Major Depression Medication
Adherence Tool Kit
Major Depression Medication Adherence Tool Kit
One of the keys to successfully managing major depression is medication adherence. VSHP has developed a new tool kit to give you additional insight into your patient population diagnosed with major depression.
Providers may use code V79.0 - Screening for depression as part of a regular office visit. Based on the time used for depression screening, the visit may need to be coded for a longer period of time which would increase the reimbursement rate.
Not everyone will be majorly depressed. Use DSM IV guidelines for alternatives to coding. There may be one principal diagnosis of major depression or two secondary diagnoses.
If you feel you have a member who may benefit from behavioral health services, you may call
VSHP Referral Assistance at 1-800-367-3403, Monday through Friday, 8 a.m. to 5 p.m. ET. Telephone consultation services are provided by Peer Advisors who are Board Certified
Psychiatrists and available to discuss all aspects of mental health and substance abuse treatment including medications. Call 1-877-241-5575, Monday through Friday, 9 a.m. to 5 p.m. ET. Identify yourself as a TennCare primary care provider seeking psychiatric consultation services.
On page 4 of this toolkit is a depression screening tool you may use during your patient office visits. Please let VSHP know if you have any questions or recommendations on how we can partner with you to enhance the care to VSHP members.
VSHP Pharmacy Benefits for AGE 21 Years and Older
• 5 prescriptions each month – only 2 brand name drugs• $3 copay for each brand name drug
• No copay for generic drugs, birth control, and medications given in hospice care, for a medical emergency, or pregnancy problems
• Attached is a memo about script limits from the Bureau of TennCare
For a current list of the drugs and supplies that do not count toward a TennCare enrollee’s monthly drug limit, go to https://tnm.providerportal.sxc.com/rxclaim/TNM/PREQS.htm. Preferred Anti-Depressants • All Classes • citalopram • fluoxetine • fluvoxamine • paroxetine • sertraline • Effexor XR® ST, QL • venlafaxine ST, QL • budeprion SR • budeprion XL QL • bupropion IR/SR • bupropion XL QL • maprotiline
• mirtazapine, mirtazapine rapdis • trazodone • amitriptyline • clomipramine • desipramine • doxepin • imipramine HCl • nortriptyline • Nardil® • Azilect® • selegiline • Zelapar™ 1
Clinical Criteria, Step Therapy and Quantity Limits for TennCare PDL
Central Nervous SystemMedication Class Medication PDL Step Therapy or Clinical Criteria Qty. Limits PA Form
Antidepressants:
SNRIs Effexor XR® P Will only be authorized if recipient has tried and failed a therapeutic course of an SSRI at an appropriate dose (Defined as: 3 weeks at the maximum tolerated dose within the recommended therapeutic range). 37.5, 75mg (1/ day); 150mg (2/day) Special Note: for 225mg dose: must use 150mg and 75mg tabs; for 375mg dose: must use 2-150mg tabs plus 75mg tab
SNRI PA Form
venlafaxine P See Effexor XR® Step Therapy 2/day Cymbalta® NP Cymbalta will be authorized for the
following diagnoses:
Depression/Major Depressive Disorder/Generalized Anxiety Disorder:
Approval after trial and failure of one SSRI AND one preferred SNRI Diabetic peripheral neuropathic pain: Approved without trial and failure of an SSRI or any preferred agents within the SNRI class. Fibromyalgia:
Approval will be granted after trial and failure, contraindication, or intolerance to:
A tricyclic antidepressant or muscle relaxant, AND
At least ONE of the following: an SSRI, preferred SNRI, pregabalin, or gabapentin
2/day
Effexor® NP See Effexor XR® Step Therapy 2/day Pristiq® NP See Effexor XR® Step Therapy 1/day Savella™ NP Will only be authorized for a
diagnosis of fibromyalgia (see Cymbalta Clinical Criteria for fibromyalgia).
2/day
Clinical Criteria, Step Therapy and Quantity Limits for TennCare PDL
Central Nervous SystemMedication Class Medication PDL Step Therapy or Clinical Criteria Qty. Limits PA Form
Antidepressants:
SSRI (continued) citalopram P 1.5/day GeneralPA Form fluoxetine P 3/day fluvoxamine P 3/day paroxetine P 10, 20mg (1/day); 30, 40mg (2/ day) sertraline P 25mg, 50mg (1.5/day); 100mg (2/ day) Celexa® NP 1.5/day fluoxetine
weekly NP May be approved if recipient has been stabilized at a dose of 20mg/ day of fluoxetine for > one month, with valid reason why recipient is unable to continue on fluoxetine 20mg daily.
4/month
Lexapro® NP 1.5/day Luvox® NP 3/day
Luvox CR® NP 100mg (3/day); 150mg (2/day) paroxetine CR NP 12.5, 25mg (1/day); 37.5mg (2/day) Paxil® NP See paroxetine
Paxil CR® NP See paroxetine CR
Pexeva® NP 10, 20mg (1/day); 30, 40mg (2/ day)
Prozac® NP 3/day Prozac
Weekly® NP See Clinical Criteria for fluoxetine weekly 4/month Sarafem® NP 3/day
Zoloft® NP See sertraline
Antidepressants:
New Generation budeprion XL P 1/day General PA Form buproprion XL P 1/day
Oleptro™ NP 150mg (1.5/day); 300mg (1/day) Wellbutrin XL® NP 1/day
The prevalence of depression within the United States (U.S.) adult population is 6.7 percent (Kessler, Chiu, Demier, & Walters, 2005). Although often undetected, about 20 percent of primary care patients suffer from significant symptoms of depression requiring further assessment and patient education (RAND Health Partners in Care). Depression is often difficult to identify and treat within the primary care setting as the
patient usually masks depressive symptomology with physical ailments; often, the patient is unaware that he/ she is depressed and/or in need of treatment (Kass-Bartelmes, 2004).
Depression screening within the primary care setting is an evidence-based practice with data supporting a positive effect on patient outcomes (Pignone, 2002). Utilization of a formal, yet simple depression screening tool provides the primary care physician the opportunity to identify this often debilitating yet, very treatable condition (AHRQ, 2002).
The “Whooely Depression Screen,” a simple two-question tool, is an easy and reliable way to identify a depressed patient within the primary care arena. Furthermore, when compared to longer traditional standardized tools, the Whooley produces similar test results with less administration time (Whooley, Avins, Miranda, & Browner, 1997).
Whooley Screening Questions
1. During the past month, have you often been bothered by feeling down, depressed, or hopeless? 2. During the past months, have you been bothered by little interest or pleasure in doing things?
If the patient answers Yes to one or both of these questions, further screening with a more detailed tool is recommended. Examples of additional standardized tools have been provided and can be located on the Internet.
Patient Health Questionnaire (PHQ-9)
Public Domain Item 9, practitioner-administered screening tool used in the diagnosing, monitoring and measuring depression severity (Kroenke & Williams, 2001). The PHQ-9 has good diagnostic properties within the primary care setting (Gilbody, et al., 2007).
Beck Depression Inventory (BDI)
The Psychological Corporation Item 21, self-administered, valid and reliable tool used for the diagnosis and rating of depression (Mullen, et al., 2004).
Hamilton Rating Scale for Depression (HAM-D)
Public Domain Items 17 to 31, (depending on the version used) practitioner-administered rating scale. The HAM-D is the most widely used tool for the clinical assessment of depressive states (Mullen, et al., 2004).
Montgomery-Asberg Depression Rating Scale
(MADRS) Public Domain
Item 10, practitioner-administered, reliable Instrument used for the evaluation and assessment of depressive symptoms in adults; also helpful in monitoring changes in depression level (Mullen, et al., 2004).
Zung Self-Rating Depression Scale
American Medical Association Although short, simple and quantitative, this tool fails to capture atypical depressive symptomology (increased appetite, hypersomnia). Note: Patients in distress may score high but are not clinically depressed (Gilbody, et al., 2007).
You may also call for VSHP Referral Assistance at 1-800-367-3403, Monday through Friday, 8 a.m. to 5 p.m., ET. Medical records for members with behavioral health diagnosis should reflect efforts that support coordination of medical and behavioral health care. Records may include written correspondence to and/or from behavioral health providers, or inquiries regarding such services, and referrals if appropriate, and follow up with patients to ensure they are taking their medication as directed.
Antidepressant Medication Management
HEDIS Measure Definitions
Antidepressant
Medication Management – Acute Phase
The measure looks at the percentage of members 18 years of age and older who were diagnosed with a new episode of major depression, treated with antidepressant medication and remained on an antidepressant medication treatment.
Acute Phase: Effective acute phase is the percentage of newly diagnosed and treated members who remained on an antidepressant medication for at least 84 days (12 weeks).
Antidepressant Medication Management – Continuation Phase
Effective continuation phase treatment is considered to last at least 180 days (6 months). Members should be taking their prescribed medication and following their treatment plan. Medical records for members with behavioral health diagnosis should reflect efforts that support coordination of medical and behavioral health care. Records may include written correspondence to and/or from behavioral health providers, or inquiries regarding such services, and referrals if appropriate, and follow up with patients to ensure they are taking their medication as directed.
Codes to Identify Major Depression
Description
ICD-9-CM
Major depression 296.20-296.25, 296.30-296.35, 298.0, 300.4, 309.1, 311
Codes to Identify Visit Type
Description
CPT
HCPCS
UB
Revenue
ED 99281-99285 045x, 0981
Outpatient, intensive outpatient and partial hospitalization 90804-90815, 98960-98962, 99078, 99201-99205, 99211-99215, 99217-99220, 99241-99245, 99341-99345, 99347-99350, 99384-99387, 99394-99397, 99401-99404, 99411, 99412, 99510 G0155, G0176, G0177, G0409-G0411, H0002, H0004, H0031, H0034-H0037, H0039, H0040, H2000, H2001, H2010-H2020, M0064, S0201, S9480, S9484, S9485 0510, 0513, 0515-0517, 0519-0523, 0526-0529, 0900, 0901, 0902-0905, 0907, 0911-0917, 0919, 0982, 0983
CPT
POS
90801, 90802, 90816-90819, 90821-90824, 90826-90829, 90845, 90847, 90849, 90853, 90857, 90862, 90870, 90875, 90876, 99221-99223, 99231-99233, 99238, 99239, 99251-99255WITH
03, 05, 07, 09, 11, 12, 13, 14, 15, 20, 22, 24, 33, 49, 50, 52, 53, 71, 72 5BlueCross BlueShield of Tennessee
1 Cameron Hill Circle | Chattanooga, TN 37402 vshptn.com
References
Agency for Healthcare Research and Quality (AHRQ). (2002). U.S. Preventive services task force now finds sufficient evidence to recommends screening adults for depression. Accessed July 19, 2011 from www.ahrq.gov/news/press/ pr2002/deprespr.htm
Gilbody S., Richards D., Brealey S., & Hewitt C. (2007). Screening for depression in medical setting with the patient Health Questionnaire (PHQ): A diagnostic meta-analysis. Journal of Internal Medicine; 22(11), 1596-602.
Kass-Bartelmes B. L. (2004). Programs and tools to improve the quality of mental health services. Accessed July 19, 2011 from www.ahrq.gov/qual/menttoolria/menttoolria.htm
Kessler R.C., Chiu W.T., Demler O., Walters E.E. (2005). Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry; 62(6), 617-27. Kroenke K., & Williams W. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of Internal Medicine; 16, 606-616.
Mullen J., Endicott J., Hirschfeld R.M., Yonkers K., Targum S.D., Bullinger A.L. (2004). Manual of rating scales for the assessment of mood disorders. AstraZeneca Pharmaceuticals LP; Wilimington Delaware.
Pignone M.P., Gaynes B.N., Rushton J.L., Burchell C.M., Orleans C.T., Mulrow C.D., Lohr K. (2002) Screening for depression in adults: A summary of the evidence for the U.S. preventive services task force. Annals of Internal Medicine; 136:756-776. RAND Health Partners in Care. Hope for those who struggle with hope, Research Highlights. Accessed July 19, 2011 from http://www.rand.org/pubs/research_briefs/RB4528/index1.html.
Whooley M. A., Avins A., Miranda J., Browner W.S. (1997). Case-finding instruments for depression. Journal of General Internal Medicine; 12, 439-445.