URSA-MSSP-CQM-DEP-PR: Depression and Follow-Up (Q134 CQM PR)

  • Published on Feb 4, 2026
  • 2 minute(s) read
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Measure Description

Among patients aged 12 years and older with a prior qualifying visit in the last 12 months, the percentage that had a standardized depression screen and if positive, a documented follow-up plan in the last 12 months.

Metadata

  • Measure Identifier: URSA-MSSP-CQM-DEP-PR
  • Measure Type: Rate Measure
  • Temporal Structure: Entity
  • Component Class: Normal-Form
  • Denominator Case Field: Patient ID
  • Target Direction: Down

Denominator Description

Patients aged 12+ with a prior qualifying visit in the last 12 months and data completeness.

Numerator Description

Patients with qualifying documentation in the last 12 months of an age-appropriate standardized depression screening tool AND if positive, a documented follow-up plan.

Published Fields

  • Data Model Keys

    • Patient ID
    • Primary Payor ID
    • Primary Plan ID
    • Primary Plan Attributee Provider ID
    • Primary Plan Attributee Provider Contract ID

  • Metadata Fields

    • Measure ID
    • Measure Name
    • Table Last Updated Datetime

  • Operations Support Fields

    • Affiliated Program Entity ID
    • Affiliated Program Entity Provider ID
    • Program Entity Operational ID
    • Program Operational ID
    • Is Patient Affiliated to a Program Entity

  • Date Fields

    • Snapshot Date -- The date, evaluated at 00:00:00 AM, giving the moment the state of the world will be set to for the purposes of an analysis. The snapshot date does not represent the freshness of the data, or the date in real time at which an analysis was executed.
    • Segment Start Date -- The start date of the reporting segment. (See also [URSA-CORE] Reporting Segment)
    • Segment End Date -- The end date of the reporting segment. (See also [URSA-CORE] Reporting Segment)
    • Current Continuous Primary Payor Membership Episode Start Date
    • Current Continuous Primary Payor Membership Episode End Date

  • Patient Fields

    • Patient Age at Beginning of Performance Period
    • Patient Date of Birth
    • Patient State Abbreviation
    • Patient ZIP Code 5-Digit
    • Is Patient Sex Female
    • Is Patient Sex Male
    • Patient Operational ID
    • Member MBI

  • Insurance Fields

    • Primary Payor Description
    • Primary Plan Description
    • Primary Plan Financial Class Description

  • Provider Fields

    • Primary Plan Attributee Provider Description
    • Affiliated Program Entity Provider NPI
    • Affiliated Program Entity Provider Description

  • Denominator Fields

    • Is Denominator Event Criterion Met
    • Qualifying Denominator Encounter Date
    • Qualifying Denominator Encounter Provider ID
    • Qualifying Denominator Encounter Provider Description
    • Is Data Completeness Continuous Membership Criterion Met
    • Is Any Required Exclusion
    • Is Required Exclusion for Bipolar Disorder
    • Is Required Exception for Registry Only Exception
    • Is Eligible Population
    • Required Exclusions Description
    • Denominator Excluded Reasons Description

  • Numerator Fields

    • Numerator Component Contribution
    • Numerator PHQ Assessment Type
    • Numerator PHQ Assessment Score
    • Numerator EMR Encounter ID
    • Numerator Observation-Generating Service Date
    • Numerator Encounter Date
    • Numerator Follow Up Category
    • Numerator Follow Up Document Effective Date
    • Numerator Follow Up Document ID
    • Is Numerator Qualifying Using Standard End-of-Year Timing
    • Numerator Component Contribution Using Standard End-of-Year Timing
    • Numerator Category Description
    • Numerator HCPCS
    • Numerator HCPCS Description

  • Measure Fields

    • Denominator