​​Thank you for your inquiry regarding CMS2v12: Preventive Care and Screening: Screening for Depression and Follow-Up Plan. The Denominator Exception language "patient refuses to participate" is intended to reflect patient refusal to participate in or complete the depression screening as reflected in the measure logic definition: "Medical or Patient Reason for Not Screening Adolescent for Depression" or "Medical or Patient Reason for Not Screening Adult for Depression" ["Assessment, Not Performed": "Adolescent depression screening assessment"] NoAdolescentScreen   with "Qualifying Encounter During Measurement Period" QualifyingEncounter     such that NoAdolescentScreen.authorDatetime during QualifyingEncounter.relevantPeriod   where ( NoAdolescentScreen.negationRationale in "Patient Declined"       or NoAdolescentScreen.negationRationale in "Medical Reason"   ) ["Assessment, Not Performed": "Adult depression screening assessment"] NoAdultScreen   with "Qualifying Encounter During Measurement Period" QualifyingEncounter     such that NoAdultScreen.authorDatetime during QualifyingEncounter.relevantPeriod   where ( NoAdultScreen.negationRationale in "Patient Declined"       or NoAdultScreen.negationRationale in "Medical Reason"   )