December 1, 2025
Boost care quality, streamline data exchange and maximize HEDIS® scores with better documentation.
Depression is a leading cause of disability, affecting both mental and physical health. Depression screening is a vital part of patient care – and a required element of NCQA’s1 HEDIS2 measures. However, without complete and accurate documentation, screenings may not count toward compliance, potentially lowering your quality scores.
Document what matters: Tool + Score
To meet NCQA guidelines and HEDIS requirements, your documentation must include:
- Name of the screening tool
- Use a validated tool such as PHQ-2, PHQ-9 or another NCQA-approved tool.
- Clearly record the tool’s name in the patient’s chart.
- Total screening score
- Document the total numerical score from the screening tool.
- Use the score to assess severity and guide clinical decisions.
Positive screens: Record action within 30 days
If the screening is positive, document the follow-up action taken within 30 days. Acceptable interventions include:
- Behavioral health visits (in-person, telehealth, or virtual check-ins).
- Case management encounters.
- Antidepressant prescription(s).
- A full-length screening confirming no need for follow-up.
Support key HEDIS measures
Proper documentation supports multiple HEDIS measures focused on timely, effective care:
- DSF-E: Depression Screening and Follow-Up
- DMS-E: Use of PHQ-9 to Monitor Symptoms
- DRR-E: Depression Remission or Response
- PND-E: Prenatal Depression Screening and Follow-Up
- PDS-E: Postpartum Depression Screening and Follow-Up
Enable interoperability: Map to LOINC
As healthcare systems advance toward electronic data exchange, mapping screening results to LOINC3 is essential for interoperability and quality reporting.
What is LOINC?
LOINC is a universal standard for identifying health measurements and observations across systems.
How to use LOINC effectively
- Map the depression screening score to the correct LOINC code.
- Link the score to the code in your electronic health records (EHR) or data exchange format (e.g., Consolidated Clinical Document Architecture, Fast Healthcare Interoperability Resources, flat files). The score can be added under ‘mental status.’
Common LOINC codes
- PHQ-9: 44261-6
- PHQ-9 (teens): 89204-2
- PHQ-2: 55758-7
Why it matters
- Ensures accurate data sharing across EHRs, payers and registries.
- NCQA Electronic Clinical Data Systems HEDIS Measure reporting requirement.
- Enables automated reporting to the health plan to process the measure.
- Improves clinical decision support, care coordination and population health.
- Reduces manual data abstraction and streamlines data workflows.
- Strengthens compliance and boosts quality scores – impacting performance incentives.
Best practices for success
- Use the correct LOINC for each screening tool.
- Capture scores as discrete values linked to the LOINC code.
- Ensure data formats include both the code and score – value needs to link to the object identifier.
- Train staff in documentation standards.
- Regularly validate workflows for consistency and accuracy.
Final reminder
Consistent documentation of the tool name, score and follow-up action is more than a compliance requirement – it’s a foundation for delivering high-quality, patient-centered care.
Need help? Contact us
If you have questions regarding the information contained in this update, contact 866 999 3945.
1NCQA = National Committee for Quality Assurance
2HEDIS = Healthcare Effectiveness Data and Information Set
3LOINC = Logical Observation Identifiers Names and Codes
This information applies to Physicians, Independent Practice Associations (IPAs), Hospitals, Ancillary Providers, and Behavioral Health Providers.
