Thank you for your inquiry. We are not able to determine why these 5 patients are non-compliant, nor are we able to tell what needs to be done to make these 5 patients compliant with the CMS 2v10 (Preventive Care and Screening: Screening for Depression and Follow-Up Plan) eCQM. We are able to help walk you through the measure logic, specifications, guidance, and intent, whereby you may be able to identify the reason these patients are considered non-compliant. As you can see from the ESAC Standards Team's comments there is more involved in meeting the measure than having PHQ-9 questionnaires in the 2021 encounter note with appropriate interventions when applicable. We agree with the information the ESAC Standards Team provided in the comments and offer a summary of the key requirements of CMS2v10. Based on your question we will assume that all five patients qualify for the initial population and therefore also qualify for the denominator. The numerator description is "Patients 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 tool AND if positive, a follow-up plan is documented on the date of the eligible encounter". The logic that supports this statement is provided in the comments from ESAC. If the depression screening is documented in the EHR as performed more than 14 days prior to the encounter or after the encounter, then the screening will not meet the numerator requirements. As noted by the ESAC Standards Team, the depression screening assessment is identified by a LOINC code in the EHR (73832-8 for adults and 73831-0 for adolescents). The result cannot be null. If the result is null, the case will not meet the numerator requirements. A negative screening is designated in the depression screening assessment field of the EHR by the presence of SNOMED code 428171000124102 from the "Negative Depression Screening" value set (2.16.840.1.113883.3.526.3.1564). Negative screenings, as you allude to in your question and the numerator statement do not require a follow-up plan. A positive screening is designated in the depression screening assessment field of the EHR by the presence of SNOMED code 428181000124104 from the "Positive Depression Screening" value set (2.16.840.1.113883.3.526.3.1565). Positive screenings, as referenced in your question and noted in the numerator statement require a follow-up plan. The follow-up plan must be documented in the EHR on the same day that the qualifying encounter ends. If the follow-up plan is documented before or after the day the encounter ends it will not meet the numerator requirements. The follow-up plan can be met by presence of a code from one of the following age specific value sets. If a code from one of these age specific value sets is not present the case will not meet the numerator requirements. Adults: Adult Depression Medications (2.16.840.1.113883.3.526.3.1566) Referral for Adult Depression (2.16.840.1.113883.3.526.3.1571) Follow Up for Adult Depression (2.16.840.1.113883.3.526.3.1568) Adolescents: Adolescent Depression Medications (2.16.840.1.113883.3.526.3.1567) Referral for Adolescent Depression (2.16.840.1.113883.3.526.3.1570) Follow Up For Adolescent Depression (2.16.840.1.113883.3.526.3.1569) You may review the codes contained within value sets on the Value Set Authority Center (VSAC) website at https://vsac.nlm.nih.gov/ You can find the CMS2 human readable html document (includes narrative descriptions of the measure, the CQL logic, and lists of value sets) at https://ecqi.healthit.gov/sites/default/files/ecqm/measures/CMS2v10.html As noted by the ESAC team, if you need support in identifying how and where this information is being captured in your EHR, we recommend you confer with your EHR vendor. We hope the above information helps you and your team identify the reasons these cases were indicated as non-compliant. Thank you.

For CMS2 Preventative Care and Screening: Screening for Depression and Follow-Up Plan, we have 5 patients who are considered non-compliant despite the fact that they all have PHQ-9 questionnaires in their 2021 encounter note with appropriate interventions when applicable i.e. positive score over 10. Could you please explain what is the cause of this error and what needs to be done to make these 5 patients compliant for CMS2?