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EC eCQMs
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Resolution: Answered
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Critical
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None
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None
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CMS0002v13
Question#1
2024 CMS2v13 - Issue in Depression screening Followup timing. Below is the specifications for adolescent Followup criteria. The same issue is with Adult criteria as well.
Most Recent Adolescent Depression Screening Positive and Follow Up Provided
from
"Most Recent Adolescent Depression Screening" LastAdolescentScreen,
"Follow Up Intervention for Positive Adolescent Depression Screening" FollowUpPositiveAdolescentScreen,
"Qualifying Encounter During Measurement Period" QualifyingEncounter
where Global."NormalizeInterval" ( LastAdolescentScreen.relevantDatetime, LastAdolescentScreen.relevantPeriod ) 14 days or less on or before day of start of QualifyingEncounter.relevantPeriod
and LastAdolescentScreen.result ~ "Depression screening positive (finding)"
and ( start of Global."NormalizeInterval" ( FollowUpPositiveAdolescentScreen.relevantDatetime, FollowUpPositiveAdolescentScreen.relevantPeriod ) during QualifyingEncounter.relevantPeriod
or FollowUpPositiveAdolescentScreen.authorDatetime 2 days or less on or after day of
end of QualifyingEncounter.relevantPeriod
)
and Coalesce(start of Global."NormalizeInterval"(FollowUpPositiveAdolescentScreen.relevantDatetime, FollowUpPositiveAdolescentScreen.relevantPeriod), FollowUpPositiveAdolescentScreen.authorDatetime)during "Measurement Period"
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Here, Followup Relevantdatetime or Relevant Period is valid if documented 'during encounter'.
But, Followup Authordatetime is valid if documented '2 days or less on or after day of encounter'.
So, If the prescribed followup is 'Intervention Performed: Follow Up for Adolescent Depression', then it has to be during encounter ONLY.
But if the prescribed followup is 'Medication, Order: Adolescent Depression Medications or Intervention, Order:Referral for Adolescent Depression' , then it can be '2 days or less on or after day of encounter'.
This logic is conflicting the numerator description, where all 3 followups should be allowed to be '2 days or less on or after day of encounter'.
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