2018 CMS Web Interface

Transcription

1 CMS Web Interface PREV-12 (NQF 0418): Preventive Care and Screening: Screening fr Depressin and Measure Steward: CMS CMS Web Interface V2.0 Page 1 f 23 11/13/2017

2 Cntents INTRODUCTION... 3 CMS WEB INTERFACE SAMPLING INFORMATION... 4 BENEFICIARY SAMPLING... 4 NARRATIVE MEASURE SPECIFICATION... 5 DESCRIPTION:... 5 IMPROVEMENT NOTATION:... 5 INITIAL POPULATION:... 5 DENOMINATOR:... 5 DENOMINATOR EXCLUSIONS:... 5 DENOMINATOR EXCEPTIONS:... 5 NUMERATOR:... 5 NUMERATOR EXCLUSIONS:... 5 DEFINITIONS:... 5 GUIDANCE:... 6 SUBMISSION GUIDANCE... 8 PATIENT CONFIRMATION... 8 SUBMISSION GUIDANCE... 9 DENOMINATOR CONFIRMATION... 9 SUBMISSION GUIDANCE NUMERATOR REPORTING SUBMISSION GUIDANCE NUMERATOR REPORTING DOCUMENTATION REQUIREMENTS APPENDIX I: PERFORMANCE CALCULATION FLOW APPENDIX II: DOWNLOADABLE RESOURCE MAPPING TABLE APPENDIX III: MEASURE RATIONALE AND CLINICAL RECOMMENDATION STATEMENTS RATIONALE: CLINICAL RECOMMENDATION STATEMENTS: APPENDIX IV: USE NOTICES, COPYRIGHTS, AND DISCLAIMERS COPYRIGHT CMS Web Interface V2.0 Page 2 f 23 11/13/2017

3 INTRODUCTION There are a ttal f 15 individual measures (including ne cmpsite cnsisting f tw measures) included in the CMS Web Interface targeting high-cst chrnic cnditins, preventive care, and patient safety. The measures dcuments are represented individually and cntain measure specific infrmatin. The crrespnding cding dcuments are psted separately in an Excel frmat. The measure dcuments are being prvided t allw grup practices and Accuntable Care Organizatins (ACOs) an pprtunity t better understand each f the 15 individual measures included in the CMS Web Interface data submissin methd. Each measured dcument cntains infrmatin necessary t submit data thrugh the CMS Web Interface. Narrative specificatins, supprting submissin dcumentatin, and calculatin flws are prvided within each dcument. Please review all f the measure dcumentatin in its entirety t ensure cmplete understanding f these measures. CMS Web Interface V2.0 Page 3 f 23 11/13/2017

4 CMS WEB INTERFACE SAMPLING INFORMATION BENEFICIARY SAMPLING Fr mre infrmatin n the sampling prcess and methdlgy please refer t the CMS Web Interface Sampling Dcument, which will be made available during the perfrmance year at CMS.gv. CMS Web Interface V2.0 Page 4 f 23 11/13/2017

5 NARRATIVE MEASURE SPECIFICATION DESCRIPTION: Percentage f patients aged 12 years and lder screened fr depressin n the date f the encunter using an age apprpriate standardized depressin screening tl AND if psitive, a fllw-up plan is dcumented n the date f the psitive screen IMPROVEMENT NOTATION: Higher scre indicates better quality INITIAL POPULATION: All patients aged 12 years and lder befre the beginning f the measurement perid with at least ne eligible encunter during the measurement perid DENOMINATOR: Equals Initial Ppulatin DENOMINATOR EXCLUSIONS: Patients with an active diagnsis fr depressin r a diagnsis f biplar disrder DENOMINATOR EXCEPTIONS: Patient Reasn(s): Patient refuses t participate OR Medical Reasn(s): Patient is in an urgent r emergent situatin where time is f the essence and t delay treatment wuld jepardize the patient s health status OR Situatins where the patient s functinal capacity r mtivatin t imprve may impact the accuracy f results f standardized depressin assessment tls. Fr example: certain curt appinted cases r cases f delirium NUMERATOR: Patients screened fr depressin n the date f the encunter using an age apprpriate standardized tl AND if psitive, a fllw-up plan is dcumented n the date f the psitive screen NUMERATOR EXCLUSIONS: Nt Applicable DEFINITIONS: Screening: Cmpletin f a clinical r diagnstic tl used t identify peple at risk f develping r having a certain disease r cnditin, even in the absence f symptms. Standardized Depressin Screening Tl A nrmalized and validated depressin screening tl develped fr the patient ppulatin in which it is being utilized. Examples f depressin screening tls include but are nt limited t: Adlescent Screening Tls (12-17 years) Patient Health Questinnaire fr Adlescents (PHQ-A) Beck Depressin Inventry-Primary Care Versin (BDI-PC) Md Feeling Questinnaire (MFQ) Center fr Epidemilgic Studies Depressin Scale (CES-D) Patient Health Questinnaire (PHQ-9) Pediatric Symptm Checklist (PSC-17) CMS Web Interface V2.0 Page 5 f 23 11/13/2017

6 PRIME MD-PHQ-2 Adult Screening Tls (18 years and lder) Patient Health Questinnaire (PHQ-9) Beck Depressin Inventry (BDI r BDI-II) Center fr Epidemilgic Studies Depressin Scale (CES-D) Depressin Scale (DEPS) Duke Anxiety-Depressin Scale (DADS) Geriatric Depressin Scale (GDS) Crnell Scale fr Depressin in Dementia (CSDD) PRIME MD-PHQ-2 Hamiltn Rating Scale fr Depressin (HAM-D) Quick Inventry f Depressive Symptmatlgy Self-Reprt (QID-SR) Perinatal Screening Tls Edinburgh Pstnatal Depressin Scale Pstpartum Depressin Screening Scale Patient Health Questinnaire 9 (PHQ-9) Beck Depressin Inventry Beck Depressin Inventry II Center fr Epidemilgic Studies Depressin Scale Zung Self-rating Depressin Scale : Dcumented fllw-up fr a psitive depressin screening must include ne r mre f the fllwing: Additinal evaluatin fr depressin Suicide Risk Assessment Referral t a practitiner wh is qualified t diagnse and treat depressin Pharmaclgical interventins Other interventins r fllw-up fr the diagnsis r treatment f depressin GUIDANCE: A depressin screen is cmpleted n the date f the encunter using an age apprpriate standardized depressin screening tl AND if psitive, either additinal evaluatin fr depressin, suicide risk assessment, referral t a practitiner wh is qualified t diagnse and treat depressin, pharmaclgical interventins, r ther interventins r fllw-up fr the diagnsis r treatment f depressin is dcumented n the date f the psitive screen. Screening Tls: The name f the age apprpriate standardized depressin screening tl utilized must be dcumented in the medical recrd The depressin screening must be reviewed and addressed in the ffice f the prvider filing the cde, n the date f the encunter The screening shuld ccur during a qualified encunter Standardized Depressin Screening Tls shuld be nrmalized and validated fr the age apprpriate patient ppulatin in which they are used and must be dcumented in the medical recrd CMS Web Interface V2.0 Page 6 f 23 11/13/2017

7 : The fllw-up plan must be related t a psitive depressin screening, example: Patient referred fr psychiatric evaluatin due t psitive depressin screening. Pharmaclgic treatment fr depressin is ften indicated during pregnancy and/r lactatin. Review and discussin f the risks f untreated versus treated depressin is advised. Cnsideratin f each patient s prir disease and treatment histry, alng with the risk prfiles fr individual pharmaclgic agents, is imprtant when selecting pharmaclgic therapy with the greatest likelihd f treatment effect. CMS Web Interface V2.0 Page 7 f 23 11/13/2017

8 PATIENT CONFIRMATION SUBMISSION GUIDANCE Establishing patient eligibility fr reprting requires the fllwing: Guidance Determine if the patient s medical recrd can be fund OR OR If yu can lcate the medical recrd select Yes If yu cannt lcate the medical recrd select N - Medical Recrd Nt Fund Determine if the patient is qualified fr the sample If the patient is deceased, in hspice, mved ut f the cuntry, r was enrlled in HMO select Nt Qualified fr Sample, select the applicable reasn frm the prvided drp-dwn menu, and enter the date the patient became ineligible Patient Cnfirmatin If N Medical Recrd Nt Fund r Nt Qualified fr Sample is selected, the patient is cmpleted but nt cnfirmed. The patient will be skipped and anther patient must be reprted in their place, if available. The CMS Web Interface will autmatically skip any patient fr whm N Medical Recrd Nt Fund r Nt Qualified fr Sample is selected in all ther measures int which they have been sampled. If Nt Qualified fr Sample is selected and the date is unknwn, yu may enter the last date f the measurement perid (i.e., 12/31/). The Measurement Perid is defined as January 1 December 31,. NOTE: - In Hspice: Select this ptin if the patient is nt qualified fr sample due t being in hspice care at any time during the measurement perid (this includes nn-hspice patients receiving palliative gals r cmfrt care) - Mved ut f Cuntry: Select this ptin if the patient is nt qualified fr sample because they mved ut f the cuntry any time during the measurement perid - Deceased: Select this ptin if the patient died during the measurement perid - HMO Enrllment: Select this ptin if the patient was enrlled in an HMO at any time during the measurement perid (i.e., Medicare Advantage, nn-medicare HMOs, etc.) CMS Web Interface V2.0 Page 8 f 23 11/13/2017

9 DENOMINATOR CONFIRMATION SUBMISSION GUIDANCE Determine if the patient is qualified fr the measure OR OR If the patient is qualified fr this measure select Yes If there is a denminatr exclusin fr patient disqualificatin frm the measure select Denminatr Exclusin If there is an ther CMS apprved reasn fr patient disqualificatin frm the measure select N - Other CMS Apprved Reasn Denminatr Exclusin cdes can be fund in the CMS Web Interface PREV Cding Dcument. The Dwnladable Resurce Mapping Table can be lcated in Appendix II f this dcument. Guidance Denminatr Denminatr Exclusin Timing - prir t any encunter during the measurement perid. If Denminatr Exclusin r N Other CMS Apprved Reasn is selected, the patient will be skipped and anther patient must be reprted in their place, if available. The patient will nly be remved frm the measure fr which ne f these ptins was selected, nt all CMS Web Interface measures. CMS Apprved Reasn may nly be selected when apprved by CMS. T request a CMS Apprved Reasn, yu wuld need t prvide the patient rank, measure and reasn fr request in a Quality Payment Prgram Service Desk inquiry. CMS decisin will be prvided in the reslutin f the inquiry. Patients fr whm CMS Apprved Reasn is selected are n lnger qualified fr the measure. The patient will be skipped and anther patient must be reprted in their place, if available. NOTE: - The term active diagnsis is defined as a diagnsis that is either n the patient s prblem list, a diagnsis cde listed n the encunter, r is dcumented in a prgress nte indicating that the patient is being treated r managed fr the disease r cnditin during the denminatr identificatin measurement perid CMS Web Interface V2.0 Page 9 f 23 11/13/2017

10 NUMERATOR SUBMISSION SUBMISSION GUIDANCE Determine if the patient was screened fr depressin using an age apprpriate standardized tl during the measurement perid OR OR OR If the patient was nt screened fr depressin using a standardized tl select N If the patient was dcumented as having been screened fr depressin using ne f the standardized tls select Yes If the patient was nt screened fr depressin using a standardized tl due t a medical reasn select N - Denminatr Exceptin Medical Reasns If the patient was nt screened fr depressin using a standardized tl due t a patient reasn select N - Denminatr Exceptin Patient Reasns Numeratr and Denminatr Exceptin cdes can be fund in the CMS Web Interface PREV Cding Dcument. The Dwnladable Resurce Mapping Table can be lcated in Appendix II f this dcument. Guidance NOTE: Numeratr - Use mst recent screening fr depressin - Althugh the patient may have access t the depressin screening tl in advance f the appintment the depressin screening results must be dcumented n the date f the encunter (date f appintment).the results must be reviewed/verified and dcumented by the eligible prfessinal in the medical recrd n the date f the encunter t meet the screening prtin f this measure - Screening fr depressin may be cmpleted during a telehealth encunter - Denminatr Exceptin timing is during the encunter during the measurement perid CMS Web Interface V2.0 Page 10 f 23 11/13/2017

11 NUMERATOR SUBMISSION SUBMISSION GUIDANCE Determine if the screen was psitive fr depressin during the measurement perid OR If the patient's screen was nt psitive fr depressin using a standardized tl select N If the patient's screen was psitive fr depressin using a standardized tl select Yes IF YES Determine if a fllw-up plan fr depressin was dcumented n the date f the psitive screen If a fllw-up plan fr depressin is nt dcumented select N OR If a fllw-up plan fr depressin is dcumented select Yes Numeratr cdes can be fund in the CMS Web Interface PREV Cding Dcument. The Dwnladable Resurce Mapping Table can be lcated in Appendix II f this dcument. Guidance NOTE: Numeratr - Screening fr Depressin Dcumented as Negative, fllw-up plan nt required - Dcumentatin f recmmended fllw-up plan fr a psitive depressin screen may be cmpleted during a telehealth encunter - If recmmended fllw-up is additinal screening, the additinal screening must ccur at the same encunter as the psitive screen - If additinal screening is cmpleted during the same encunter as the psitive screen, the results f the additinal screening is nt necessary fr data abstractin - Psitive r Negative-Whether r nt a standardized screening tl scre is cnsidered psitive r negative wuld be determined by the eligible prfessinal administering and reviewing the standardized tl. If the result is psitive, dcumentatin f a recmmended fllw-up is required. - This measure des nt require dcumentatin f a specific scre, just whether results f the nrmalized and validated depressin screening tl used are cnsidered psitive r negative. Each standardized screening tl prvides guidance n whether a particular scre is cnsidered psitive fr depressin. CMS Web Interface V2.0 Page 11 f 23 11/13/2017

12 DOCUMENTATION REQUIREMENTS When submitting data thrugh the CMS Web Interface, the expectatin is that medical recrd dcumentatin is available that supprts the actin reprted in the CMS Web Interface i.e., medical recrd dcumentatin is necessary t supprt the infrmatin that has been submitted. CMS Web Interface V2.0 Page 12 f 23 11/13/2017

13 Appendix I: Perfrmance Calculatin Flw Patient Cnfirmatin Flw Fr, cnfirmatin f the Medical Recrd Fund, r indicating the patient is Nt Qualified fr Sample with a reasn f "In Hspice", "Mved ut f Cuntry", "Deceased", r "HMO Enrllment", will nly need t be dne nce per patient. Start* Mark apprpriately fr cmpletin and STOP ABSTRACTION. This remves the patient frm the beneficiary sample fr all measures. The patient will be skipped and replaced. N Medical Recrd Fund Yes Mark apprpriately fr cmpletin and STOP ABSTRACTION. This remves the patient frm the beneficiary sample fr all measures. The patient will be skipped and replaced. N Patient Qualified fr the Sample. IF NOT, Select the Reasn & Enter Date** Patient Became Ineligible fr Sample (In Hspice, Mved ut f Cuntry, Deceased, HMO Enrllment) Yes Cntinue t Measure Cnf *See the Measure Submissin Dcument fr further instructins n hw t submit this measure **If date is unknwn, enter 12/31/ CMS Web Interface V2.0 Page 13 f 23 11/13/2017

14 Measure Cnfirmatin Flw fr PREV-12 Fr, measure specific reasns a patient is Nt Cnfirmed r excluded fr Denminatr Exclusin r Other CMS Apprved Reasn will need t be dne fr each measure where the patient appears. Start* Cmplete fr cnsecutively ranked patients aged 12 years and lder at the beginning f the measurement perid** Mark apprpriately fr cmpletin and STOP ABSTRACTION. Patient is remved frm the perfrmance calculatins fr this measure. The patient will be skipped and replaced. N Patient Qualified fr Measure, IF NOT, Select: Denminatr Exclusin fr Patient Disqualificatin Yes Mark apprpriately fr cmpletin and STOP ABSTRACTION. Patient is remved frm the perfrmance calculatins fr this measure. The patient will be skipped and replaced. N Patient Qualified fr the Measure. IF NOT, Select: N - Other CMS Apprved Reasn fr Patient Disqualificatin*** Yes Cntinue t Measure Flw *See the Measure Submissin Dcument fr further instructins n hw t submit this measure **Further infrmatin regarding patient selectin fr specific disease and patient care measures can be fund in the CMS Web Interface Sampling Methdlgy Dcument. Fr patients wh have the incrrect date f birth listed, a change f the patient date f birth by the abstractr may result in the patient n lnger qualifying fr the PREV-12 measure. If this is the case, the system will autmatically remve the patient frm the measure requirements. *** Other CMS Apprved Reasn may nly be selected if yu have received an apprval frm CMS in the reslutin f a requested Quality Payment Prgram Service Desk Inquiry at qpp@cms.hhs.gv CMS Web Interface V2.0 Page 14 f 23 11/13/2017

15 Start* Measure Flw fr PREV-12 Include Remainder f Patients Listed in the CMS Web Interface that were Cnsecutively Cnfirmed and Cmpleted fr this Measure in the Denminatr (i.e., 227 Patients) d The measure diagrams were develped by CMS as a supplemental resurce t be used in cnjunctin with the measure specificatins. They shuld nt be used as a substitutin fr the measure specificatin. Fr Dwnladable Resurce Mapping Table, g t Appendix II and use the Variable Names lcated in the appendix alng with the applicable tabs within the PREV Cding Dcument. Yes Patient Screened fr Depressin Using an Age Apprpriate Standardized Tl During the Measurement Perid N Patient Had a Psitive Screen fr Depressin During the Measurement Perid N Negative Screen Perfrmance Met: Include in Numeratr (i.e., 50 Patients) a 1 Patient Nt Screened fr Depressin Using a Standardized Tl fr a Denminatr Exceptin, Medical Reasn(s) Yes Denminatr Exceptin: Subtract frm Denminatr (i.e., 18 Patients) b 1 Yes N Fllw-up Plan fr Depressin Dcumented n the Date f the Psitive Screen Yes Perfrmance Met: Include in Numeratr (i.e., 116 Patients) a 2 Patient Nt Screened fr Depressin Using a Standardized Tl fr a Denminatr Exceptin, Patient Reasn(s) Yes Denminatr Exceptin: Subtract frm Denminatr (i.e., 23 Patients) b 2 N N Perfrmance Nt Met: D Nt Include in Numeratr Perfrmance Nt Met: D Nt Include in Numeratr SAMPLE CALCULATION: Perfrmance Rate= Perfrmance Met (a 1 =50 Patients + a 2 =116 Patients) 166 Patients = 89.25% Denminatr (d=227 Patients) - Denminatr Exceptin (b 1 =18 Patients + b 2 =23 Patients) = 186 Patients CALCULATION MAY CHANGE PENDING PERFORMANCES MET ABOVE *See the Measure Submissin Dcument fr further instructins n hw t submit this measure CMS Web Interface V2.0 Page 15 f 23 11/13/2017

16 Patient Cnfirmatin Flw Fr, cnfirmatin f the Medical Recrd Fund, r indicating the patient is Nt Qualified fr Sample with a reasn f In Hspice, Mved ut f Cuntry, Deceased, r HMO Enrllment, will nly need t be dne nce per patient. Refer t the Measure Submissin Dcument fr further instructins. 1. Start Patient Cnfirmatin Flw. 2. Check t determine if Medical Recrd can be fund. a. If n, Medical Recrd nt fund, mark apprpriately fr cmpletin and stp abstractin. This remves the patient frm the beneficiary sample fr all measures. The patient will be skipped and replaced. Stp prcessing. b. If yes, Medical Recrd fund, cntinue prcessing. 3. Check t determine if Patient Qualified fr the sample. a. If n, the patient des nt qualify fr the sample, select the reasn why and enter the date (if date is unknwn, enter 12/31/) the patient became ineligible fr sample. Fr example; In Hspice, Mved ut f Cuntry, Deceased, HMO Enrllment. Mark apprpriately fr cmpletin and stp abstractin. This remves the patient frm the beneficiary sample fr all measures. The patient will be skipped and replaced. Stp prcessing. b. If yes, the patient des qualify fr the sample; cntinue t the Measure Cnfirmatin Flw fr PREV-12. CMS Web Interface V2.0 Page 16 f 23 11/13/2017

17 Measure Cnfirmatin Flw fr PREV-12 Fr, measure specific reasns a patient is Nt Cnfirmed r excluded fr Denminatr Exclusin r Other CMS Apprved Reasn will need t be dne fr each measure where the patient appears. Refer t the Measure Submissin Dcument fr further instructins. 1. Start Measure Cnfirmatin Flw fr PREV-12. Cmplete fr cnsecutively ranked patients aged 12 years and lder at the beginning f the measurement perid. Further infrmatin regarding patient selectin fr specific disease and patient care measures can be fund in the CMS Web Interface Sampling Methdlgy Dcument. Fr patients wh have the incrrect date f birth listed, a change f the patient date f birth by the abstractr may result in the patient n lnger qualifying fr the PREV-12 measure. If this is the case, the system will autmatically remve the patient frm the measure requirements. 2. Check t determine if the patient qualifies fr the measure (Denminatr Exclusin). a. If n, the patient des nt qualify fr the measure select: Denminatr Exclusin fr patient disqualificatin. Mark apprpriately fr cmpletin and stp abstractin. Patient is remved frm the perfrmance calculatins fr this measure. The patient will be skipped and replaced. Stp prcessing. b. If yes, the patient des qualify fr the measure, cntinue prcessing. 3. Check t determine if the patient qualifies fr the measure (Other CMS Apprved Reasn). a. If n, the patient des nt qualify fr the measure select: N Other CMS Apprved Reasn fr patient disqualificatin. Mark apprpriately fr cmpletin and stp abstractin. Patient is remved frm the perfrmance calculatins fr this measure. The patient will be skipped and replaced. Other CMS Apprved Reasn may nly be selected if yu have received an apprval frm CMS in the reslutin f a requested Quality Payment Prgram Service Desk Inquiry at QPP@cms.hhs.gv. Stp prcessing. b. If yes, the patient des qualify fr the measure, cntinue t the PREV-12 measure flw. CMS Web Interface V2.0 Page 17 f 23 11/13/2017

18 Measure Flw fr PREV-12 The measure diagrams were develped by CMS as a supplemental resurce t be used in cnjunctin with the measure specificatins. They shuld nt be used as a substitutin fr the measure specificatins. Fr Dwnladable Resurce Mapping Table, g t Appendix II and use the Variable Names lcated in the appendix alng with the applicable tabs within the PREV Cding Dcument. 1. Start prcessing PREV-12 (NQF 0418) Flw fr the patients that qualified fr sample in the Patient Cnfirmatin Flw and the Measure Cnfirmatin Flw fr PREV-12. Nte: Include remainder f patients listed in the CMS Web Interface that were cnsecutively cnfirmed and cmpleted fr this measure in the denminatr. Fr the sample calculatin in the flw these patients wuld fall int the d categry (eligible denminatr, i.e. 227 patients). 2. Check t determine if the patient was screened fr depressin using an age apprpriate standardized tl during the measurement perid. a. If n, the patient was nt screened fr depressin using an age apprpriate standardized tl during the measurement perid, cntinue prcessing and prceed t step 5. b. If yes, the patient was screened fr depressin using an age apprpriate standardized tl during the measurement perid, cntinue prcessing. 3. Check t determine if the patient had a psitive screen fr depressin during the measurement perid. a. If n, the patient did nt have a psitive screen fr depressin during the measurement perid, perfrmance is met and the patient will be included in the numeratr. Fr the sample calculatin in the flw these patients wuld fall int the a¹ categry (numeratr, i.e. 50 patients). Stp prcessing. b. If yes, patient had a psitive screen fr depressin during the measurement perid, cntinue prcessing. 4. Check t determine if the patient had a fllw-up plan fr depressin dcumented n the date f the psitive screen. a. If n, the patient did nt have a fllw-up plan fr depressin dcumented n the date f the psitive screen, perfrmance is nt met and the patient shuld nt be included in the numeratr. Stp prcessing. b. If yes, the patient had a fllw-up plan fr depressin dcumented n the date f the psitive screen, perfrmance is met and the patient will be included in the numeratr. Fr the sample calculatin in the flw these patients wuld fall int the a² categry (numeratr, i.e. 116 patients). Stp prcessing. 5. Check t determine if the patient was Nt screened fr depressin using a standardized tl fr a denminatr exceptin, medical reasn(s). a. If n, the patient was Nt screened fr depressin using a standardized tl fr a denminatr exceptin, medical reasn(s), cntinue prcessing. b. If yes, the patient was Nt screened fr depressin using a standardized tl fr a denminatr exceptin, medical reasn(s), this is a denminatr exceptin and the case shuld be subtracted frm the denminatr. Fr the sample calculatin in the flw these patients wuld fall int the b¹ categry (denminatr exceptin, i.e. 18 patients). Stp prcessing. 6. Check t determine if the patient was Nt screened fr depressin using a standardized tl fr a denminatr exceptin, patient reasn(s). CMS Web Interface V2.0 Page 18 f 23 11/13/2017

19 a. If n, the patient Nt screened fr depressin using a standardized tl fr a denminatr exceptin, patient reasn(s), perfrmance is nt met and the patient shuld nt be included in the numeratr. Stp prcessing. b. If yes, the patient was Nt screened fr depressin using a standardized tl fr a denminatr exceptin, patient reasn(s), this is a denminatr exceptin and the case shuld be subtracted frm the denminatr. Fr the sample calculatin in the flw these patients wuld fall int the b² categry (denminatr exceptin, i.e. 23 patients). Stp prcessing. Sample Calculatin Perfrmance Rate Equals Perfrmance Met is categry a¹ plus a² in the measure flw (166 patients) Denminatr is categry d in the measure flw (227 patients) Denminatr Exceptin is categry b¹ plus b² in the measure flw (41 patients) 166 (Perfrmance Met) divided by 186 (Denminatr minus Denminatr Exceptin) equals a perfrmance rate f percent Calculatin May Change Pending Perfrmance Met CMS Web Interface V2.0 Page 19 f 23 11/13/2017

20 Appendix II: Dwnladable Resurce Mapping Table Each data element within this measure s denminatr r numeratr is defined as a pre-determined set f clinical cdes. These cdes can be fund in the CMS Web Interface PREV Cding Dcument. *PREV-12: Preventive Care and Screening: Screening fr Depressin and Measure Cmpnent/Excel Tab Data Element Variable Name Cding System(s) Denminatr Exclusin/ Denminatr Exclusin Cdes Exclusin BIPOLAR_DX_CODE I9 I10 SNM DEPRESSION_DX_CODE I9 I10 SNM Numeratr/Numeratr Depressin SCREENING_CODE LN Cdes/Numeratr Drug Cdes Screen NEG_SCREENING_CODE SNM POS_SCREENING_CODE SNM Psitive Screen POS_SCREENING_CODE SNM Fllw-up Plan ADDITIONAL_EVAL_CODE SNM FOLLOW_UP_CODE SNM REFERRAL_CODE SNM SUICIDE_RISK_CODE SNM DEP_DRUG_CODE RxNrm (Drug EX=N) Denminatr Exceptin/ Medical Reasn MEDICAL_OTHER_REASON SNM Denminatr Exceptin Cdes Patient Reasn PATIENT_REASON_REFUSED SNM * Fr EHR mapping, the cding within PREV-12 is cnsidered t be all inclusive CMS Web Interface V2.0 Page 20 f 23 11/13/2017

21 Appendix III: Measure Ratinale and Clinical Recmmendatin Statements RATIONALE: 2014 U.S. survey data indicate that 2.8 millin (11.4 percent) adlescents aged 12 t 17 had a majr depressive episde (MDE) in the past year and that 15.7 millin (6.6 percent) adults aged 18 r lder had at least ne MDE in the past year, with 10.2 millin adults (4.3 percent) having ne MDE with severe impairment in the past year (Center fr Behaviral Health Statistics and Quality, 2015). The Wrld Health Organizatin (WHO), as cited by Pratt & Brdy (2008), fund that majr depressin was the leading cause f disability wrldwide. Data indicate that apprximately 80% f peple diagnsed with depressin reprt sme level f difficulty in functining because f their depressive symptms. Fr example, 35% f males and 22% f females with depressin reprted that their depressive symptms make it extremely difficult fr them t wrk, get things dne at hme, r get alng with ther peple. Additinally, mre than ne-half f all persns with mild depressive symptms als reprted sme difficulty in daily functining attributable t their depressive symptms (Pratt & Brdy, 2008). In yung adulthd, majr depressive disrder (MDD) has been fund t be assciated with early pregnancy, decreased schl perfrmance, and impaired wrk, scial, and family functining (Williams et al., 2009, p. e716). In the perinatal perid, depressin and ther md disrders, such as biplar disrder and anxiety disrders, can have devastating effects n wmen, infants, and families. Maternal suicide rates rise ver hemrrhage and hypertensive disrders as a cause f maternal mrtality (American Cllege f Obstetricians and Gyneclgists, 2015). Negative utcmes assciated with depressin make it crucial t screen in rder t identify and treat depressin in its early stages. While Primary Care Prviders (PCPs) serve as the first line f defense in the detectin f depressin, studies shw that PCPs fail t recgnize up t 50% f depressed patients (Brner, 2010, p. 948). "Cyle et al. (2003), suggested that the picture is mre grim fr adlescents, and that mre than 70% f children and adlescents suffering frm serius md disrders g unrecgnized r inadequately treated" (Brner, 2010, p. 948). In natinally representative U.S. surveys, abut 8% f adlescents reprted having majr depressin in the past year. Only 36% t 44% f children and adlescents with depressin receive treatment, suggesting that the majrity f depressed yuth are undiagnsed and untreated (Sui, A. and USPSTF, 2016). Evidence supprts that screening fr depressin in pregnant and pstpartum wmen is f mderate net benefit and treatment ptins fr psitive depressin screening shuld be available fr patients twelve and lder including pregnant and pstpartum wmen. If preventing negative patient utcmes is nt enugh, the substantial ecnmic burden f depressin fr individuals and sciety alike makes a case fr screening fr depressin n a regular basis. Depressin impses ecnmic burden thrugh direct and indirect csts. In the United States, an estimated $22.8 billin was spent n depressin treatment in 2009, and lst prductivity cst an additinal estimated $23 billin in 2011 (Sui, A. and USPSTF, 2016). This measure seeks t align with clinical guideline recmmendatins as well as the Healthy Peple 2020 recmmendatin fr rutine screening fr mental health prblems as a part f primary care fr bth children and adults (U.S. Department f Health and Human Services, 2014) and makes an imprtant cntributin t the quality dmain f cmmunity and ppulatin health. CLINICAL RECOMMENDATION STATEMENTS: Adlescent Recmmendatin (12-18 years) The USPSTF recmmends screening fr MDD in adlescents aged 12 t 18 years. Screening shuld be implemented with adequate systems in place t ensure accurate diagnsis, effective treatment, and apprpriate fllw-up (B recmmendatin) (Sui, A. and USPSTF, 2016, p. 360). Clinicians and health care systems shuld try t cnsistently screen adlescents, ages 12-18, fr majr depressive disrder, but nly when systems are in place t ensure accurate diagnsis, careful selectin f treatment, and clse fllw-up (ICSI, 2013, p. 16). CMS Web Interface V2.0 Page 21 f 23 11/13/2017

22 Adult Recmmendatin (18 years and lder) The USPSTF recmmends screening fr depressin in the general adult ppulatin, including pregnant and pstpartum wmen. Screening shuld be implemented with adequate systems in place t ensure accurate diagnsis, effective treatment, and apprpriate fllw-up (B recmmendatin) (Sui, A. and USPSTF, 2016, p. 380). The Institute fr Clinical Systems Imprvement (ICSI) health care guideline, Adult Depressin in Primary Care, prvides the fllwing recmmendatins: 1. Clinicians shuld rutinely screen all adults fr depressin using a standardized instrument. 2. Clinicians shuld establish and maintain fllw-up with patients. 3. Clinicians shuld screen and mnitr depressin in pregnant and pst-partum wmen. (Trangle, 2016 p.p. 9 10) CMS Web Interface V2.0 Page 22 f 23 11/13/2017

23 Appendix IV: Use Ntices, Cpyrights, and Disclaimers COPYRIGHT Limited prprietary cding is cntained in the measure specificatins fr cnvenience. Users f the prprietary cde sets shuld btain all necessary licenses frm the wners f these cde sets. Quality Insights, Inc. disclaims all liability fr use r accuracy f any Current Prcedural Terminlgy (CPT ) r ther cding cntained in the specificatins. (CPT ) cntained in the Measure specificatins is cpyright American Medical Assciatin. LOINC cpyright [2.58] Regenstrief Institute, Inc. This material cntains SNOMED Clinical Terms (SNOMED CT ) cpyright [ ] Internatinal Health Terminlgy Standards Develpment Organizatin. All Rights Reserved. THE MEASURES AND SPECIFICATIONS ARE PROVIDED AS IS WITHOUT WARRANTY OF ANY KIND. CMS Web Interface V2.0 Page 23 f 23 11/13/2017