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  2. CQM-4857

Requirement for new follow-up action for every depression screen is inconsistent with clinical practice in certain circumstances

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    • Icon: EC eCQMs EC eCQMs
    • Resolution: Answered
    • Icon: Moderate Moderate
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    • 2023600299
    • MedStar Health
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      Thank you for your inquiry about CMS2v10: Preventive Care and Screening: Screening for Depression and Follow-Up Plan. We appreciate your feedback about the measure calculation. As a patient-based measure, a depression screening is required once per measurement period, not at all encounters. The measure evaluates whether the patient had a depression screening completed within a specified timeframe in relation to a qualifying encounter and if any applicable follow up was completed in order to meet the numerator. Specifically, the measure assesses the most recent depression screening completed within the specified timeframe. A diagnosis of depression (or bipolar disorder) before the qualifying encounter results in a denominator exclusion, and the Depression diagnosis value set (2.16.840.1.113883.3.600.145) contains codes that correspond to mild or minor depression. Implementors are encouraged to use their best clinical judgement and use the codes if deemed clinically appropriate. For more details on the codes contained in the value sets, please visit the Value Set Authority Center (https://vsac.nlm.nih.gov/). However, if a patient is not documented as having depression (or bipolar disorder) using the codes in the applicable diagnosis value sets, follow-up is required if the most recent patient screen for depression is positive during the measurement year. Review codes in the Follow Up for Adolescent Depression (2.16.840.1.113883.3.526.3.1569) and Follow Up for Adult Depression (2.16.840.1.113883.3.526.3.1568) value sets if continued treatment is determined to be the recommended follow-up plan.
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      Thank you for your inquiry about CMS2v10: Preventive Care and Screening: Screening for Depression and Follow-Up Plan. We appreciate your feedback about the measure calculation. As a patient-based measure, a depression screening is required once per measurement period, not at all encounters. The measure evaluates whether the patient had a depression screening completed within a specified timeframe in relation to a qualifying encounter and if any applicable follow up was completed in order to meet the numerator. Specifically, the measure assesses the most recent depression screening completed within the specified timeframe. A diagnosis of depression (or bipolar disorder) before the qualifying encounter results in a denominator exclusion, and the Depression diagnosis value set (2.16.840.1.113883.3.600.145) contains codes that correspond to mild or minor depression. Implementors are encouraged to use their best clinical judgement and use the codes if deemed clinically appropriate. For more details on the codes contained in the value sets, please visit the Value Set Authority Center ( https://vsac.nlm.nih.gov/ ). However, if a patient is not documented as having depression (or bipolar disorder) using the codes in the applicable diagnosis value sets, follow-up is required if the most recent patient screen for depression is positive during the measurement year. Review codes in the Follow Up for Adolescent Depression (2.16.840.1.113883.3.526.3.1569) and Follow Up for Adult Depression (2.16.840.1.113883.3.526.3.1568) value sets if continued treatment is determined to be the recommended follow-up plan.
    • CMS0002v11
    • This requirement penalizes clinicians and practices for doing more than one depression screen during a CY, when the result is positive for mild depression.

      CMS2v10 states that patients 12+ without major depression or bipolar disorder should be screened annually for depression, and if the screening is positive - an appropriate follow-up must be done and documented during the visit (counseling, treatment, referral). We have built reminders within our EHR such that medical assistants make this a routine part of part rooming. We then alert clinicians when the screening is positive that they must review the results and do and document an appropriate follow-up. CMS2v11 has the same requirements.

      These workflows and follow-ups make clinical sense, and are appropriately scored by the measure.
      1. Patients are screened once or multiple times and the results are negative.
      2. Patients are screened once or multiple times, and the results show major depression and an appropriate follow-up is done and documented. This works for multiple screens (let's say PHQ9's because once a diagnosis of major depression is documented, the patient would meet the exclusion criteria.

      Here's where routine workflow results in a problem..
      The patient is screened for depression and comes back with results suggesting minor depression, dysthymia, or mixed anxiety / depression - and an appropriate follow-up is done and documented (such as a referral to psychiatry). The patient has another depression screen during the calendar year, intentionally as follow-up to the first, or unintentionally (the medical assistant doesn't follow the reminders to do depression screening, and just does it. The repeat depression screen comes back again as positive for minor depression. The patient is already in treatment - no new referral or counseling is necessary or appropriate. However, because of how the measure is constructed - this later in the CY depression screen without a new documentation of treatment, counseling, or referral results in a measure fail.

            edave Mathematica EC eCQM Team
            pbasch1 Peter Basch
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