CMS 2 Depression Screening- Refusal of treatment

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    • Type: EC eCQMs - Eligible Clinicians
    • Resolution: Answered
    • Priority: Moderate
    • Component/s: None
    • None
    • 812-450-5138
    • Deaconess Health System- Deaconess Clinic
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      Inquiry Correction – January 8, 2026
       
      We are issuing a correction to the previously posted solution to reflect the denominator exception should this ticket be used for future reference. Thank you for your inquiry regarding CMS2v11: Preventive Care and Screening: Screening for Depression and Follow-Up Plan. Per the measure specification, only patients who have been diagnosed with depression or bipolar disorder are captured as denominator exclusions.
       
      Patient refusal to participate in screening is captured as a denominator exception. Codes that may be used to document patient refusal are included in the "Patient Declined" (OID: 2.16.840.1.113883.3.526.3.1582) value set. The denominator exception does not apply to patients who refuse to participate in the follow-up plan if the screening was positive. The criteria for follow-up is met if the provider documents a follow-up using one of the values included in the “Follow-Up for Adult Depression” (OID: 2.16.840.1.113883.3.526.3.1568) or “Follow-Up for Adolescent Depression” (OID: 2.16.840.1.113883.3.526.3.1569) value set.
       
      Value sets can be reviewed in the Value Set Authority Center (VSAC) at https://vsac.nlm.nih.gov/.
      Show
      Inquiry Correction – January 8, 2026   We are issuing a correction to the previously posted solution to reflect the denominator exception should this ticket be used for future reference. Thank you for your inquiry regarding CMS2v11: Preventive Care and Screening: Screening for Depression and Follow-Up Plan. Per the measure specification, only patients who have been diagnosed with depression or bipolar disorder are captured as denominator exclusions.   Patient refusal to participate in screening is captured as a denominator exception. Codes that may be used to document patient refusal are included in the "Patient Declined" (OID: 2.16.840.1.113883.3.526.3.1582) value set. The denominator exception does not apply to patients who refuse to participate in the follow-up plan if the screening was positive. The criteria for follow-up is met if the provider documents a follow-up using one of the values included in the “Follow-Up for Adult Depression” (OID: 2.16.840.1.113883.3.526.3.1568) or “Follow-Up for Adolescent Depression” (OID: 2.16.840.1.113883.3.526.3.1569) value set.   Value sets can be reviewed in the Value Set Authority Center (VSAC) at https://vsac.nlm.nih.gov/ .
    • CMS0002v15
    • CMS0002v14
    • CMS0002v13
    • CMS0002v11

      I am inquiring on whether or not patient refusal is allowed for depression follow up plan for CMS 2. For instance, a patient has a positive depression screening and the provider suggests treatment whether a referral for mental health or a medication and the patient refuses the treatment.  Is the refusal of treatment an exclusion for this measure or is the patient refusal exception only applicable if the patient is refusing the screening itself? 

      I believe there are established SNOMED codes that could be used in these instances if the refusal of treatment is found to be an appropriate exclusion. 

      For treatment refusal to be included in Denominator Exceptions

      Current Exceptions:
      Patient Reason(s)
      Patient refuses to participate OR
      Medical Reason(s)

      Documentation of medical reason for not screening patient for depression (e.g., cognitive, functional, or motivational limitations that may impact accuracy of results; patient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient's health status)

            Assignee:
            AIR EC eCQM Team
            Reporter:
            Amy Scales (Inactive)
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              Created:
              Updated:
              Resolved:
              Solution Posted On: