Implementation of a Depression Screening Protocol Using the PHQ-9 Instrument to Screen for Depression and Initiate Billing for a Brief Behavioral Assessment in an Outpatient Behavioral Health Office in Southern New England

Background: Depression has many devastating effects on individuals and families. At the project site, there is no standard operating procedure (SOP) for depression screening, and the office is not reimbursed for these screenings. Method: This quality improvement project aimed to determine whether implementing a standard operating procedure (SOP) would increase the utilization of the Patient Health Questionnaire (PHQ-9) tool and the addition of the Current Procedural Terminology (CPT) code. Piloted over six weeks in an outpatient Behavioral Health Office in Southern New England, it involved implementing the PHQ-9 in all adult visits and a retrospective chart review. The Institute for Healthcare Improvement (IHI) framework was the theoretical foundation. Results: Anonymized electronic medical records indicated a rise in PHQ-9 screenings from 3 visits during a 6-week retrospective period to 173 post-implementation. The documentation for 96127 increased from 0 in the pre-implementation period to 170. Conclusion: Implementing this SOP can enhance depression screening and reimbursement, though a more extended screening period is needed for greater reliability.