Preventive Care and Screening: Screening for Depression and Follow-Up Plan

Identifying Attributes

Care Settings
Primary Care
Country
United States of America
Publishing Organisation
Centers for Medicare & Medicaid Services (CMS): Traditional Merit-based Incentive Payment System (MIPS)
Type of Quality Indicator
Process
IOM Quality Dimension
Effectiveness
Domain
Mental Health

Defining Attributes

Definition

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 standardised 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

Numerator

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 standardised 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

Denominator

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

Exclusions

Patients who have ever been diagnosed with bipolar disorder at any time prior to the qualifying encounter. Patient refuses to participate in or complete the depression screening. 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 jeopardise the patient's health status)

Use of Risk Adjustment
No
Risk Adjustments

None

Stratifications

None

Collection and Reporting Attributes

Type of Data Collection
Administrative data, Electronic/paper chart records
Data Collection Methods

Merit-Based Incentive Payment System traditional reporting

Frequency of Data Collection
Annually
Frequency of Data Collection in Days
365
Reporting Methods

Merit-Based Incentive Payment System

Reporting Frequency
Annually
Reporting Frequency in Days
365
Indicator Has Recommended Targets
No

Source and Reference Attributes

Link to Measurement Tools
Quality Indicator Confirmed to be Part of a Program Used to Monitor Quality and Safety of Care Among Older People at a Population-Level between 2012-2022
Yes
Assessed by the Australian Consortium for Aged Care Collaborators as Generally Containing Good Properties (Importance and Scientific Acceptability)
Yes
Australian Consortium for Aged Care Endorsed
No
Identified by PHARMA-Care Project
No
Upload Date
02 December 2025