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  1. eCQM Issue Tracker
  2. CQM-5743

CMS2v11 Numerator Qualifiers and Denominator Exceptions

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    • Icon: EC eCQMs EC eCQMs
    • Resolution: Answered
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    • Tara Altman
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      ​​Thank you for your inquiry regarding CMS2v11: Preventive Care and Screening: Screening for Depression and Follow-Up Plan. Per the measure specifications, the measure assesses the most recent depression screening completed either during the eligible encounter or within the 14 days prior to that encounter. To meet the numerator criteria, if a depression screening is positive, a follow-up plan must be documented on the date of the eligible encounter. Therefore, the patient in scenario 1 does not meet the numerator criteria, as there is no follow-up plan documented on the date of the eligible encounter following the most recent positive depression screening. In scenario 2, if the patient refuses to complete the screening or has a documented medical reason for not completing the depression screening, the patient meets the denominator exception criteria.

      To meet denominator exception criteria, there must be documentation that the patient declined to participate as per the "Patient Declined" valueset (OID: 2.16.840.1.113883.3.526.3.1582) or a medical reason for not completing the depression screening per the "Medical Reason" value set (2.16.840.1.113883.3.526.3.1007).
      Show
      ​​Thank you for your inquiry regarding CMS2v11: Preventive Care and Screening: Screening for Depression and Follow-Up Plan. Per the measure specifications, the measure assesses the most recent depression screening completed either during the eligible encounter or within the 14 days prior to that encounter. To meet the numerator criteria, if a depression screening is positive, a follow-up plan must be documented on the date of the eligible encounter. Therefore, the patient in scenario 1 does not meet the numerator criteria, as there is no follow-up plan documented on the date of the eligible encounter following the most recent positive depression screening. In scenario 2, if the patient refuses to complete the screening or has a documented medical reason for not completing the depression screening, the patient meets the denominator exception criteria. To meet denominator exception criteria, there must be documentation that the patient declined to participate as per the "Patient Declined" valueset (OID: 2.16.840.1.113883.3.526.3.1582) or a medical reason for not completing the depression screening per the "Medical Reason" value set (2.16.840.1.113883.3.526.3.1007).
    • CMS0002v11
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      Good evening,

      Our project team received the inquiry below from an external partner regarding the following measure: Preventative Care and Screening: Screening for Depression and Follow-Up (CMS2v11). We would appreciate any insight your team is able to provide on this inquiry.
      Show
      Good evening, Our project team received the inquiry below from an external partner regarding the following measure: Preventative Care and Screening: Screening for Depression and Follow-Up (CMS2v11). We would appreciate any insight your team is able to provide on this inquiry.

      A patient has two qualifying encounters in the measurement period. Within 14 days of both encounters, this patient screens positive for depression. The first qualifying encounter occurs in February of 2022 and a follow up plan is noted and ordered. The second qualifying encounter occurs in August of 2022, and the patient again has a depression screen and no intervention is charted.

      Question 1: Is this patient a Numerator?

      The most recent screen is positive for depression. And, a follow up intervention for a positive depression screen is completed. Specifications are met even though the follow up plan did not occur after the last positive screen. The results of the last depression screen are the same as the previous screen which did result in a follow up plan.

      Question 2: If the depression screen just prior to the second encounter in August of 2022 was incomplete, or the patient refused screening, is this patient a Denominator Exception? If not, is this patient a Numerator due to the prior positive depression screen and follow up plan at the first encounter in February of 2022?

      If you could clarify, that would be most appreciated. Thank you.

            edave Mathematica EC eCQM Team
            taltman Tara Altman
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