​Hello, Thank you for your inquiry about CMS2v10: Preventive Care and Screening: Screening for Depression and Follow-Up Plan.   The measure guidance states “This eCQM is a patient-based measure. Depression screening is required once per measurement period, not at all encounters,” so, the measure only requires a depression screening once per measurement period, not at all encounters, which follows the national guideline to screen for depression once a year. The measure logic is looking at the most recent depression screening in the measurement year. If one is done, in accordance with national guidelines, the measure will use the date of the screening. If multiple screenings are done, then the measure will use the date of the most recent or last in the measurement year. The measure then looks to see if the screening was performed within 14 days prior to or on the same day as a qualifying encounter. The measure does not require the screening be performed during a qualifying encounter, just within 14 days prior to or on the same day. The measure does not require that the screening be performed during any specific type of encounter. Therefore, the fact that the screenings noted in the question were performed during telehealth encounters is not relevant. The measure looks only at the date of the screening and whether the results or negative or positive and if positive was follow-up provided. It appears the reason these cases did not meet numerator requirements is because there was not a qualifying encounter within 14 days after the screening or on the same day as the screening. In previous versions of this measure the screening had to occur on the same day as the qualifying encounter. This time frame was extended up to 14 days prior based on clinician feedback indicating screenings being performed prior to an encounter is common practice. The time frame for a depression screening is limited to within 14 days prior to a qualifying visit to ensure that the screening result documented is accurate and applicable to the qualifying visit.

Good afternoon, Our project team received the inquiry below from an external partner regarding the following eCQM measure: Preventive Care and Screening: Screening for Depression and Follow-Up Plan (CMS 2v10). To ensure that we have the correct understanding of the measure, we would appreciate any insight your team is able to provide on this inquiry. Inquiry: After reviewing our numerator fall out cases for this metric we discovered that the overwhelming majority of patients who failed numerator compliance had screening done during a telehealth visit. Since telehealth billed CPT codes are not in the value set of qualifying visits, the screening did not count. Then the patient comes in for a true in-person encounter (qualifying) later in the year, and the screening is not redone because national guideline for screening is once yearly. This is an issue because of the logic that the screening has to be done within 14 days of the qualifying encounter. When the national guideline is for once a year screening, the metric should follow the same. What is the rationale for limiting the screening to 14 days prior to qualifying visits? In the example presented, it would seem unfair not to qualify these patients who had a screening done over a telehealth visit during a global pandemic. Thank you! Megan