Facility Guide to Entering the Clinical Depression Assessment in EQRS

Why does CMS want facilities to report the Clinical Depression status of patients in EQRS?

Depression has been identified as the most commonly diagnosed mental illness within the ESRD community. This is due to newly diagnosed patients having to come to terms with living with a chronic disease and the adjustments and shifts made in their daily lives. Depression is linked to a decrease in quality of life, an impairment in social and occupational function, and an increased risk of mortality and morbidity. Because of this, CMS requires all dialysis facilities to report in EQRS that their patients have been screened for depression and confirm that follow-up plans have been developed, if applicable.

What depression scale tool may facilities use?

CMS will not specify a specific screening tool however any specific screening tool not specific to depression (e.g. KDQOL) is not considered a screening tool for the purpose of measuring clinical depression.  Below are some of the screening tools facilities may utilize.

  • Patient Health Questionnaire (PHQ-9, PHQ-2, PHQ-A)

  • Center for Epidemiologic Studies Depression (CES-D 10)

  • Beck Depression Inventory (BDI)

  • Hamilton Depression Rating Scale (HDRS)

  • Geriatric Depression Scale (GDS)

How often are facilities required to submit clinical depression and follow up plan information?

Facilities must submit data for each eligible patient at least once every calendar year. The assessment period is from January 1st to December 31st of each calendar year, and follows the most current CMS - EQRS Clinical Entry schedule. Facilities have two months beyond the end of the reporting month to enter the data in EQRS. 

Example: Patient’s Depression Screening occurred in April 2022. Facilities have until June 30, 2022 to enter April Depression [and Clinical] Data into EQRS.

Which patients are required to be reported on?

Reporting is only required for, 1.) Patients 12 years of age or older, 2.) Patients who have been treated at your facility for 90 days or longer, 3.) Facilities with a minimum of eleven eligible patients during the assessment period, and 4.) Facilities with a CCN open date prior to April 1st of the assessment year selected.

Figure 1. Depression Screening Choices and Definitions

Depression Screening Choices and Definitions

EQRS Choices/Options


Screening for clinical depression is documented as being positive, and follow up plan is documented

Provider has deemed that patient is positive for signs of depression and a documented outline of care has been completed

Screening for clinical depression documented as positive, and a follow-up plan not documented, and the facility possess documentation stating the patient is not eligible

Provider has deem the patient positive for symptoms of depression; but a follow-up plan was not documented because the facility has documented that the patient was ineligible or treatment is medically contraindicated

Screening for clinical depression documented as positive, the facility possesses no documentation of a follow-up plan, and no reason is given

Provider has deemed that the patient is positive for signs for depression

Screening for clinical depression is documented as negative, and a follow-up plan is not required

No further action is required

Screening for clinical depression not documented, but the facility possesses documentation stating the patient is not eligible

Ineligibility includes: 

  • Patient refusal, 

  • An emergent situation where Medical attention is needed immediately, 

  • Patient’s motivation to improve could impact the results, 

  • Patient participated in ongoing treatment in the previous reporting period, 

  • Severe mental and/or physical incapacity

Clinical depression screening not documented, and no reason is given

No further action required

Below are step by step instructions of how to document in EQRS a patient’s depression screening. This tool was meant to aid as a guide for all EQRS leads in dialysis facilities.

Step One: Log into the EQRS system.


Click the dropdown Patients tab and select Clinical Depression.

Step Two: Find Your Facility 

Under Facility Search, enter your Medicare 6-digit CCN# or the facility’s NPI. Once your facility is listed, select it by clicking on it.

Step Three: Choose Your Facility’s Reporting Period.

Select the assessment period you will be reporting for.

2021 entry is CLOSED and will not appear on this list. 

Step Four: Choose the Depression Screening Status.  

Select Submitted to see which patients [and how many patients] have depression screening information already reported in EQRS for the reporting year.

This is confirmed by the submit date under the Last Updated column:

Select Required to see which patients [and how many patients] still need their depression screening to be reported. 

You may also search for a specific patient by entering their name in the Patient Name Search box.

Step Five: Reporting Patient Screening Status.

  • Click Report to select a patient that has already been screened. The image below will appear.  
  • Select from one of the six options (refer to Figure.1 Screening Choices and Definition section of this guide). 
  • Click Submit.  
  • You have successfully documented the clinical depression screening and follow-up in EQRS!