Major Depression Audit Form 2009 FINAL

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Blue Cross and Blue Shield of Minnesota R e cog nizing Excellence 2009 Major Depressive Disorder Treatment Response Monitoring Audit Form Pay-for-performance program Last Updated: 08/2009 Blue Cross and Blue Shield of Minnesota is a licensee of the Blue Cross and Blue Shield Association Numerator Tally SMRecognizing Excellence (RE) Medical Record Audit Form MAJOR DEPRESSIVE DISORDER TREATMENT RESPONSE MONITORING Numerator criteria met? 1Yes 1No Date of Review: ___/___/____ Reviewer: __________________________ Clinic Sample ID#: ______________ Clinic System:_______________________ Specialty: Behavioral Health Clinic Site: __________________________ BCBS Member ? 1Yes 1No Clinician ID (optional):________________ Instructions: Audit only those records that meet the verified inclusion criteria referenced in the 2009 Criteria Summary Table: patient age 18 or older, diagnosis of Major Depressive Disorder with no diagnosis or treatment of depression at the clinic system in the previous 6 months. Answer each question with either yes or no. Missing information is considered NO. Retain this audit tool with your Recognizing Excellence records for reference and validation. Verify audit inclusion criteria: A ...

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B l u eC r o s sa n dB l u eS h i e l do fM i n n e s o t aRec o gn i z i n gE x c e l l e n c e2009Major Depressive Disorder Treatment Response MonitoringAuditFormPayforperformanceprogram Last Updated:08/2009 BlueCrossandBlueShieldofMinnesotaisalicenseeoftheBlueCrossandBlueShieldAssociation

Numerator Tally SM Recognizing Excellence(RE) Medical Record Audit Form MAJOR DEPRESSIVE DISORDER TREATMENT RESPONSE MONITORING Numerator criteria met? 1Yes1No Date of Review: ___/___/____Reviewer: __________________________ Clinic Sample ID#: ______________Clinic System:_______________________ Specialty:Behavioral HealthClinic Site: __________________________BCBS Member ?1Yes1NoClinician ID (optional):________________ Instructions: Audit only those records that meet the verified inclusion criteria referenced in the 2009 Criteria Summary Table: patient age 18 or older, diagnosis of Major Depressive Disorder with no diagnosis or treatment of depression at the clinic system in the previous 6 months.Answer each question with either yes or no.Missing information is considered NO. Retain this audit tool with your Recognizing Excellence records for reference and validation.Verify audit inclusion criteria: A. Doesthe patient have a behavioral health diagnostic evaluation documented in the record in 2009? 1Yes 1No If Yes, proceed with next question. IfNo, do not includethis record in the denominator. Pull a new record from the eligible population. B. Isthe patient 18 years or older as of the date of the diagnostic evaluation? (Birth date on or before Dec. 31, 1991) 1Yes 1No If Yes, proceed with next question. IfNo, do not includePull a new record from the eligible population.this record in the denominator. C. Doesthe patient have a confirmed diagnosis of Major Depressive Disorder (296.2x, 296.3x) documented in the diagnostic evaluation? 1Yes 1No If Yes, proceed with the next question. IfNo, do not includethis record in the denominator. Pull a new record from the eligible population. D. Doesthe patient have a diagnosis of depression documented in the clinic system record in the six months prior to the diagnostic evaluation?[Major Depressive Disorder (296.2x, 296.3x), Dysthymic Disorder (300.4) or Depressive Disorder NOS (311)] 1Yes 1No IfYes, donot includethis record in the denominator. Pull a new record from the eligible population. IfNo, include this recordin the denominator and proceed with next question in the assessment section.

Assess optimal Treatment Response Monitoring through the following measures: 1. Isthere documentation on the date of Major Depressive Disorder diagnosis of the results of administration of astandardized depression screening questionnairethat provides categorization of the severity of symptoms? (Examples of standardized tools that categorize the severity of depressive symptoms and have research validation for monitoring purposes are the PHQ9 and the Beck Depression Inventory II.) 1Yes, check the questionnaire used. PRIMEMDPatient Health Questionnaire9 (PHQ9) o BeckDepression Inventory II (BDIII) o OtherList name_________________________________________________________ o 1No If Yes, proceed with next question. IfNo, do not includethis record in the numerator.The record is included in the denominator and the audit of this record is complete. 2. Isthere at least one additional administration and documentation of results of the same standardized depression questionnaire between 30 and 90 days of the initial diagnosis date? 1Yes PHQ9 o BDIII o OtherList name_________________________________________________________ o 1No IfYes, includeThe audit of this record is complete.this record in the numerator. IfNo, do not includeThe record is included in the denominator; the audit of this record isthis record in the numerator. complete.

Recognizing Excellence Numerator Checklist Count in the numerator:If Questions 1 and 2 are Yes, include the record in the numerator for the Major Depressive Disorder Treatment Response Monitoring measure.Check the Yes box in the Numerator Tally on the front of the form. Do not count in the numerator:If either Question 1 or 2 are No, this record cannot be included in the numerator.This record is included in the denominator only.Check the No box in the Numerator Tally on the front of the form.

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