Contents
Measure Details
Percentage of patients aged 12 years and older screened for depression on the date of the encounter or up to 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 or up to two days after the date of the qualifying encounter.
Measure Parameters
Patients screened for 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 or up to two days after the date of the visit.
All patients aged 12 years and older at the beginning of the measurement period with at least one visit note during the measurement period.
- Exclude patients who have ever been diagnosed with bipolar disorder at any time prior to the qualifying encounter.
- Except patients who refuse to participate in or complete the depression screening.
- Except patients with documentation of medical reason for not screening patient for depression (e.g., cognitive, functional, or motivational limitations that may impact accuracy of results; patient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient's health status).
Elation Workflows
| 1 |
Click Address in the Depression screening is due reminder at the top of the visit note draft.
- This reminder will automatically appear if the patient is 12 years of age or older by January 1, 2026.
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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. |
| 4a |
If the result is negative, no further action is needed.
- If the patient has a PHQ-2 score less than or equal to 2 (negative result), then they will be automatically added to the measure's Numerator.
- If the patient has a PHQ-9 score less than or equal to 4 (negative result), then they will be automatically added to the measure's Numerator.
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| 4b | If the result is positive, record a follow-up plan on the date of the visit or up to 2 days after the date of the visit. The follow-up plan must be one of the following actions listed below. |
Clicking Dismiss will dismiss the reminder and the reminder will not appear again until a new visit note draft is opened.
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Prescribe pharmaceutical intervention.
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Prescribe pharmaceutical intervention (e.g. depression medication) using Elation’s Prescription Form on the date of the visit or two days prior to the visit. Select the appropriate medication from Elation’s database (i.e. not a user created medication) in order for the system to calculate the patient in the Numerator.
Click here for a list of medications that meet this requirement.
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Refer for counseling.
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- Use the Referral feature to refer the patient for counseling.
- Add the corresponding Document Tag to the visit note to reflect the action taken during the encounter.
- The following Document Tags can be used for this follow-up action:
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- Referral to intellectual disability psychiatrist (procedure)
- Referral to intellectual disability psychiatry service (procedure)
- Referral to psychiatry service (procedure)
- Referral to psychiatrist for the elderly mentally ill (procedure)
- Refer to mental health worker (procedure)
- Referral to emergency clinic (procedure)
- Referral to liaison psychiatry service (procedure)
- Referral to psychogeriatric service (procedure)
- Referral to psychogeriatric day hospital (procedure)
- Referral to mental health counseling service (procedure)
- Referral for mental health counseling (procedure)
- Referral to mental health counselor (procedure)
- Referral to child and adolescent psychiatrist (procedure)
- Referral to psychologist (procedure)
- Referral to psychiatrist (procedure)
- Child referral - clinical psychologist (procedure)
- Referral to mental health team (procedure)
- Referral to primary care service (procedure)
- Referral to family therapy (procedure)
- Referral to support group (procedure)
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Prescribe other follow-up plan (besides pharmaceutical intervention or counseling).
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- Take any actions you normally would to prescribe other follow-up plan(s) for depression (see options below).
- Add the corresponding Document Tag to the visit note to reflect the action taken during the encounter.
- The following Document Tags can be used for this Numerator requirement:
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- Family psychotherapy procedure (regime/therapy)
- Brief group psychotherapy (regime/therapy)
- Expressive psychotherapy (regime/therapy)
- Individual psychotherapy (regime/therapy)
- Cognitive and behavioral therapy (regime/therapy)
- Exercise therapy (regime/therapy)
- Interactive group medical psychotherapy (regime/therapy)
- Implementation of measures to provide psychological support (regime/therapy)
- Coping support assessment (procedure)
- Coping support management (procedure)
- Emotional support assessment (procedure)
- Emotional support education (procedure)
- Emotional support management (procedure)
- Mental health history taking assessment (procedure)
- Mental health history taking education (procedure)
- Mental health history taking management (procedure)
- Telephone consultation (procedure)
- Completion of mental health crisis plan (procedure)
- Dialectical behavior therapy (regime/therapy)
- Mental health care assessment (procedure)
- Mental health care education (procedure)
- Mental health care management (procedure)
- Mental health promotion assessment (procedure)
- Mental health promotion education (procedure)
- Mental health promotion management (procedure)
- Mental health screening assessment (procedure)
- Mental health screening education (procedure)
- Mental health screening management (procedure)
- Mental health treatment assessment (procedure)
- Mental health treatment education (procedure)
- Management of mental health treatment (procedure)
- Case management follow up (procedure)
- Discharge by mental health primary care worker (procedure)
- Crisis intervention with follow-up (regime/therapy)
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| 1 | Open a visit note draft for the patient. |
| 2 | Go to the Clinical Profile -> Psych section -> add special and select a PHQ-2 or PHQ-9 Questionnaire. |
| 3 | Complete the questionnaire with the patient and click Save. |
| 4a |
If the result is negative, no further action is needed.
- If the patient has a PHQ-2 score less than or equal to 2 (negative result), then they will be automatically added to the measure's Numerator.
- If the patient has a PHQ-9 score less than or equal to 4 (negative result), then they will be automatically added to the measure's Numerator.
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| 4b | If the result is positive, record a follow-up plan on the date of the visit or up to 2 days after the date of the visit. The follow-up plan must be one of the following actions listed here. |
| 1 | Open the relevant report/document in the patient's chart. |
| 2 | Click Actions -> Edit Details. |
| 3 |
Add the appropriate tag to the Tags section depending on the patient's age and depression screening result:
- Adolescent depression screening - negative (finding)
- Adolescent depression screening - positive (finding)
- Adult depression screening - negative (finding)
- Adult depression screening - positive (finding)
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| 4a | If the result is negative, no further action is needed as they will be automatically added to the measure's Numerator. |
| 4b | If the result is positive, record a follow-up plan on the date of the visit or up to 2 days after the date of the visit. The follow-up plan must be one of the following actions listed here. |
| Exclusion/Exception | Steps |
| Exclude patients who have ever been diagnosed with bipolar disorder at any time prior to the qualifying encounter. |
Add a diagnosis of bipolar disorder to the patient's
Problem List or visit note with a start date prior to December 31, 2026.
Click here for a list of qualifying ICD-10 codes for bipolar disorder.
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| Except patients who refuse to participate in or complete the depression screening. | Click + Tag at the bottom of the visit note draft and add one of these document tags to the visit note based on the patient’s age:
- 12-17 years old: Adolescent depression screening - declined (situation)
- 18 years and older: Adult depression screening - declined (situation)
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Except patients with documentation of medical reason for not screening patient for depression (e.g., cognitive, functional, or motivational limitations that may impact accuracy of results; patient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient's health status).
| Click + Tag at the bottom of the visit note draft and add the appropriate document tag from this list:
- Adolescent depression screening not performed - Procedure contraindicated (situation)
- Adolescent depression screening not performed - Treatment not indicated (situation)
- Adolescent depression screening not performed - Drug treatment not indicated (situation)
- Adolescent depression screening not performed - Absent response to treatment (situation)
- Adolescent depression screening not performed - Late effect of medical and surgical care complica...
- Adolescent depression screening not performed - Drug resistance (disorder)
- Adolescent depression screening not performed - Complication of medical care (disorder)
- Adolescent depression screening not performed - Treatment not tolerated (situation)
- Adolescent depression screening not performed - Not indicated (qualifier value)
- Adolescent depression screening not performed - Contraindicated (qualifier value)
- Adolescent depression screening not performed - Allergy to drug (finding)
- Adolescent depression screening not performed - Procedure not indicated (situation)
- Adolescent depression screening not performed - Intolerance to drug (finding)
- Adolescent depression screening not performed - Adverse reaction caused by drug (disorder)
- Adolescent depression screening not performed - Drug interaction (finding)
- Adult depression screening not performed - Procedure contraindicated (situation)
- Adult depression screening not performed - Treatment not indicated (situation)
- Adult depression screening not performed - Drug treatment not indicated (situation)
- Adult depression screening not performed - Absent response to treatment (situation)
- Adult depression screening not performed - Late effect of medical and surgical care complication ...
- Adult depression screening not performed - Drug resistance (disorder)
- Adult depression screening not performed - Complication of medical care (disorder)
- Adult depression screening not performed - Treatment not tolerated (situation)
- Adult depression screening not performed - Not indicated (qualifier value)
- Adult depression screening not performed - Contraindicated (qualifier value)
- Adult depression screening not performed - Allergy to drug (finding)
- Adult depression screening not performed - Procedure not indicated (situation)
- Adult depression screening not performed - Intolerance to drug (finding)
- Adult depression screening not performed - Adverse reaction caused by drug (disorder)
- Adult depression screening not performed - Drug interaction (finding)
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Reference: CMS2v15 eCQM Flow
Measure Information
Depression affects more than two hundred sixty million people across the world and is a leading cause of disability, with a variety of depressive disorders that are independent risk factors for chronic diseases, such as cardiovascular disease and diabetes, lending screening for depression as paramount to identify depressive disorders that can affect the most vulnerable populations (Costantini et al., 2021). Results from a 2018 U.S. survey indicated that 14.4 percent of adolescents (3.5 million adolescents) had a major depressive episode (MDE) in the past year, with nine percent of adolescents (2.4 million adolescents) having one MDE with severe impairment (Substance Abuse and Mental Health Services Administration, 2019). The odds of a diagnosis of depression are believed to be 2.6 times greater for children and adolescents exposed to trauma as compared to those unexposed or less exposed (Vibhakar et al., 2019). Children and teens with major depressive disorder (MDD) have been found to have difficulty carrying out their daily activities, relating to others, growing up healthy, and are at an increased risk of suicide (Siu on behalf of the U.S. Preventive Services Task Force [USPSTF], 2016).
Reference: Measure information from CMS
Frequently Asked Questions
How can I enter a PHQ-2 or PHQ-9 result from the past to count toward this measure’s Numerator?
To document a past PHQ-2 or 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, 2025 with a score of 11 will look like:
Do I need to reference the PHQ-2 or PHQ-9 result in the visit note for it to count towards the Numerator?
No, you do not need to reference any PHQ-2 or 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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