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  1. eCQM Issue Tracker
  2. CQM-6072

CMS 2 v11 - CQL vs guidance

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    • Icon: EC eCQMs - Eligible Clinicians EC eCQMs - Eligible Clinicians
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    • Varun Gregory
    • Health Catalyst
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      Thank you for your inquiry into CMS2v11 Preventive Care and Screening: Screening for Depression and Follow-Up Plan. The questions posed fell into two areas.

      The CQL Logic pertaining to the guidance you mentioned can be found on the eCQI Resource Center site. https://ecqi.healthit.gov/sites/default/files/ecqm/measures/CMS2v11.zip. Please refer to either the “Most Recent Adolescent Depression Screening Positive and Follow Up Provided” or “Most Recent Adult Depression Screening Positive and Follow Up Provided” definitions.
       

      The ticket you reviewed was for CMS2v6 and the intent of the measure and logic has changed since then. For CMS2v11, the intent of the measure is for each patient to be screened for depression (at least once a year) on the date of the encounter or up to 14 days prior AND receive documented follow-up care as appropriate. Since this measure is patient-based, and performance is not calculated based upon every qualifying encounter, if the measure is met at least once, the patient is considered to be in the numerator. In a shared EHR system, where data is aggregated, more than one provider could meet the measure requirements. It is expected that patient outcomes recorded or achieved by another provider can and should count towards another member of the care team provided they have the data that confirms the patient satisfies the numerator.
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      Thank you for your inquiry into CMS2v11 Preventive Care and Screening: Screening for Depression and Follow-Up Plan. The questions posed fell into two areas. The CQL Logic pertaining to the guidance you mentioned can be found on the eCQI Resource Center site. https://ecqi.healthit.gov/sites/default/files/ecqm/measures/CMS2v11.zip . Please refer to either the “Most Recent Adolescent Depression Screening Positive and Follow Up Provided” or “Most Recent Adult Depression Screening Positive and Follow Up Provided” definitions.   The ticket you reviewed was for CMS2v6 and the intent of the measure and logic has changed since then. For CMS2v11, the intent of the measure is for each patient to be screened for depression (at least once a year) on the date of the encounter or up to 14 days prior AND receive documented follow-up care as appropriate. Since this measure is patient-based, and performance is not calculated based upon every qualifying encounter, if the measure is met at least once, the patient is considered to be in the numerator. In a shared EHR system, where data is aggregated, more than one provider could meet the measure requirements. It is expected that patient outcomes recorded or achieved by another provider can and should count towards another member of the care team provided they have the data that confirms the patient satisfies the numerator.
    • CMS0002v12

      I would like to request some clarification on the CMS 2 v11 CQL. In the CQL provided, I cannot find any CQL logic pertaining to this piece of guidance: “The measure assesses the most recent depression screening completed either during the eligible encounter or within the 14 days prior to that encounter. Therefore, a clinician would not be able to complete another screening at the time of the encounter to count towards a follow-up, because that would serve as the most recent screening. In order to satisfy the follow-up requirement for a patient screening positively, the eligible clinician would need to provide one of the aforementioned follow-up actions, which does not include use of a standardized depression screening tool.”

      I have reviewed this ticket and understand that the denominator encounter provider must be the provider to perform the follow-up to receive numerator credit.

      Where does the CQL logic match the denominator encounter provider to the numerator follow-up provider? For example: when evaluating an adolescent screening follow-up, I would expect to see some logic along the lines of: where "Qualifying Encounter During Measurement Period".provider_id = "Follow Up Intervention for Positive Adolescent Depression Screening".provider_id. The match of provider seems so pivotal to this measure, yet I'm not seeing that the CQL contains logic to address it.

            edave Mathematica EC eCQM Team
            varun.gregory Varun Gregory
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