Depression Screening CDSM

PHQ-2 / PHQ-9 eCQM Follow-Up Helper for PCPs, Specialists, and Surgeons

A simple, scope-aware way to recognize, document, and route a depression screen. Built so a busy team can use it in under 30 seconds.

CMS2v15 / MIPS #134 (2026) Scope-aware No PHI stored Local-only
988

988 Suicide & Crisis Lifeline · 24/7, free, confidential

Anyone in the U.S. can call or text 988, or chat at 988lifeline.org. Many patients don’t know this exists - sharing it is part of your safety plan.

Start here · Pick your path

Two ways to use this tool. Pick the one that fits your moment - you can switch anytime.

Pick one
A Path A · Quick Lane In a hurry · pick one button below, or scroll to Steps 2–4 for detail

Safety check

If either flag is positive, the tool routes to a direct safety assessment regardless of total score.

Pick your role & follow-up

Role drives the wording and what you’re expected to do.

Document - generate the plan & copy/paste note

Click the button. Your result, recommendations, and copy-paste-ready note appear right below.

Your result will appear right here.
Result generated. Review and copy below.

Don’t overcomplicate this

Clinical pearls

Tap any card to flip it for the evidence. Short, quotable, source-linked - use them with patients, in M&Ms, in pre-op clinic, or in your next QI huddle.

85% / 85%
PHQ-9 sensitivity and specificity for major depression (cut-off ≥ 10)
BMJ 2021 · IPD meta-analysis
Tap for evidence →
← Tap to flip back

The PHQ-9 is genuinely accurate

In an individual participant data meta-analysis (n = 17,357), the PHQ-9 at a cut-off ≥ 10 had sensitivity 85% (95% CI 0.79–0.89) and specificity 85% versus semistructured diagnostic interviews. Specificity rose to 89% in screen-eligible populations.

So what: a positive PHQ-9 is a strong signal worth acting on - but it is still a screen, not a diagnosis.

Negeri ZF et al. BMJ. 2021;375:n2183. Individual participant data meta-analysis, n = 17,357.
5–13%
Prevalence of major depressive disorder in adult primary care
USPSTF evidence review
Tap for evidence →
← Tap to flip back

Depression is common - and the clinic finds it

Major depressive disorder prevalence in U.S. primary care is estimated at 5–13% in adults (6–9% in adults > 55). Lifetime prevalence is ~ 13%. One third to one half of treated adults get that treatment in primary care.

So what: universal screening isn’t fishing - it’s reasonable case-finding for a high-prevalence, under-detected condition.

USPSTF - Screening for Depression & Suicide Risk in Adults. USPSTF current recommendation and evidence review.
+ 17–28%
Higher odds of SSI, wound complications, ED visits for pain & readmission with pre-op depression
Distal radius fracture cohort · Hand (NY) 2023
Tap for evidence →
← Tap to flip back

Pre-op depression tracks with worse surgical outcomes

In a large cohort of distal radius fracture surgeries, pre-op depression was associated with higher odds of SSI (OR 1.25, 95% CI 1.14–1.37), wound complications (OR 1.17), hardware complications (OR 1.18), ED visits for post-op pain (OR 1.28), and 30-day readmission (OR 1.21).

So what: recognizing and routing a positive screen isn’t a soft “wellness” task - it touches the surgical outcome you’re being graded on.

Preoperative Depression and Distal Radius Fracture Surgery Complications. Hand (NY). 2023. Large insurance-claims cohort; adjusted odds ratios reported.
3.6×
Higher odds of wound necrosis in smokers vs non-smokers across surgical specialties
Br J Surg / Ann Surg meta-analysis
Tap for evidence →
← Tap to flip back

Smoking hits wound healing hard

Across surgical specialties, smokers had pooled adjusted OR 3.60 (95% CI 2.62–4.93) for wound necrosis, 2.07 for healing delay/dehiscence, 1.79 for surgical site infection, and 2.07 for hernia (Sorensen meta-analysis). At least 4 weeks of pre-op cessation reduces SSI.

So what: behavioral risk factors are perioperative risk factors. Recognize, communicate, route.

HbA1c ≥ 8%
~ 2.4–3× higher odds of 30-day surgical site infection
Non-cardiac surgery · J Periop Pract 2020
Tap for evidence →
← Tap to flip back

Glycemic control matters for the OR

In 3,064 non-cardiac surgical patients, HbA1c 8.0–10.0% had OR 2.4 (95% CI 1.2–4.7) and HbA1c ≥ 10.0% had OR 3.0 (95% CI 1.2–7.3) for 30-day SSI vs HbA1c < 6.5%. Cardiac and arthroplasty literature is similar in direction.

So what: the goal isn’t to become the patient’s endocrinologist - it’s to recognize and route for optimization before elective surgery.

Gabriel RA et al. J Periop Pract / SAGE. 2020. Multivariable logistic regression, 30-day SSI as primary outcome.
Higher odds of persistent opioid use at 3 months post-arthroplasty with even mild depression
Heliyon 2023 · TJA cohort
Tap for evidence →
← Tap to flip back

Mood interacts with post-op pain & opioids

In a total joint arthroplasty cohort (n = 542), patients with even mild depression had ~ 4-fold higher odds of persistent opioid use 3 months after surgery vs non-depressed peers. Depression and anxiety were present in nearly a third of patients.

So what: a positive screen has downstream pain-management and stewardship implications, not just psychiatric ones.

Depression, anxiety, and post-op opioid use after TJA. Heliyon. 2023. Single-center prospective cohort; adjusted analyses.
Higher 1-year IADL decline risk in older adults with high pre-op depressive symptom burden
JAGS 2020 · Major elective surgery
Tap for evidence →
← Tap to flip back

Pre-op mood predicts how older patients function a year later

In older adults undergoing major elective surgery, moderate pre-op depressive symptoms were associated with ~ 3-fold and high-burden symptoms with ~ 9-fold increased risk of 1-year decline in instrumental activities of daily living (IADLs), with an exposure-response gradient and increased risk of post-acute care discharge.

So what: screening + routing isn’t cosmetic - it’s tied to whether grandma walks back into her own kitchen next year.

Preoperative depressive symptoms and post-op functional recovery. J Am Geriatr Soc. 2020. Prospective cohort, adjusted for age, comorbidities, surgery type.
Recognize · Document · Communicate · Route
A specialist doesn’t become the patient’s hypertension doctor because the BP is high in clinic. Same for a positive PHQ.
Scope-aware risk management

What counts for eCQM follow-up

CMS2v15 / MIPS #134 - Screening for Depression and Follow-Up Plan (2026)
  • Screen with an age-appropriate standardized validated tool on the encounter date or within the prior 14 calendar days.
  • Document the name of the screening tool.
  • Use the most recent tool result. Positive or negative status follows the validated tool's instructions; the measure does not require a particular numeric score.
  • If positive, document a follow-up plan on the date of the encounter or up to 2 calendar days after.
  • Patients with bipolar disorder documented before the encounter are excluded.
  • Numerator logic can be met by documented qualifying follow-up or qualifying active depression medication, subject to measure exceptions.
  • Follow-up plan examples that satisfy include:
    • Referral to provider for additional evaluation.
    • Referral to behavioral health / psychiatry.
    • Pharmacologic intervention when appropriate.
    • Psychotherapy / behavioral health evaluation.
    • Other intervention or follow-up for treatment of depression.
  • Additional screening alone does not count as the follow-up plan for a positive screen.
  • A positive screen is not automatically a depression diagnosis - it requires clinical assessment.
  • Make sure the follow-up plan is explicitly tied to the positive depression screen in the note.
Local workflow reminders (Athena / NextGen / other EHR)
  • eCQM follow-up is generally met by placing/documenting a referral to PCP or behavioral health, medication when appropriate, or other qualifying depression follow-up.
  • For specialists not treating depression, referral to PCP or BH is the default.
  • If the clinician is the PCP, PCP evaluation/follow-up itself can be documented as the follow-up plan.
  • Tie the follow-up order or note phrase directly to the positive depression screen.
Scope and risk-management language

Screening does not make the surgeon the treating psychiatrist. The risk-management issue is failing to recognize and route an abnormal result, especially when safety concerns are present. This is clinical workflow guidance, not legal advice - follow local policy and consult compliance/legal leadership for organization-specific rules.

References

Tap a card to see the citations and direct links. Same idea as the pearls - less scrolling, more substance.

CMS / eCQI
CMS2v15 / MIPS #134 · Screening for Depression & Follow-Up Plan (2026)
Measure logic & specifications
Tap for links →
← Tap to flip back

Where the measure logic lives

Use these for measure definition, value sets, encounter timing (14 days prior → 2 days after), and qualifying follow-up plans.

eCQI Resource Center - CMS2v15 (2026)
CMS QPP - MIPS Quality Measures Primary CMS sources; check annually for measure updates.
PHQ-9
Original validation & scoring reference
Kroenke 2001 · phqscreeners.com
Tap for links →
← Tap to flip back

The instrument itself

Original PHQ-9 validation paper plus the canonical PHQ screener site for clean copies of PHQ-2, PHQ-9, and translations.

Kroenke K, Spitzer RL, Williams JBW. J Gen Intern Med. 2001;16(9):606–613.
PHQ Screeners - official site Use the official forms for screening to avoid translation/wording drift.
Joint Commission
Suicide-risk assessment standards & NPSGs
National Patient Safety Goals
Tap for links →
← Tap to flip back

National safety standards

Reference for screening, assessment, mitigation, and discharge expectations when there is suicide risk. Pair with your local policy.

USPSTF
Adult depression & suicide-risk screening recommendation
Why we screen at all
Tap for links →
← Tap to flip back

The recommendation that drove the workflow

USPSTF recommends screening all adults for depression in clinical practices that can support accurate diagnosis, effective treatment, and follow-up. This is the public-health basis for the eCQM.

USPSTF - Screening for Depression and Suicide Risk in Adults Recommendation statement plus evidence review.
C-SSRS
Columbia Protocol · Suicide risk assessment
Public domain · Joint Commission · Primary Care
Tap for links →
← Tap to flip back

The structured assessment behind the tool

The C-SSRS (Columbia Suicide Severity Rating Scale) is the most-cited validated suicide risk assessment, endorsed by the Joint Commission and widely used in primary care, EDs, behavioral health, and surgical clinics. The 6-question Primary Care Screener with Triage Points is what fires inside this tool when the safety lane is triggered.

Columbia Lighthouse - Risk identification & triage
Primary Care Screener with Triage Points (PDF) Use official Columbia forms for any documented administration.
988
Suicide & Crisis Lifeline · 24/7 · free & confidential
Patient-facing safety resource
Tap for links →
← Tap to flip back

What to give the patient at discharge

Call or text 988, or chat at 988lifeline.org. SAMHSA also runs a general behavioral-health line (1-800-662-HELP). Veterans Crisis Line: dial 988, then press 1, or text 838255.

988 Suicide & Crisis Lifeline
SAMHSA National Helpline (1-800-662-HELP)
Veterans Crisis Line Print-and-give resource for after-visit summaries and safety plans.
PREPARED BY RAYMOND BLAIR, MD EST. 2025 IRON PASSAGE HOLDINGS B

Authoritative sources

Educational support only. Verify patient-specific decisions against current source guidance and local policy.