?
Click here for a list of ICD-10 codes for depression and dysthymia that will be counted towards the Denominator criteria.
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:
For example, a PHQ-9 evaluation performed on May 1, 2024 with a score of 11 will look like:
How can I record a missing visit note from last year to count toward this measure’s Denominator?
To document a historical patient encounter:
| 1 |
Go to the patient's chart and click Visit Note. Then select a visit note format you want to use for your documentation.
- An Elation Note will not be counted in MIPS calculations at this time.
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| 2 | Update the date of the visit note to the correct date. |
| 3 | Complete your visit note documentation. |
| 4 | Click +Add Billing Information and ensure one of the following CPT or HCPCS Codes are in the bill - CMS159v13 - Visit Codes. |
| 5 | Sign the visit note. |
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.
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