Thank you for your question about CMS2 "Preventive Care and Screening: Screening for Depression." The intent of the measure as written in the description is to measure the percentage of patients aged 12 years and older screened for depression on the date of the encounter or up to 14 days prior to the date of the encounter using an age-appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the eligible encounter. The guidance and the measure numerator describe the timing of the screening in the same manner. In the numerator, the specification explains the qualifying action as follows: Patients screened for depression on the date of the encounter or up to14 days prior to the date of the encounter using an age-appropriate standardized tool AND if positive, a follow up plan is documented on the date of the eligible encounter. Therefore, in order to meet the measure, the screening must take place on the date of or up to 14 days prior to the encounter. As you note, separately from the measure description and numerator, the guidance also states that "Depression screening is required once per measurement period, not at all encounters." This statement provides context for the preceding sentence "This e-CQM is a patient-based measure." This information is intended to differentiate the measure from an episode-based measure that requires a clinician provide the quality action during every encounter. In the example provided with your inquiry, the timing of the screening does not meet the numerator and so it would not be applicable to encounters that took place greater than 14 days after the screening. Please note the denominator of this measure is the same as the initial population, which is defined as "All patients aged 12 years and older at the beginning of the measurement period with at least one eligible encounter during the measurement period." The patient in your example is only counted in the denominator of the measure if they have an eligible encounter during the measurement period. To meet the numerator, this patient would have to be screened during an encounter or up to 14 days prior to an encounter.

The measure guidance states "Depression screening is required once per measure period, not at all encounters." However, it also states that "A depression screen is completed on the date of the encounter or up to 14 days prior to the date of the encounter". How, should this scenario be handled: Patient w/out dx of depression/bipolar had only 1 depression screen during MY 01/08/2020 and screened negative. So far so good, screened patient during MY as as is the intent of the measure. However, patients denominator qualifying encounters were all more than 14 days after the date of the depression screen on 01/08/2020. The patient screened negative, no follow up is required, and per the measure specs, no additional screenings are required. Does this patient meet the numerator due to screened at least once (screening negative) during MY? Considering that a negative depression screen does not require a follow up, should the difference between the date of the screen and the date of any qualifying encounter be relevant? If the patient in this scenario fails the numerator then, by design, the measure IS requiring a depression screening at each encounter despite stating that is not the intent. Please advice.