Measure 134 – Preventive Care and Screening: Screening for Depression and Follow-Up Plan

Audit Criteria

When we’re reviewing your clinicians’ data, it may be helpful to know what we are looking for in order for us to verify to CMS that your data is accurate and complete. Measure 134 requires documentation that an age appropriate standardized depression screening tool has been used with a patient AND if positive, a follow-up plan is documented on the date of the positive screen.

This documentation may be found in the patient’s medical record, AAOE Empower (if using the survey functionality available to you in Empower), and/or in another survey database. The relevant document should be made available to the auditor for the patient requested.

 

What does the auditor need to see in the medical record?

The measure requires, for successful completion, the use of a standardized depression screening tool and, if the screen is positive, a follow-up plan to treat the patient. We need to see evidence that an age appropriate standardized depression screening tool has been administered and in the event of a positive screen that there was a follow-up plan for the patient’s treatment.

Below is a list of surveys that qualify for this measure’s definition of standardized screening tools along with their age categorizations (instruments with a * are included in AAOE Empower):

 

Survey Instrument

Adolescent (12-17 years)

Adult (18+ years)

Perinatal

Patient Health Questionnaire for Adolescents (PHQ-A)

✔️

 

 

Beck Depression Inventory-Primary Care (BDI-C)

✔️

 

 

Mood Feeling Questionnaire (MFQ)

✔️

 

 

Patient Health Questionnaire (PHQ-9)*

✔️ ✔️ ✔️

Pediatric Symptom Checklist (PSC-17)

✔️

✔️

 

PRIME MD-PHQ2

✔️ ✔️

 

Beck Depression Inventory (BDI or BDI-II)

 

✔️

 

Center for Epidemiologic Studies Depression Scale (CES-D)

 

✔️

 

Depression Scale (DEPS)

 

✔️

 

Duke Anxiety-Depression Scale (DADS)

 

✔️

 

Geriatric Depression Scale (GDS)

 

✔️

 

Cornell Scale for Depression in Dementia (CSDD)

 

✔️

 

Hamilton Rating Scale for Depression (HAM-D)

 

✔️

 

Quick Inventory of Depressive Symptomology Self-Report (QID-SR)

 

✔️

 

Survey Instrument

Adolescent (12-17 years)

Adult (18+ years)

Perinatal

Computerized Adaptive Testing Depression Inventory (CAT-DI)

 

✔️

 

Computerized Adaptive Diagnostic Screener (CAD-MDD)

 

✔️

 

Edinburgh Postnatal Depression Scale

 

 

✔️

Postpartum Depression Screening Scale

 

 

✔️

Beck Depression Inventory

 

 

✔️

Beck Depression Inventory-II

 

 

✔️

Center for Epidemiologic Studies Depression Scale

 

 

✔️

Zung Self-rating Depression Scale

 

 

✔️

 

Documented follow-up must include one or more of the following:

  • Additional evaluation or assessment for depression;
  • Suicide risk assessment;
  • Referral to a provider who is qualified to diagnose and treat depression;
  • Pharmacological interventions; and/or,
  • Other interventions or follow-up for the diagnosis or treatment of depression.