Measure 134: Preventive Care and Screening: Screening for Depression and Follow-Up Plan (SOAP 2.0)

This is a guide for 2.0 measure reporting. For 1.0 measure reporting, click here.

Depression is a serious medical illness associated with higher rates of chronic disease, increased health care utilization, and impaired functioning (Pratt, Brody 2014). U.S. survey data (2014) indicates that 2.8 million (11.4 percent) adolescents aged 12 to 17 had a major depressive episode (MDE) in the past year and that 15.7 million (6.6 percent) adults aged 18 or older had at least one MDE in the past year.

Who can report this measure?

PTs and OTs can report this measure.

Patient Qualifications

  • Patient age (12 or older) 
  • Patient does not have an active diagnosis of depression 
  • Patient has not been diagnosed with bipolar disorder 
  • Visit type: Initial Evaluation

Note: Patients with a previous diagnosis of bipolar disorder or an active medical diagnosis of depression are not eligible for Measure 134.

When do I report on this measure?

Reporting is once per performance period and only when an eligible procedure code is billed.

Eligible Procedure Codes

PT: 97161, 97162, 97163

OT: 97165, 97166, 97167

Measure Requirements

  • Screen the patient using one of the following Outcome Measurement Tools based on age:
  • If the depression screening is positive, then you must have a follow-up plan that includes details regarding one or more of the following options:
    • Additional evaluation or assessment for depression
    • Suicide Risk Assessment
    • Referral to a practitioner who is qualified to diagnose and treat depression
    • Pharmacological interventions
    • Other interventions or follow-up for the diagnosis or treatment of depression

Measure Specification

For more information on Measure 134, please see the Measure Specification Guide.

Geriatric Depression Scale

  1. Click the MIPS badge in the Case Summary to view the current Measure Status. Here you will see all measures that the patient is eligible for based on their Diagnoses and Procedure Code.
  2. On the Objective section, select the Standardized Tests subsection to view and edit the required fields for Measure 134.
  3. In the Standardized Tests subsection, the Geriatric Depression Scale or Mood and Feelings Questionnaire will automatically populate based on the patient's age. For this example, we’ll use the Geriatric Depression Scale.
  4. Administer the test and complete the OMT by selecting the radio buttons. 
  5. The EMR will calculate the Total Score automatically.
  6. Measure Met: If the patient does seem depressed, complete the required Follow-up Plan field. This triggers a Measure Met indicator in the Measure Status column. 
  7. When finished documenting, validate the selection in the MIPS tab.
  8. Excluded: Select the Excluded radio button if the patient has a documented medical reason, then select the Reason in the required field. Possible reasons may include:
    • Patient has an active diagnosis of depression prior to any encounter during the measurement period
    • Patient has as a diagnosed bipolar disorder prior to any encounter during the measurement period
    • Patient refuses to participate
    • 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
    • Patient has cognitive, functional, or motivational capacities that may impact the accuracy of results (for example: certain court appointed cases or cases of delirium)
    • Patient has a documented Medical Reason
  9. Not Met: Select the Not Met radio button if :
    • Depression screening is not documented, reason not given
    • Depression screening is documented as positive, follow-up plan not documented, reason not given
  10. If the note is signed without completing the required fields, an alert will appear. Required fields must be completed before submitting the note.

Mood and Feeling Questionnaire

If you are reporting for a patient aged 12-17, you would select the Mood and Feeling Questionnaire in the Standardized Tests subsection, then follow the instructions below.

  1. Administer the questionnaire and complete the OMT by selecting the appropriate radio buttons. 
  2. Measure Met: If the patient does seem depressed, complete the required Follow-up Plan field. This triggers a Measure Met indicator in the Measure Status column. When finished documenting, validate in the MIPS tab.
  3. Excluded: Select the Excluded radio button if the patient has a documented medical reason, then select the Reason in the required field. Possible reasons may include:
    • Patient has an active diagnosis of depression prior to any encounter during the measurement period
    • Patient has as a diagnosed bipolar disorder prior to any encounter during the measurement period
    • Patient refuses to participate
    • 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
    • Patient has cognitive, functional, or motivational capacities that may impact the accuracy of results (for example: certain court appointed cases or cases of delirium)
    • Patient has a documented Medical Reason
  4. Not Met: Select the Not Met radio button if :
    • Depression screening is not documented, reason not given
    • Depression screening is documented as positive, follow-up plan not documented, reason not given
  5. If the note is signed without completing the required fields, an alert will appear. Required fields must be completed before submitting the note.

Other Depression Scale

If you are reporting for a patient who needs additional flexibility for the depression screening, you would select the Other Depression Scale in the Standardized Tests subsection.

  1. From the Standardized Tests subsection, select Add Standardized Test+.
  2. Use the search bar and drop-down menu and select Other Depression Scale.
  3. Enter the Depression Screening Instrument you have selected and select the appropriate radio buttons.
  4. Measure Met: If the patient does seem depressed, select the Yes radio button and complete the Follow-up Plan field. This triggers a Measure Met indicator in the Measure Status column.
  5. If the patient does not seem depressed, select the No radio button and validate the selection in the MIPS tab.
  6. Excluded:  Select the Excluded radio button if the patient has a documented medical reason, then select the Reason in the required field. Possible reasons may include:
    • Patient has an active diagnosis of depression prior to any encounter during the measurement period
    • Patient has as a diagnosed bipolar disorder prior to any encounter during the measurement period
    • Patient refuses to participate
    • 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
    • Patient has cognitive, functional, or motivational capacities that may impact the accuracy of results (for example: certain court appointed cases or cases of delirium)
    • Patient has a documented Medical Reason
  7. Not Met: Select the Not Met radio button if :
    • Depression screening is not documented, reason not given
    • Depression screening is documented as positive, follow-up plan not documented, reason not given
  8. If the note is signed without completing the required fields, an alert will appear. Required fields must be completed before submitting the note.