“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Constitution of the World Health Organization
For most, the holidays brings joy and happiness but unfortunately, that is not the case for everyone. Many people are affected by the holidays in a different way. Memories of lost loved ones, diminished health and other issues can cause people to suffer seasonal depression. This condition can magnify and worsen other forms of depression. For many older adults who are already at an increased risk of depression the holidays can be especially difficult.
Despite this being common knowledge, many patients go undiagnosed. Luckily, Medicare has developed tools to help Primary Care Providers identify and treat depression.
Diagnosing depression can be tricky. According to the National Council on Aging, “Depression in elderly people often goes untreated because many people think that depression is a normal part of aging—a natural reaction to chronic illness, loss and social transition.” Also, depression often mimics other illnesses such as:
- Alzheimer’s Disease
- Heart Disease
- Parkinson’s Disease
- Thyroid Disorders
Late-life depression increases risk for medical illness and cognitive decline when it is not recognized or treated. Depression can also have fatal consequences in terms of both suicide and non-suicide mortality.
The NCOA goes on to state that “For seniors, symptoms of depression may manifest themselves in a variety of ways. Memory problems, confusion, social withdrawal, loss of appetite, weight loss, vague complaints of pain, inability to sleep, irritability, delusions (fixed false beliefs) and hallucinations are common symptoms found with depressed individuals. For older adults, symptoms may also include: persistent and vague complaints, help-seeking, moving in a slower manner and/or demanding behaviors.”
Diagnosis may be difficult as patients 65 or older will often tell their providers they are not depressed to avoid negative stereotypes. Many older persons think depression is a character flaw and are worried about being teased or humiliated. They may blame themselves for their illness and are too ashamed to get help. Others worry that treatment would be too costly. Yet research has shown that treatment is effective and, in fact, can manifest itself with physical changes to the brain when it works.
To learn more about the symptoms and effects of depression in seniors, visit the National Association of Mental Illness’s Depression in Older Persons FACT SHEET.
Screening and Treatment under Medicare
There are a variety of ways that Medicare has begun promoting the utilization of depression screening. Not only does Medicare pay for annual depression screenings, but it has also built in a risk analysis for depression as part of patient’s Annual Wellness Visit and Introduction to Medicare visits. Depression screening is also one of the quality indicators used by Medicare and private insurers.
During our pilot project, we included the PQRS 2 as an integral part of the Medicare Annual Wellness Visit. We were able to identify between 25% to 30% of the seniors we screened as experiencing some level of depression. This is consistent with studies that demonstrate a population that is dealing with chronic illness or negative social determinants of health.
Medicare created G-Codes to allow reimbursement for depression screening. The Introduction to Medicare Visit and the Annual Wellness Visit both require a simple depression questionnaire as part of the visit to determine the likelihood of depression.
The AAFP advises the depression screening may not be billed individually during the Introduction to Medicare Visit (IPPE) or the initial Annual Wellness Visit. You may only bill for depression screening during the subsequent Annual Wellness Visits. As stated already, we recommend the PQRS 2. In our experience, it is not appropriated for further depression screening to take place the day of the AWV/IPPE. We therefore recommend the patient be asked to return to the clinic for further testing if indicated.
Medicare will not pay FQHC/RHCs for multiple visits on the same day. For this reason the follow-up depression screening should always be done as a stand-alone visit. We recommend that your wellness nurses, who developed a relationship with the patient during the AWV, schedule identified patients for a more thorough screening such as the GDS-30 which can be billed as an individual visit.
Ideally, if the patient score shows depression, they should be introduced to a counselor that day. Your wellness nurse can act as a liaison between the patient and behavioral services. If this handoff is done correctly, we believe more patients needing counseling will actually use your behavioral services.
Medicare and private payors alike have developed a variety of quality improvement measures. MACRA through MIPS/APMs all require these measures be met or the practices face a penalty. In some cases the Medicare AWV/IPPE will meet these requirements but not in all cases. We recommend your practice develop a depression screening process that includes the AWV as well as further depression screening as a way to ensure your measures are met. For your convenience, we have included the sample Quality Measures Chart to show which measures are met by your screening process.
|1. Depression Screening and Follow-up (All, DM)||X||X||X||X||X||X|
|2. Adult Depression Medication Continuation||2016||X|
With the serious issues related to depression in the senior population, we highly recommend your practice develop a depression screening and treatment protocol. Medicare’s initial preventive service programs such as the IPPE and AWV are both appropriate places to assess patients for the risk of depression. Further screening may be a stand alone visit (especially in FQHC/RHCs) or followed up on immediately after subsequent Annual Wellness Visits. Regardless of how you build your depression screening program, ultimately, it is imperative that you have a treatment protocol in place. Patients who are experiencing depression need a way to manage the illness either with your help or the help of mental health professionals.